Monday, May 02, 2011

Sympathy for the devil: Anything good in RyanCare?

One year ago, against enormous resistance, Barack Obama and his allies muscled RomneyCare, aka the Patient Protection and Affordable Care Act, into law. It will come into full effect by 2014 assuming the GOP doesn't get complete control of Congress in 2012 (even if they do, the ACA will survive albeit with much less coverage for the poor and disabled).

The ACA was very much a political compromise. A Democratic controlled Congress was barely able to pass a GOP designed health care reform bill against hysterical GOP opposition.

Nobody is happy with RomneyCare, though I believe it was the best that could be done in for our time. A lot of palms had to be greased to get it through (I suspect the AMA was paid off with a CPT deal).

These days the GOP is talking a lot about RyanCare, which has some remarkable resemblances to RomneyCare. Sadly, like RomneyCare, and unlike McCain's half-hearted proposals, both plans keep health care insurance tightly coupled to employment.

The differences between RyanCare and RomneyCare are predictable. The ACA provides support for the poor and the weak and protects people with disabilities and illnesses. RyanCare does not ...

Consensus and Conflict in Health System Reform — The Republican Budget Plan and the ACA | NEJM Health Policy and Reform

...  The Republican plan offers additional (often inadequate) assistance only to very poor elderly and disabled persons, and to very-low-income pregnant women and families with children. The ACA, by contrast, offers assistance to uninsured Americans with incomes as high as 400% of the poverty level.

Second, the plans differ in the protection they afford against health-status–based discrimination. The Republican Roadmap assures guaranteed issue, requires risk adjustment among insurers, and offers high-risk pools, but the ACA prohibits insurers from varying coverage or premiums on the basis of health status and bans preexisting-condition exclusions altogether...

Like RomneyCare, RyanCare puts healthcare firmly into a large corporate framework. This isn't surprising, large corporations have robust control of their ecosystem. This isn't to my tastes.

There are three poles of service provision in the US - diverse market, corporate, and government. My preference for service provision is "diverse market" - small business, large business all with active competition. My second choice, and it's rather a distant second, is governmental provision. My last choice, far behind the other two, is provision of goods and services strictly through large minimally competitive corporate entities. Both RomneyCare/ACA and RyanCare drive all healthcare provision towards large minimally competitive corporation. There's more regulation in the ACA, and less regulation in RyanCare. In the case of Verizon/AT&T/Goldman Sachs like corporate entities lack of regulation is not a feature.

Overall RyanCare is, in some ways, an improvement on healthcare of 2008. It's a huge step backwards from the ACA. There's only one aspect of it for which I have some mild sympathy ...

... vouchers limit federal expenditures by shifting the risk of inflation in health care costs to the states, Medicare beneficiaries, and ordinary Americans ...

Vouchers are not necessarily evil. There are some voucher plans worth considering ...

A Comprehensive Cure: Universal Health Care Vouchers - Emanuel and Fuchs - Brookings Institution

... The Universal Healthcare Voucher System (UHV) achieves universal health coverage by entitling all Americans to a standard package of benefits comparable to that received by federal employees. Enrollment and renewal are guaranteed regardless of health status, as is the individual's right to buy additional services beyond the standard benefits with aftertax dollars. Health plans would receive a risk-adjusted payment based on their enrollment. UHV is funded entirely by a dedicated value-added tax (VAT) with the rate set by Congress. A VAT of approximately 10 to 12 percent would insure all Americans under age 65 at a cost no greater than current public and private health care expenditures.

UHV offers true universality, individual choice, effective cost control, and competition based on quality of care and service. To foster accountability and efficient administration, the voucher system creates a National Health Board and twelve regional boards with a governance structure and reporting requirements similar to the Federal Reserve system. ... UHV is relatively simple compared with other reforms that have similar objectives. Most importantly, it is congruent with basic American values: equality of opportunity and freedom to pursue personal goals.

Ezekiel Emanuel's UHV system looks now like a cross between RomneyCare and RyanCare. It would have been intensely disruptive, it is not necessarily corporate friendly and it would have severed health care coverage from employment. In a world where the GOP had not gone insane, and where corporations were less powerful, the UHV might have been a compromise solution.

Disruption is what we need, and markets can be good at that. Governments, and especially large corporations are much better at stasis. The ACA is much better than RyanCare, but the disruption it promises will be mediated by large, powerful, senator-owning corporations. That's not going to go well.

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