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February 24, 2018

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The hidden consensus on reforming health care

To follow what’s happening with the new health care law right now, you have to understand that for all the deep divisions on the issue, there’s actually a real bipartisan consensus about how the U.S. health care system ought to be reformed.

Or rather, there are two of them — a dishonest consensus among politicians and an honest consensus among people who study public policy for a living.

The politicians’ consensus is that health care reform shouldn’t alter or disrupt the way the majority of Americans get their insurance today. This is President Barack Obama’s official position on the issue: Again and again throughout the fraught 2009 debate, he reassured voters that, if they liked their existing health care plan, his bill wouldn’t prevent them from keeping it. It’s also the official position of his Republican critics, who have consistently attacked Obamacare for undercutting that presidential promise — for slashing Medicare, for driving up premiums and for threatening the employer-provided insurance status quo.

The policy consensus, though, is that the status quo is actually the problem and that it deserves to be threatened, undermined and replaced as expeditiously as possible. Wonks of the left and right disagree on what that replacement should look like. But they’re united in regarding employer-provided coverage as an unsustainable relic: a burden on businesses, a source of perverse incentives for the health care market and an obstacle to more efficient, affordable and universal coverage.

Obamacare has an unwieldy, Frankenstein’s monster quality in part because the law is trying to serve both consensuses at once. The core of the bill, the subsidies for the uninsured and the exchanges where they can purchase plans, is designed to offer a center-left alternative to the existing system. But much of the surrounding architecture is designed to prop up existing arrangements.

Or at least, it was designed that way. But then came the recent announcement that the White House would be delaying the new health care law’s employer mandate, which requires businesses with more than 50 employees to offer health coverage or face a fine.

Republicans reacted by hyping the announcement as a sign that the entire law is unraveling, Democrats by minimizing the significance of the move. But the more telling reaction came from the policy world, where conservatives and liberals took a break from their usual disagreements to agree that the White House and Congress should probably just scrap the employer mandate altogether.

That’s because the mandate is mostly just a political device designed to hide the full cost of the bill and discourage employers from eliminating employee coverage too quickly.

Like many politically minded regulations, it risked perverse economic consequences — delayed hiring, reduced work hours — which explains why the White House decided to punt it to 2015. But the mandate’s outright abandonment is more desirable, because that would have a clarifying effect on the entire health care debate.

Right now, both parties are still pretending that H.R. departments will go on doubling as welfare states forever. If it dropped the employer mandate, the Obama White House would be fully committed to a more disruptive future, in which exchanges and subsidies gradually replaced the employer-based system.

And since those exchanges and subsidies are going to be implemented by this administration no matter what — barring a Martian invasion or a zombie apocalypse, at least — the sooner we find out if they really work and what they really cost the better.

Either way, the White House’s decision is a step toward honesty in policymaking. It takes us a little closer to a world where politicians of both parties actually level with the public and acknowledge that employer-provided health insurance is an idea whose time has passed.

Ross Douthat is a columnist for The New York Times.

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