[This op-ed appeared in today’s Wall Street Journal and was composed by 8 health care experts from across the right-left political divide: Sara Rosenbaum, Gail Wilensky, Ron Pollack, Lanhee Chen, John McDonough, Grace-Marie Turner, Stuart Butler and Joe Antos.
[The 8 of us are working with the Convergence Center for Policy Resolution to explore areas of bipartisan agreement as the U.S. health reform conversation remains intensely divided. Our agreement on substantive policy matters is, by no means, a “grand bargain” on the plethora of policy controversies surrounding the Affordable Care Act and Republican-proposed successor statutes. We hope that our process may develop more points of agreement and consensus.]
The current congressional debate about health reform focuses on two closely linked issues: how to structure subsidies and the future of Medicaid. We write to support two propositions that can better serve economically vulnerable families, while also ensuring that public dollars are spent effectively. First, we believe public subsidies for private insurance premiums should be means-adjusted to make coverage affordable for lower-income people. Second, we believe states should be given new flexibility to streamline coverage options in Medicaid, the Children’s Health Insurance Program and other publicly supported insurance, so that families can obtain the coverage that best suits their circumstances and serves their needs.
We, along with Sara Rosenbaum, Gail Wilensky, Joe Antos, John McDonough, Grace-Marie Turner and Stuart Butler—a group of health policy researchers who join in this article—hold diverse political views and policy outlooks. But we believe these propositions transcend partisanship and ideology.
Most Americans receive employer-sponsored health insurance, which is heavily subsidized through the tax system. Many millions of others are enrolled in Medicaid and CHIP, funded jointly by the federal government and the states, and Medicare, funded through federal tax revenue and individual contributions. Until 2014, individuals who were not eligible for employer-sponsored insurance or public programs could buy their own insurance, but most did not receive any financial help. As a result of the Affordable Care Act, millions more people receive subsidies to help pay for their insurance premiums.
Public support for health coverage should be spent as effectively and efficiently as possible. Toward that end, we agree that the existing tax exclusion for employer-sponsored health insurance should have reasonable limits. We also agree that it is prudent to provide subsidies for people who need help to purchase adequate insurance. While hundreds of billions of taxpayer dollars reduce the cost of health coverage and care for most Americans, until recently, those with limited financial means seeking individual coverage were left out. This lack of access to affordable care drove many uninsured Americans to skip medical treatment that would have averted suffering and higher costs over time.
If we expect low-income families to purchase health insurance, we must structure the subsidies to make affordable coverage a realistic possibility. That means providing greater subsidies to those who can least afford the premiums.
While we have differing perspectives about the level and structure of Medicaid funding, we all believe that carefully developed state testing can be a primary engine for reforming Medicaid and providing care to low-income families. The improved use of waivers, for example, can help states develop fiscally sound and affordable coverage options for their most vulnerable citizens.
States should be given greater authority to configure and redirect revenue streams from Medicaid, CHIP and private insurance to improve and strengthen coverage. Integration of funding streams would make it easier for individuals to keep the same coverage and providers when their employment or other life circumstances change. It would also allow all family members to share the same health plan. Experimentation would enable states to integrate health care options better so that families could choose the best plan for their needs.
To ensure cost-effectiveness, states seeking waivers should be required to meet an overall federal budget-neutrality standard. Neutrality should be required for the cumulative budget impact of a proposal involving multiple programs and subsidies, not for each program. States should be allowed to align better the federal subsidies available to their citizens, even if allowing them to do so would require specific changes to one or more forms of coverage.
This additional flexibility, however, must be subject to safeguards. While we differ about the extent of the federal safeguards needed to protect state coverage and benefits, we all agree that flexibility should not allow funds for health-care services to be diverted to other purposes. Furthermore, funding for low-income populations must not be diverted to cover higher-income individuals.
With this new authority, states could simplify their insurance markets and enable children to receive coverage with their parents. This would allow parents to shop for better and more integrated coverage for their children while retaining the protections established by CHIP. Lawmakers should also consider altering Medicaid, CHIP and tax-subsidy rules to ensure that families without employer coverage for their children can receive support to buy affordable child-only plans. Similarly, states could help healthy adults buy private insurance.
We believe that these incremental policies would establish a more equitable health-care system and help families of limited means secure the care they need to remain healthy.