Wednesday, September 22, 2010

The Pledge to America on Health Care

Cross-posted from The Agenda on National Review Online.

CBS News and other outlets have published a draft version of House Republicans’ “Pledge to America,” to be formally unveiled tomorrow in Virginia. As far as its health care provisions are concerned, on a scale of 1 to 10, I give it a 7. Given the political constraints a GOP-controlled House would face, that’s not terrible. It’s a reasonably substantive document, much more so than the 1994 Contract with America. For better or worse, the Pledge is designed to reach the broadest possible consensus, and therefore avoids some of the thorniest questions in health care policy.

We knew that repealing PPACA would be a core component of the House Republican agenda, and indeed it is. The outstanding question was: in the “repeal and replace” formulation, what would “replace” look like? The “replace” part takes special importance given that the President is certain to veto any repeal measure.

The planks of the House GOP health care platform, aside from repealing Obamacare, are: reforming medical malpractice; legalizing interstate purchasing of health insurance; expanding health savings accounts; “strengthening the doctor-patient relationship”; ensuring access for those with pre-existing conditions; and permanently prohibiting taxpayer-funded abortion. It’s a sensibly modest platform that is nearly identical to that which Republicans proposed as an alternative to PPACA throughout 2009. If enacted, it would certainly represent several steps in the right direction.

I put “strengthening the doctor-patient relationship” in quotes because it’s not clear that, other than by repealing PPACA, what the Pledge to America does to strengthen the doctor-patient relationship. The document is no more specific than stating that Republicans seek to “replace [PPACA] with common-sense reforms.”

The pre-existing conditions plank is the most detailed of the seven. This clearly suggests that Republicans were sensitive to the question of access for those with pre-existing conditions. The document advocates expanding state high-risk pools and reinsurance programs. It states that “we will make it illegal for an insurance company to deny coverage to someone with prior coverage on the basis of a pre-existing condition”: but this was already illegal prior to Obamacare. Same goes for the desire to “prevent insurers from dropping your coverage just because you get sick.” I guess it’s simpler to say that you’re in favor of these things than to explain that they are already ensconced in federal and state law.

The single best solution to the pre-existing condition problem is to eliminate the employer tax exclusion that subsidizes employer-purchased health insurance at the expense of an efficient individual market. Unfortunately, the President is opposed to such a measure, and Republicans are understandably uninterested in advocating a tax increase that the President will hammer them on.

It’s notable that abortion is the last of the seven planks, something that was true throughout the pledge: social issues were consistently listed at the back end of the various policy proposals. To me, this is tonally appropriate.

Actually, the most interesting and consequential health care proposal in the Pledge is one that appears elsewhere in the document: a promise to “require congressional approval of any new federal regulation that has an annual cost to our economy of $100 million or more.” If Republicans were ever able to get such a provision signed into law, it would have a significant impact on the regulatory implementation of PPACA, along with being an all-around excellent check upon the metastasis of the regulatory state.

Importantly, the Pledge says almost nothing about the biggest and most difficult questions in health policy: Medicare and Medicaid reform. It criticizes PPACA’s “massive Medicare cuts” without offering an alternative solution for putting the program on stable long-term footing. The fiscal section of the Pledge promises that Republicans “will make the decisions that are necessary to protect our entitlement programs for today’s seniors and future generations. That means requiring a full accounting of Social Security, Medicare, and Medicaid, setting benchmarks for these programs and reviewing them regularly, and preventing the expansion of unfunded liabilities.” About as bracing as a glass of milk.

But perhaps it would have been unrealistic to expect more. Democrats have engaged in their fair share of entitlement demagoguery, which is likely to intensify as we get closer to the election. Up to this point, the President has not shown a serious interest in entitlement reform, and so Republicans surely feel that they’re better off speaking in generalities.

It’s hard, however, to imagine serious entitlement reform taking place until politicians come forth to seek a popular mandate for reform, as Paul Ryan has tried to do. Oh well; there’s always 2012?

(Here's the full text:)


  1. A 7? As you note, they do not even mention Medicare/Medicaid. Any plan that does not even acknowledge this as an issue is not a plan, it is a guide to re-election.

    The rest is all moderate stuff that will do little good or bad. We have had the interstate argument, and it will do nothing I believe.

    Since I am a practicing doc, how does the ACA weaken my patient-doctor relationship? I do not see how it does that.

    The $100 million clause might slow down cost growth. I am dubious, but if they want to try it, go ahead. Need I point out that it is Congress which has been increasing spending all along, both parties? Remember the SGR, passed by Republicans but then never acted upon?


  2. Actually I'd originally given it a "6.5" but felt that was too tough and upped it to "7". Here's why -- as much as I criticize them for not addressing entitlement reform, where is the Democrats' plan for entitlement reform? I haven't seen one, have you? So I don't want to hold them to a politically unrealistic standard. Having said that, the entitlement issues are too important to ignore, and that's why I'm no higher than "7".

    I agree with you that the other stuff is mostly piecemeal. The best parts are the tort reform, the interstate purchasing of insurance, and the regulatory oversight.

    I think we're going to have to wait for the Presidential election for a serious conversation on entitlement reform. I hope we get one.

  3. As much as I would like tort reform, it remains unclear to me if anything can really be done at the federal level.

    Entitlements? You may not think it will work, but the ACA does take a run at it with the advisory board, which seems loosely modeled on the base closing panels.


  4. For better or worse, the only spending cuts the Independent Payment Advisory Board is allowed to make are reductions in reimbursements to doctors and hospitals. They aren't able to cut benefits. So, whether you're a fan of the IPAB or not, it's pretty much a useless body.