Where are the Conservative Ideas on Health Reform? All Over the Map.

The liberals have it all wrong. Conservatives are not lacking health reform ideas. They’re drowning in them.

Following the publication of Mark Pauly and John Goodman’s “Tax Credits for Health Insurance and Medical Savings Accounts,” many right-of-center health policy analysts endorsed the principle of lump sum tax credits to subsidize private health insurance and most endorsed some version of Health Savings Accounts [here and here]. The patient-centered point of view in John Goodman and Gerald Musgrave’s Patient Power, and the focused-factory, supply-side competition envisioned in Regina Herzlinger’s Consumer Driven Health Care are also generally accepted.

These ideas are reflected in the Coburn/Burr/Ryan/Nunes bill as well as in the health plan John McCain adopted when running for president, although neither plan has been endorsed by most Republican Members of Congress.

Beyond that, where do conservatives stand on the critical problems of controlling costs, increasing quality, improving access to care and reforming insurance markets? Answer: they’re all over the place. In fact, there is probably no other public policy area on which there is so much diversity of right-of-center opinion than there is right now on health policy. This may explain why the current House Republican plan is so anemic.

A brief summary of conservative/libertarian proposals is below the fold.

Arm chair warriors often fail, and we’ve been poisoned by these fairy tales…
Who knows how long this will last, now we’ve come so far, so fast.


1.  Mark McClellan (Brookings), Joe Antos (AEI) and Mark Pauly (AEI/Wharton): Dole/Daschle proposal:
 Full study
2. Mark McClellan (Brookings), Joe Antos (AEI) and Mark Pauly (AEI/Wharton):
 Study: Bending the Curve by Improving the Senate (Baucus) bill
3. Mark Pauly (AEI/Wharton) and Steve Parente (University of Minnesota):
 Full Plan
 Comments at John C. Goodman (JCG) Blog
4. Jim Capretta (EPPC) and Tom Miller (AEI):
 Comments at JCG Blog
5. Regina Herzlinger (Harvard): Swiss Plan:
 Linda Gorman Critique
 JCG Health Alert
6. Martin Feldstein (Harvard):
 Washington Post editorial
 JCG Health Alert
7. John Cochrane (Chicago): Health Status Insurance:
 Cato Study
 JCG Health Alert
8. Bob Moffitt and Nina Owcharenko (Heritage): Massachusetts Health Plan:
 Study: The Massachusetts Health Plan: Lessons for the States
 NCPA Critique: Romney Health Plan: The Good, the Bad and a Question Mark
9. Michael Cannon (Cato):  
 Cato’s Free Market Plan
10. John Cogan, Glenn Hubbard and Daniel Kessler (Hoover):
 AEI Book: Healthy, Wealthy, and Wise: Five Steps to a Better Health Care System
 Michael Cannon (Cato): Book Review
11. NCPA Position on Health Exchanges and Managed Competition:
 Book Chapter on Managed Competition
 Private Sector Socialism, Part I
 Private Sector Socialism, Part II
12. NCPA Plan:
 5 Reforms
 10 Reforms

Comments (20)

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  1. Charlotte says:

    As I was saying to you in another context, I’ve just quit listening because they are literally all over the place. Someone should corral them a few at a time (to get some control) and teach them listening to reason and logic. Once you can get them to stop talking and grasping at straws, someone needs to help sort through the options and come up with a plan. I’m not volunteering no matter what.

  2. william c waters iii md says:

    Dear me, you left off my book, TWO DAYS That Ruined Your Health Care (and how you can provide the cure)! It’s now had over 20,000 circulation and been sent to all the key decision-makers in Washington.
    But why would I think they would read it, since they haven’t even read the Health Bill?!

  3. Arnold Kling says:

    I’m hurt, John. You also left out my book, Crisis of
    Abundance, with proposals to gradually wean the country off not only employer-provided health insurance but Medicare, which is surely the elephant in the room.

  4. Chris Ewin, MD says:

    Primary Care Physicians are fixing the problem of Quality, Access and Cost in our own communities.
    Direct Practices have evolved to be a solution. The
    Coburn/Burr/Ryan/Nunes Bills include an amendement to the IRC that allows us to be recognized as “medical care”……How nice…..
    If passed, our patients can use their HSA’s to pay for our services.
    Imagine that….One transparent fee, once a year for unlimited access to your personal,trusted PCP who’s quality is determined by the patient.
    This is market driven. Our patients have been asking for it. Sometimes the solutions come from the front lines and not the top down by people who have never run a PCP’s office before.
    Which goes to show you, stay out of the way of people who know what they are doing…
    And big thanks goes to Roy Ramthun (hsaconsultingservices.com) for his knowledge on how to get through the maze of DC much like we do for our patients, and helping me write this amendment.


    (f) Certain Physician Fees To Be Treated as Medical Care-

    (1) IN GENERAL- Section 213(d), is amended by adding at the end the following new paragraph:

    ‘(12) PRE-PAID PHYSICIAN FEES- The term ‘medical care’ shall include amounts paid by patients to their primary physician in advance for the right to receive medical services on an as-needed basis.’.

    (2) EFFECTIVE DATE- The amendment made by this section shall apply to taxable years beginning after the date of the enactment of this Act.

  5. John Goodman says:

    My apologies to Arnold Kling and William Waters. I expect we will hear from quite a few others before the day is out.

  6. Karen says:

    Can’t we somehow get this information out to the people? I’m so tired of hearing the conservatives have no plan. Such a downright distortion. Thanks for putting this in one place for me to read.

  7. Devon Herrick says:

    Free market health reform ideas face an uphill battle because too many people are wedded to the notion that health coverage somehow should be free. It’s free for poor children and pregnant mothers. It’s mostly free for seniors. And it’s heavily subsidized for people who get their health coverage through work (or at least they perceive it as mostly free). This means more than half of the population does not face a real premium for their health coverage.

    When I spoke on consumer-driven health care at a conference in Honolulu, the guy running the AV equipment raised his hand and said… “all that shopping and comparing medical prices you talked about… I don’t want to do any of that!”

    Insurance agents often tell me that the people who really understand the trade-off between premiums and benefits are the ones buying in the individual market and small businesses. Those who really “get it” understand the need to control their own health care dollars and like HSAs.

  8. Chris Ewin, MD says:

    When the average cost for direct practice primary care is $50-150/month, it’s easy to see why our patients (many unemployed) can afford it. They know what they are getting, and it’s cheaper than cigarettes ($150-180/month).

    Health insurance is not healthcare, it’s accident and sickness insurance.

  9. Stan Ingman says:

    John … where were all their efforts and ideas from 2000- 2008?

  10. wanda dickinson says:

    The House and Senate better get it right this time. The American people don’t want any part of what Capital Hill want! No Health Care (murder) plan ; not today, not tomorrow,never. W e have been so badly treated thus far by the liberal leftists, that I and many others will rebel. Why did we attend tea parties all spring,summer and fall if Congress didn’t listen? Congress and the President serve at the will of the population, not just a chosen few. NO New HEALTH PLAN!

  11. Gail Wilensky says:

    Agree that Republicans have not lacked ideas. Unfortunately the elected politicians have never pursued their ideas with the single-minded passion and constancy of the Democrats which is clearly what’s needed to get something significant passed. The main contribution Republicans have made in the last 20 years they controlled the executive branch is to pass the largest unfunded entitlement expansion in history…
    Some legacy!

  12. Michael Cannon says:

    Thanks for the plugs.

  13. Matthew Holt says:

    I guess Gail’s Christmas Card from the RNC will be lost in the mail after that comment!

    Unfortunately, it’s true as Stan says. With 12 years in charge of Congress and 6 in charge of everything, the Republicans did nothing (apart from smothering Medicare drug coverage in a bunch of corporate welfare) and by their actions showed that they don’t give a rats arse about the uninsured, or the fundamental problems in the system.

    Many of us who won;t make any “free-marketeer” idea lists aren’t delighted with what the Democrats are doing, But at least they’re doing something.

    And much as I love Michael Cannon, his book has 3 whole lines about the problems of spending past the deductible. Which is somewhat representative of the overall level of ideas about systemic change from this list.

    But have fun complaining guys. The more sensible ones among you will move over to a topic Republicans care about (moose hunting?) by the time they get their next shot at government–which might come rather sooner than the country or the world needs–given how well they did last time.

  14. Jennie Fiedler says:

    Is it true that in 18th century England (and maybe America), people sought the skills of their local barber if they were sick or injured? I guess you could get a haircut, shave and bullet removed all at once! Hmmm…

  15. Bart I. says:

    The video should have been Springsteen’s “57 channels and nothing on.”

    But at least many of the proposals more-or-less acknowledge the importance of addressing the tax code. A more thorough analysis of what they’re trying to reform would have been nice though.

    For starters, how about listing some attributes of the employer tax exclusion:

    1. The tax incentive to overconsume is fairly high for those in the higher tax brackets, because the size of the tax benefit happens to be an accident of the employee’s tax bracket.
    2. The tax exclusion is regressive, providing next to nothing for low-income employees, again because the tax break is tied to the employee’s tax bracket.
    3. The tax exclusion discriminates against individuals who pay for identical (e.g. COBRA) or nearly identical (e.g. HIPAA or continuation) coverage themselves.
    4. The tax exclusion differentiates between group coverage and individually-rated insurance.
    5. The benefit of the tax exclusion is based on the size of the insurance premium (not a flat amount, in other words).
    6. In addition to 4, the tax exclusion is open-ended and extends to any size insurance premium.

    To me, attributes 1-3 are inexcusable. 4-6 are defensible, or at least arguable to the extent that defenders would likely stymie any attempt to reform the tax code.

  16. Bart I. says:

    Attribute #6 should have read “In addition to 5…”

  17. Don Levit says:

    My take on the tax exclusion is that health insurance is designed for those with a lot of assets.
    People who have a net worth of $1million need $1million in coverage.
    Those with a net worth of $50,000 can probably afford only $50,000 of coverage, or maybe a small multiple thereof.
    The primary motivation for health insurance, at least for smaller businesses, is to protect the owner’s assets.
    Having more employees join in simply lowers the premiums for all, particularly the owner.
    Don Levit

  18. […] John Goodman responds to criticism of right-leaning health policy ideas, noting, “there is probably no other public policy area on which there is so much diversity of right-of-center opinion than there is right now on health policy.” (emphasis his)  He lists 12 different right-leaning proposals, saying the main area of agreement is Health Savings Accounts. […]

  19. Ron Bachman says:

    Missed My Work from CHT:


    A 21st Century Intelligent Healthcare Solution to
    Creating a 300 Million Payer System


    A 21st Century Intelligent Healthcare Solution to health and healthcare transformation requires establishing a vision and a process for change that wins over the hearts and minds of Americans with a message that this is a problem that can be solved with American ingenuity and entrepreneurship in a uniquely American way. This is a values issue where lives and the health of citizens are in danger. Family security and financial stability are at risk. Americans must demand a change from a world that does not work to a world that does work. Today we have the worst of all worlds. We have a costly government healthcare system that locks citizens into restrictive limited choices, and a private market that is overburdened with state and federal laws and regulations.

    Change must include things that are real, tangible, and results oriented for real people with real health, healthcare, and health insurance problems. Solutions must be based on American values of financial freedom, personal responsibility, individual ownership, and choice. There are two camps of thought for our future. We will either move to a Washington-based insurance system or we will develop expanded market-based insurance solutions. Unless the free-market is given more flexibility to meet this problem, citizens will undoubtedly turn to the federal and state governments to “solve the crisis.”

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