Tag Archives: health policy

Is a one-year Obamacare delay acceptable?

As part of an ongoing conversation about the government shutdown, my dad emailed me this morning to ask if a one-year delay in Obamacare would be an acceptable concession to give in exchange for the House Republicans agreeing to repeal the debt ceiling forever. This post is edited from my response.

Like anyone who is paying attention, I find the debt ceiling pointless and terrifying, and I want it dead yesterday. I was and still am a big fan of #mintthecoin, I’m a recent devotee of Matt Levine’s idea of selling high-interest Treasuries at a premium to fund the government at the limit, and I’ve argued that Obama should negotiate to kill the debt ceiling forever (but not over just raising the debt ceiling), and that there exist policy concessions that would be well worth making to eliminate the possibility of repeated hostage crises.

But is delaying Obamacare, even for just a year, an acceptable price?

Not a chance.  Even a one-year delay in Obamacare is  morally unacceptable when the President has other tools to avoid default.

NOTE: By a “one-year delay,” I assume we’re referring  to delaying the individual mandate, the exchanges opening, and Medicaid expanding, and not changing  the other administrative rules/delivery system reforms/parts of the law that have already gone into effect. Maybe it also includes a delay of the device tax, and pushes back IPAB’s spending review, although that looks to be irrelevant this year regardless. That may not be what the Republicans are asking for – I’m not sure.

What that means, though, is preventing ~20 million people from becoming insured, in exchange for avoiding an already-preventable default. On top of that, the exchanges are already operating (as of Tuesday) – so we’d not only have to deny people insurance, we’d have to revoke insurance they already thought they had purchased. It would be terribly cruel. And it would kill people.

If negotiation truly was the only means of preventing default on our debts, you could make a plausible argument that the overall pain of a default would be even worse than taking health insurance away from millions of people. Being uninsured is bad, but  global economic crises are bad for people, too. But that argument is shaky, and it doesn’t hold up when (as noted) the President has several ways to avoid default unilaterally if it becomes necessary.

So, what would be an acceptable policy compromises in a deal to repeal the debt ceiling?

  • One thing that should be included is a repeal of the platinum coin option, by setting a maximum face value for commemorative coins. Creating money and depositing it at the Treasury is not a power any President should have – but until the debt ceiling is gone, no President should be willing to give it up, either.
  • Repeal of medical device tax.
  • A one-year delay in the individual mandate, or alternatively a total rewrite of the mandate to use some non-mandate way of encouraging people to register, e.g. “If you decline insurance, you’re ineligible for subsidies on the exchanges for five years thereafter.”
    NOTE: The mandate penalty this year is small ($95), so I don’t think this would have a huge effect on insurance enrollment or cause a death spiral, but it includes the risk of pretty bad outcomes in the private insurance market (and it’s sure to royally tick off private insurers, who were promised a supply of young, healthy, cheap new customers).
  • A political compromise, rather than policy compromise: ~20 House Dems (enough to replace any Tea Partiers who defect after the deal) agree to support Boehner for Speaker for the rest of this Congress
  • Are there other ideas? Probably – I haven’t been paying that close of attention to what the GOP demands. But even if I had, it’s not easy to respond to delusional talking points with actual policy concessions.

My first policy paper!

While at the New America Foundation, I wrote a paper on the health care workforce with Shannon Brownlee and Thom Walsh. That paper has finally been released, and I think it has the potential to be a useful contribution to how people think about health care workforce planning.

The tl;dr: The health care workforce pays a lot of highly-skilled people to do jobs that they don’t need to be doing, either because their tasks could be done more cheaply by someone less highly trained, or because the work they’re doing doesn’t need to happen at all (since it doesn’t benefit patients). There are examples scattered across the country of health care systems that do a better job of using their workforce effectively, and it allows them to provide good care with much lower spending. We need to focus workforce development efforts on emulating those more efficient systems.

I hope you’ll read it!