The Realities of Defunding

Last week the once relevant political operative of right wing influences, Karl Rove, wrote an editorial in the Wall Street Journal, Republicans Do Have Ideas for Health Care. In case you were concerned that defunding the Affordable Care Act would leave the country’s healthcare system in chaos and peril you can now rest easy – the Party of No has a plan. Except they don’t if you go by Mr. Rove’s article.

Before I continue I should note that high hopes of defunding the ACA may reflect a personal perception of authentic patriotism but for most those hopes belie an understanding of our healthcare delivery system, the Affordable Care Act – and most pragmatically, political realities. At the request of Tom Coburn (R-OK), the Congressional Research Service recently published Potential Effects of a Government Shutdown on Implementation of the Patient Protection and Affordable Care Act.

As discussed in that memorandum, defunding of the ACA via government shutdown would not have the intended consequence of stopping much of its implementation while risking the consternation of various constituencies that the Republican party has yet to alienate. Of course, that won’t stop Senators Cruz (R-TX), Lee (R-UT) and Rubio (R-FL) from making political hay out of an issue that strikes a harmonious chord with their conservative bases, and why should it. Those who look for sincerity in the motivations of either (any) political party fail to accept the realities of campaigning and democratic elections in the 21^st century.

I should also note that Mr. Rove is on record of disagreeing with these senators. He believes defunding the Affordable Care Act through a government shutdown would give the President, "a gigantic stick with which to beat [Republicans]." I tend to agree and would hope the Republican party could spend more time on developing new ideas that reflect the realities of our current delivery system instead of just being against the ideas of others (and sometimes their own).

In his editorial, Mr. Rove points out several Republican policy initiatives that taken one by one have some merit – both within the context of ACA implementation and under the unlikely hypothetical assumption of its outright repeal. But it is beyond a stretch to suggest that even taken together those several examples he cites constitute a legitimate alternative to the comprehensive approach of the ACA. And therein lies the challenge that many (most?) political wonks, talking heads and sound bite artisans face when discussing healthcare policy. Our healthcare delivery system is complicated and complex beyond reason, and certainly way beyond necessity. But you have to play the game on the field you’re given not on a chalkboard.

Several of the policy initiatives Mr. Rove cites deal with health insurance: portability of policies, employer risk pooling and selling premiums across state lines. I think these are plausible modifications and/or addendums to the ACA approach that are worth circumstantial testing.  But part of the recognized challenge up front is that these approaches are dependent upon employer-based insurance, which most policy experts agree was never a good idea to begin with. And they leave out a wide swath of the population that doesn’t receive employer-based health insurance. If we didn’t think there was merit in providing healthcare benefits to those unable to afford such coverage, then these would be top of mind ideas.

Another initiative cited, medical liability (or tort) reform is a bit like the weather: everyone complains about it but nobody really ever does anything to change it. Perhaps that’s because of the preponderance of Congress who are also lawyers. But there is another line of thought that believes increasing quality and safety might also be a pragmatic approach to lowering malpractice liability. What would we rather have: the forbearance of frivolous suits that also risk restricting justice to individuals – or the reduction in the basis upon which such suits are brought. In reality, we probably need both.

Of the several reform initiatives Mr. Rove shared transparency has to be the weakest example of meaningful policy. Pulling the cover off of the Invisible Man won’t change your view of him. And mandating that meaningless provider charge rates (prices) be published won’t enable better decision making by consumers (patients). I addressed this back in February in a post I entitled, Pick a Price.

Moving on, allowing Medicaid patients to apply their governmental benefits toward private insurance sounds reasonable enough. Unfortunately, it would be bad policy. Although there are already a number of states seeking to leverage private insurance capitation models as a hybrid compromise to Medicaid expansion within the context of the ACA, those models still maintain control over risk pooling so as to address adverse selection.  While allowing funds to be indiscriminately repurposed may sound like an idea promising to partner individual choice with market efficiencies, as Naomi Freundlich addressed in her Healthcare Blog post, the reality of implementing such an idea is another matter entirely.

Finally, Mr. Rove writes that, “the president and his liberal posse have a fundamental, philosophical objection to conservative ideas on health care. They oppose reforms that put the patient in charge rather than government, that rely on competition rather than regulation, and that strengthen market forces rather than weaken them.”

Disingenuous assertions like this do little to advance meaningful healthcare policy discussion. This is no different than liberal talking heads claiming that conservatives seek to advance healthcare policies that benefit (or are structurally biased toward) the wealthy at the expense of the poor. More generally, asserting that the ACA’s hidden agenda is to abscond personal liberty in favor of governmental control misses the point of the real debate entirely. Both the theoretical and practical debate is not over whether the government knows better than the individual what is best for the individual. The debate is in how public policy can best balance the protection of personal liberties while morally advocating for the rights of those individuals with far less ability to secure affordable, quality healthcare. Some feel healthcare is a basic right secured by the Constitution. Others do not. What do you believe?

Cheers,
  Sparky