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Two Big ACA Breakthroughs

Posted by John McDonough  February 21, 2013 09:14 PM

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The period since the November 6th federal elections has been a remarkably fluid period in U.S. politics and policy -- more than anyone could have anticipated.  The Republican Party embraced tax increases for the wealthiest Americans to avoid the "fiscal cliff;" prospects for federal immigration reform legislation have changed from impossible to more than likely; gun control, an issue on which Democrats have feared to tread since Al Gore's loss in the 2000 presidential election, has re-emerged with gusto since the Connecticut school shootings. 

And change is affecting prospects for the Affordable Care Act/ObamaCare as well.  In the past two days, we have seen developments inconceivable before November 6th.

First, yesterday, Florida Governor Rick Scott became the 7th Republican chief executive to endorse the ACA's Medicaid expansion for his state.  More than Arizona's Jan Brewer and Ohio's John Kasich, Scott has been the most virulent opponent of the ACA before nearly anyone else.  Back in 2008, even before Obama took the oath of office, Scott was using part of his large fortune to finance TV ads opposing health reform.  Though Scott repeatedly denounced the ACA's Medicaid expansion, yesterday he said:

"While the federal government is committed to pay 100 percent of the cost, I cannot, in good conscience, deny Floridians the needed access to health care."

Scott only endorsed the expansion through 2016, the first three years when the federal government pays 100% of the cost.  After that, the federal share gradually declines over three years to 90%.  And there is no guarantee that the Republican controlled Senate and House will go along with Scott's recommendation.  Scott is already facing a vigorous 2014 re-election challenge from former Republican Governor Charlie Crist (who turned Democrat last year).  This recognition of reality by one of the nation's fiercest ObamaCare critics is an important political signals of the changing landscape for the ACA.

Second, yesterday Douglas Holtz-Eakin, president of the American Action Forum, who served as director of the Congressional Budget Office from 2003 to 2005 and Avik Roy, a senior fellow at the Manhattan Institute, and a 2012 healthcare adviser to Republican nominee Mitt Romney, published a Reuters column calling on conservatives to now focus on modifying rather than repealing the ACA:

"For far too long, conservatives have failed to coalesce around a long-term vision of what a free-market healthcare system should look like. Republican attention to healthcare, in turn, has only arisen sporadically, in response to Democratic initiatives.

"Obamacare is the logical byproduct of this conservative policy neglect. President Barack Obama’s re-election was a strategic victory for his signature healthcare law. Once the bulk of the program begins to be implemented in 2014 — especially its trillions of dollars in new health-insurance subsidies — it will become politically impossible to repeal. And as the baby boomers retire and Obamacare is fully operational, government health spending will reach unsustainable levels.

"The great irony of Obama’s triumph, however, is that it can pave the way for Republicans to adopt a comprehensive, market-oriented healthcare agenda.  The market-oriented prescription drug program in Medicare has controlled the growth of government health spending. Similarly, conservatives can use Obamacare’s important concession to the private sector — its establishment of subsidized insurance marketplaces — as a vehicle for broader entitlement reforms."

In other words, rather than a socialist takeover the U.S. health care system, the ACA is actually a concession to a private market vision of how the system can reflect conservative principles.  This from one of the nation's leading conservative policy critics of ObamaCare for the past three years. 

From me, no gloating, no "I told you so," no smugness.  Instead, I feel appreciation for common sense overtaking extremism and myopia.  Thanks to Gov. Rick Scott, Douglas Holtz-Eakin, Avik Roy, and others, we are reaching the point where Congress can consider how to improve and enhance the ACA.

Better times ahead, just in time.

This blog is not written or edited by or the Boston Globe.
The author is solely responsible for the content.

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About the author

John E. McDonough is a professor of practice at the Harvard School of Public Health. He is the author of the book “Inside National Health Reform”, published in 2011 by More »


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