None of these thoughts are new from me, but recent events brings them to the forefront.
It's always seemed to me health reform should have the goal of lowering costs, expanding coverage, and leveraging competition (both public and private). In practice, expanding coverage seems to dominate the other two for the administration. This is a short-term view. In the long-term lowering costs is supposed to come too. It may, but we'll have to see.
It seems to me the heart of all this is the mandates - not necessarily the individual mandate, but the coverage mandates.
A much more balanced solution would have been to:
1. Mandate a minimum of catastrophic coverage. This is a lot of what we care about - going bankrupt for medical circumstances outside of your control. Mandate no denials on the basis of pre-existing conditions, but provide a public catastrophic option.
2. Subsidize low income families for any type of insurance (not just catastrophic), end tax breaks for employer provided plans.
3. Subsidize all these things that are currently mandated. If you think certain coverage is a good thing, subsidize those private plans.
4. Have a public option, or perhaps what's equivalent, just let people buy into Medicaid (with their subsidies) at some actuarially sound rate (i.e. - don't let public options kill the private market through subsidies that aren't available in the private market).
5. Allow considerable state variation of terms and experimentation above this coverage floor.
6. Ultimately, deal with fee for service payment systems. This is almost certainly the bedrock problem with cost issues in the U.S. as far as I can tell.
The rollout record seems to be mixed for Obamacare, which isn't surprising to me because I've always thought the law was mixed. But where problems are raised (aside from silly accusations that Obama somehow lied about keeping coverage) it's usually around the coverage mandates and what they're doing to private plans.
I can see why coverage mandates are desirable, but what's the argument for that rather than minimal mandates plus subsidies? This isn't typically how we do social safety nets in this country, so why are we doing it this way with health reform?
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