Harold Pollack wants the administration to do everything within its power to get buy-in from “Republican state office-holders who have actual responsibilities to govern who will eventually own their state’s version of health reform”:
Liberals like me may be disappointed by compromises the White House is likely to make to provide GOP governors with a dignified path to accept Medicaid expansion. Some states wish to impose (modest) co-pays for non-generic drugs or for emergency department use. Others ostensibly maintain the right to opt-out of the Medicaid expansion if the federal government lowers its matching rates. Republican governors require such concessions. After all, they have spent the past five years bitterly opposing health reform. Maybe HHS will follow the Arkansas compromise and allow more poor people into exchanges rather than Medicaid in states that request that option.
The administration always seemed willing to negotiate on medical malpractice, too. This proved to be a moot point in 2009 and 2010, as Republicans preferred to trumpet this issue politically rather than to negotiate any deal. But perhaps we have another chance for movement.
We may also be wise to revisit just how minimal the most minimal insurance packages should be.
In 2011, an Institute of Medicine committee was asked to clarify what the “essential health benefits” under the new law. The IOM recommended a package based on what the typical small business would cover, and noted the importance of such restraint to keep premiums low. It was a much more limited plan than many advocates support, and the committee was sharply criticized. But this month’s backlash underscores the wisdom of the IOM’s approach. I don’t know yet what can be done without compromising public health components such as substance abuse and mental health coverage, but these matters deserve a real look.
For liberals, these may be painful concessions. Yet this isn’t November 2008, when Democrats could plausibly look forward to imposing their legislative will. Democrats need Republican buy-in for health reform to secure public legitimacy and to help millions of needy people. Democrats also need the administrative capacity of state governments, willingly deployed, to make health reform actually work.
Don Taylor suggests other reforms. A big one:
For 2015, replace the individual mandate with the auto-enroll provisions envisioned by Rep. Paul Ryan’s Patients’ Choice Act. Strong auto-enroll policies enacted while allowing an opt out (presumably with some consequences, correct Libertarians?) could actually pool risk better than the weak individual mandate we now have. We will also have to develop a default insurance option to make auto-enroll work, which is the one thing I would add to the ACA if I could do just one thing.
The Dish 