Let's face it, this is a strange time in U.S. health policy. Over the past two years, beliefs and policies that united liberals and conservatives have been blown apart. Repair work is needed, and one place to start is by exploring blown assumptions. From a liberal perspective I offer these.
First, Medicare: Before the health reform debate, broad bipartisan agreement prevailed that the health system in general and Medicare in particular were loaded with waste and inefficiency, and that eliminating waste could help finance universal coverage. Then, during and after the brawl leading to passage of the Affordable Care Act, Republicans relentlessly attacked Democrats for cutting Medicare by $450 billion between 2010 and 2019 to help pay for the health overhaul. Never were the attacks more pitched than during the 2010 Congressional campaigns.
Democrats' defense was that most reductions had been negotiated with affected industries -- $155 billion in hospital reductions as Exhibit A -- to finance coverage expansions. The defense did not stick with the public, and the effectiveness of the Republican assault is credited as a key driver that helped them score huge gains in last November's House and Senate elections.
Now, the budget plan advanced by Rep. Paul Ryan, R-Wis., and supported by all but nine Senate and House Republicans, proposes complete repeal of the health law with one exception, the $450 billion in Medicare savings. Ryan's plan even maintains the measure's cuts to their beloved Medicare Advantage private plans. It now seems Republicans did not mind cutting Medicare. They just objected to how the saved funds would be used -- to cover the uninsured. This key element of the Ryan blueprint has been obscured by the raucous debate over his proposal for Medicare vouchers/premium support, though it demands explanation.
How do Republicans explain their current support for Medicare cuts to which they so strenuously and publicly objected in last fall's elections and before?
Second, the individual mandate: Since its conception in the 1980s by conservative Wharton School economist Mark Pauly, the individual mandate has been associated with Republicans and conservatives, including the Heritage Foundation; Newt Gingrich; and Republican former and current senators including Bob Dole from Kansas, John Chafee of Rhode Island, Iowa's Chuck Grassley and Utah's Orrin Hatch. Heck, even Sen. Jim DeMint, R-S.C., embraced it in 2007 when he backed former Massachusetts Gov. Mitt Romney's presidential bid. The mandate has a long pedigree in Republican circles, and a very limited constituency among Democrats.
No wonder Romney thought he was on solid ground advancing it in Massachusetts in 2006. Well into 2009, there was little indication the mandate would be a divisive part of the health reform debate. The breaking point came during the town meetings held in August of that year as angry Tea Partiers transformed the political landscape. If there were an emblematic moment then, it was DeMint's comment that defeat of health reform would be President Barack Obama's "Waterloo."
It prompts another question: What happened in conservative circles to the concept of individual responsibility?
Third, health insurance exchanges: Recently, speaking with state legislators, I took them to the website of the Massachusetts Health Insurance Connector Authority , and walked them through the process of signing up online for individual health insurance in about seven and a half minutes -- about the time it takes to fill a car with gas, I suggested. And that is the point worth noting, because I remember when it was illegal for me to gas up my car (still is, by the way, in New Jersey and Oregon). That is the essence of the exchange -- to allow individuals and small businesses to pump their own insurance.
The exchange is a conservative, free-market idea -- Stuart Butler from Heritage deserves most credit. Heritage gave the idea to Romney who loved it, as did Massachusetts Democrats, who changed the name to "Connector" to deny Romney naming rights. In the federal health reform process, Republicans insisted on state-based exchanges. House Democrats and the White House wanted one big federal exchange. The Senate sided with Republicans and, under the health law, states have right of first refusal with feds as back up.
Now, Republicans criticize exchanges as a federal takeover. Yet the real federal takeover happens only if a state refuses to act -- precisely what some conservative governors, such as Louisiana's Gov. Bobby Jindal, and some right-leaning legislatures want.
Why is this conservative, free-market idea now so anathema to Republicans?
Fourth, comparative effectiveness research and end-of-life counseling: I first read about the idea to establish a national CER entity in a Health Affairs article in 2005 by widely respected Republican health policy thinker Gail Wilensky. In the June 2008 health reform summit organized by Sens. Max Baucus, D-Mont., AND Chuck Grassley, Grassley highlighted areas where he already saw consensus. CER was among them. When Republicans later demanded that CER efforts not examine costs, they got their wish.
During the Senate HELP Committee's health reform markup in June and July 2009, Sen. Johnny Isaakson, R-Ga., first proposed adding end-of-life counseling to the legislation by proposing that people shouldn't be able to enroll in Medicare without an advance directive. Sen. Barbara Mikulski, D-Md., convinced him to just pay physicians to counsel enrollees. Both issues morphed into the accusation that health reform would create "death panels" to decide, as Grassley later put it, "whether to pull the plug on granny."
Where does the Republican/conservative health policy world stand on comparative effectiveness research (now led by the Patient Centered Outcomes Research Institute) and voluntary end-of-life counseling? What happened to delivery system improvement?
Finally, universal coverage: Sen. Kay Bailey Hutchinson, R-Texas, often remarked: "Of course, we all want universal health care ... we all want everyone to have health insurance." And, "We all agree, doing nothing is not an option." Having been part of this strange health policy world since 1985, I always believed most Republicans wanted to improve the system and expand coverage, just along other pathways.
Part of the aftershock on the liberal/Democratic side is that this idea is no longer easy to believe. When the Republican House voted earlier this year to repeal the health law, their slogan was "repeal and replace." Last month, House Ways and Means Chairman Dave Camp, R-Mich., admitted the House would offer no replacement.
Two final questions: Do any Republicans still believe in the goal of universal coverage? What is the basis for moving forward together from here?
John E. McDonough is a professor at the Harvard School of Public Health.