Zack Buck at the Harvard Petrie Flom Center’s blog raises an interesting argument about the Biden Administration’s health care plans:
Though health policy debates during the 2020 presidential primaries centered around expanding access to public health insurance programs (e.g., “Medicare-for-All”), the focus of the nascent Biden administration has been on making private health insurance more durable, not deconstructing it.
While these changes are likely to make private insurance plans more affordable and attainable, choosing to reinforce private insurance plans puts global systemic reform, the goal of many advocates, further out of reach.
But changing tax subsidy formulae and income cliffs is highly specific, individualized, and detail-oriented. While the changes are welcome, they may fail to address the deep, structural causes of America’s health care cost crisis, like hospital and prescription drug prices, saturated marketplaces, and inefficient and fragmented payment structures. Those challenges remain.
In some ways, I completely agree with his argument. The Biden Administration’s current accomplishments and ongoing priorities are “individualized, and detail-oriented” and do not “address the deep structural causes of America’s health care cost crisis….” And at the same time, I am completely underwhelmed by the argument for several reasons.
Most importantly, the most critical number in implementing big change is 218-51-1-5.
Democrats on the best of days can assemble that coalition. They were able to assemble that coalition for the American Rescue Plan. They can assemble that coalition for a “Puppies are adorable and Ice Cream is yummy” bills.
They currently can’t assemble that coalition on prescription drug pricing bills. They can’t assemble that coalition on Medicare for all. They can’t assemble that coalition for a national public option with prices linked to Medicare. The possibility space is constrained by the plausible coalitions that can be assembled especially if we assume that anything that has long term structural changes to the provision of health insurance coverage to any one under the age of 65 is likely to be a Democrats only bill.
Secondarily, as I wrote in January 2019, prioritization was a key:
Prioritization will be a key differentiator of Democratic Presidential and Senate primary candidates. I believe that most Democrats will share significant elements of what is on their top-10 list of areas that need federal government attention in a government that could theoretically have a narrow Democratic trifecta. But the key will be prioritization….
Senate floor time is a key constraint. A very productive Senate might have slots for two big bills, three or four medium actions (such as SCOTUS nominees) and a lot of housekeeping. A productive Senate is most likely positively correlated with the size of the effective majority.
Right now, there are numerous agenda items that could qualify as a “big” thing from the Democratic/liberal perspective….
Candidates are likely to share the same items on a top-10 list but the rank ordering and asset allocation will matter a lot. One candidate might want to spend six months on healthcare again at the cost of doing not much if anything on immigration and naturalization. Another candidate could want to spend a little time on a minimal “fix-it” healthcare bill while spending more time on global warming policy. Those are all defensible choices.
Biden during the campaign never focused on making healthcare reform one of his two big priorities. He was pretty clear that he wanted to build on pre-existing structures and improve known problems and extend on successes. That was a major point of contrast to several of his opponents including Senators Sanders and Warren. Agree with that prioritization or not, it was a clearly communicated priority. And it has been accomplished for at least the next two years.
I think that there is a difference in opinion on the value of optimization versus improvement. Is there value in pocketing a few rolls versus holding out for the full loaf of bread? That is a moral question, that is a risk tolerance question and that is technocratic question all at once. Given very narrow Democratic majorities with a clear blocking coalition that is unlikely to want to go big in the direction of Medicare for All and given a clear history of healthcare being an important but not the most important priority of the Biden campaign nor Biden administration, I’m more than happy to pocket a few rolls and getting back to work on improving the current system as is instead of hoping for a complete reconstruction of a kludged up system with a fairly high probability of failure of the reconstruction project. But that is a personal judgement…