April 1, 2016

Obamacare, a book and a documentary

Inside National Health Reform (California/Milbank Books on Health and the Public)

If you want to know the details about how Obamacare was created, the most remarkable book was written by John McDonough five years ago. Today I would like to highlight these statements about the origins:

We decided to focus the first meeting on coverage for all Americans. We conceptualized three avenues we could travel in search of consensus:
• The first we called Constitution Avenue, meaning a radical, systemic shift away from the current system, in which mostAmericans get insurance through their jobs. It could be achieved with a  government-run Canadian-style “single payer” system replacing private insurance with public coverage, sometimes called “Medicare for All.” Or it could be done through the private sector, through the Healthy Americans Act, the scheme devised by Senator Ron Wyden (D-OR), which replaced employer coverage and Medicaid with an individual choice of private plans. Either way, employer-based coverage was eliminated.
• The second we called Independence Avenue, meaning an incremental “go slow” approach to minimize conflict. The federal government could support state high-risk pools to cover those with preexisting conditions, subsidize uninsured lower-income folks, expand Medicaid a bit, and implement limited insurance market reforms. Though it did not come close to universal or even a major expansion, and though it would disappoint and anger many on the Democratic and progressive side because it would fall far short of their expectations, it might get done quickly as a bipartisan measure.
• The third we called Massachusetts Avenue, meaning reform based on the key elements of the near-universal coverage law enacted in Massachusetts in 2006. Those elements include deep and systemic health insurance market reform, a mandate on individuals to purchase insurance, subsidies to make insurance affordable, and an insurance “exchange” to connect people easily with coverage.
After ninety minutes of talking, we wanted them to choose. We would not let them leave without getting a sense of their preferences. “How many want to go down Constitution Avenue?” I asked. Zero hands were raised. “OK, how many want to take Independence Avenue?” Zero hands. “All right, how many want to travel down Massachusetts Avenue?” Of the twenty or so in the room, fifteen hands went up. Impressive, I thought. I noticed the five unraised hands all belonged to business representatives:those from the Business Roundtable, the National Federation of Independent Businesses, the U.S. Chamber of Commerce, the American Benefits Council, and the National Retail Federation. “What’s up?” I asked.“Couldn’t we have a Wisconsin Avenue?” asked Paul Dennett from the American Benefits Council, a large corporate-benefits coalition.“Sure,” I said. “Wisconsin, Pennsylvania, Rhode Island, whatever. You five folks get together, work out what your Wisconsin Avenue looks like, bring it back. Let’s compare it with Massachusetts Avenue, and if that’s where people want to go, that’s what we’ll do.” They came back the following week but had no alternative avenue to propose.
It helps to understand the begining, not the current situation. These statements are in chapter 2, you should follow the whole book to get a clear undestanding. Highly recommended.

And the BBC has recently released a documentary, unfortunately I can't watch it from my location.