It Was Too Much to Hope For: The Fight Goes On

November 26, 2012

In an opinion piece in the Wall Street Journal on November 18, James Capreta and Yuval Levin argue that states can effectively “repeal” the Affordable Care Act by refusing to go along with key provisions. They conclude:

President Obama won re-election and Democrats maintained control of the Senate this month, but the states hold the future of ObamaCare in their hands. Knowing the harm the law would do to their citizens, to the economy and to American health care, governors should refuse to become its enablers.

More specifically, they recommend that states refuse to implement health insurance exchanges, challenge the idea that people can receive subsidies to buy health insurance if they get coverage through a federal exchange, refuse to expand Medicaid, and declare that the “maintenance of effort provisions” in the ACA are no longer applicable. Their idea for health reform is to turn Medicaid into a block grant (for all beneficiaries except dual-eligibles) and make it a premium assistance program to help the poor buy private health insurance.

This opinion piece has been wildly popular among conservative thinkers, reprinted in just about every conservative journal there is—from the Weekly Standard to the National Review—and posted on the websites of most conservative think tanks. Its message is that while proponents of the ACA felt the question of whether or not the ACA would go forward was settled by the election, that is not necessarily true: the effort to block the ACA can go on, just in a different form.

Of course, continuing to block the ACA is also a goal of many in Congress whose approach is to place administrative obstacles in the way of full implementation: holding nuisance hearings, blocking funding, raising procedural questions, and the like.

While it is certain that most of those who are arguing for this path are doing that based on their conviction that the ACA is bad policy and not just for political reasons, their strategy is bad for progress on health care in America: not just because of the potential effect on millions who would be eligible for coverage under the Medicaid expansion, but also because it is a strategy of delay that does nothing to deal with the core issues of health care in America: access to care and the cost of that care.

Instead, the administration and state legislatures will be spending time and resources fighting over the legalities of the subsidy language in the ACA, the strength of the maintenance of effort provisions, and ways to reach to those eligible for the federally-run exchanges.

Buried in messages like those of Capreta and Levin is a belief that health care should not be a right, but rather a market good. Their views are very consistent with Paul Ryan’s proposals for changing Medicare’s defined benefit to a defined contribution.

While these views do not seem to reflect the beliefs of the majority of Americans, strategies and policies that move the U.S. away from health care as a social good do have the potential to create uncertainty in the health care world. Health care providers, health plans, purchasers, health care suppliers and all others in the health care marketplace are craving clarity on the direction for health care reform.

What is really lost by trying the ACA’s approach to health reform? If the policies in the ACA are as bad as the opponents think, they can always be changed later. But if the ACA works to increase access to health care and begin to deal with some of the underlying problems we face with the cost, quality and safety of health care, isn’t that a good thing?

Wasn’t the message of the election that people just want to stop the fighting and move on?

It is time to move on. Let’s deal with the real problems we face in health care: they are big enough.