The fate of Obamacare and the direction of the next step in health reform is the clearest choice in the presidential election.
Obamacare has already expanded insurance coverage to young adults by allowing them to remain on their parents’ insurance, and it will begin the setup of state-based markets (think Orbitz.com) in which the uninsured and those working for small businesses can purchase private insurance coverage with income-based subsidies. North Carolina will have the choice of expanding Medicaid in financially advantageous terms if we wish to do so (the Supreme Court said states could not be forced).
Obamacare contains many efforts that begin changing the way we pay for care — policies that if tried, evaluated and implemented, could help us address cost inflation while improving quality.
However, the hardest steps on cost containment will never be taken so long as health reform remains the policy of only one political party. Eventually, there has got to be a deal that makes both political parties responsible for taking the hardest steps.
Re-electing President Obama and moving forward with Obamacare will provide the conditions under which such a political deal is most likely to occur, yielding the best chance for the best health policy.
Gov. Romney is in many ways a hero of health policy, having achieved near universal coverage in Massachusetts; his plan is the pattern for Obamacare. He now says that he will repeal and replace it on day one of his presidency, and that is the clear sentiment of the Republican Party.
When viewed purely in policy terms, Obamacare represents a moderate track, and not the single-payer system that many liberals want. The part of Obamacare that is most offensive to Republicans is the Obama part.
If Republicans record a clean sweep in this election (presidency and both houses of Congress), they will be able to repeal the vast majority of Obamacare. However, there is no reason to believe they will get around to the replace part. It is not that they don’t have ideas on health reform. They do. What they lack is the political will (it takes 218 votes in the House, 60 in the Senate, months of discussion) to push a reform through from scratch.
When was the last time the Republican Party invested political capital to push a health reform effort that would expand insurance coverage while addressing costs and quality? There is no example.
There is a tremendous amount of policy work that must be done in Washington in the coming weeks and months on taxes and spending, and the scope of the tax and spending changes that happen by default mean that the time will be ripe for a large-scale deal, one whose inevitability has been delayed only by the election. If we can identify some modifications of Obamacare that are to the liking of Republicans in the midst of these broad negotiations, and while doing so make the hardest work of health reform the responsibility of both parties, then we have a reasonable chance of moving toward a sustainable budget over the next decade.
If the first step on health reform is back to nothing via repeal, then I fear that will be the last step for some time. And we have no hope of a sustainable budget without consequential health reform because health care costs are our biggest long-run spending problem.
If you want a sustainable budget, the best course of action is to stay the course and re-elect President Obama, in large part because he already has a health reform vehicle that provides many great steps and is flexible enough to accommodate the inevitable next ones.
Donald H. Taylor Jr. is an associate professor of public policy at Duke University and author of “Balancing the Budget is a Progressive Priority.” Taylor has contributed financially to the Obama campaign and has canvassed, but this column was not seen by anyone else and he is not a policy adviser to the campaign. This commentary was originally published in The Durham Herald-Sun on Nov. 1, 2012.