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Ssrsh Kliff analyzes the long-awaited Republican alternative to the Affordable Care Act.

Sam Baker writes that the plan is for people to pay more for their own care.

Commonwealth Fund Report: How States Stand to Gain or Lose Federal Funds by Opting In or Out of the Medicaid Expansion

Abstract: Following the Supreme Court’s decision in 2012, state officials are now deciding whether to expand their Medicaid programs under the Affordable Care Act. While the states’ costs of participating in the Medicaid expansion have been at the forefront of this discussion, the expansion has much larger implications for the flow of federal funds going to the states. This issue brief examines how participating in the Medicaid expansion will affect the movement of federal funds to each state. States that choose to participate in the expansion will experience a more positive net flow of federal funds than will states that choose not to participate. In addition to providing valuable health insurance benefits to low-income state residents, and steady sources of financing to state health care providers, the Medicaid expansion will be an important source of new federal funds for states.

Complete report here.

Net Loss of Federal Funds in 2022 for States That Aren't Expanding Medicaid

Where Have I Heard This Before?

From Paul Ryan's original health care proposal, which established him in some eyes as tough-minded health policy intellectual with bold and innovative solutions. Such as these:

Provides a refundable tax credit – $2,300 for individuals and $5,700 for families – to purchase coverage in any State, and keep it with them if they move or change jobs.

Provides transparency in health care price and quality data, making this critical information readily available before someone needs health services.

Creates state-based health care exchanges, so individuals and families have a one-stop marketplace to purchase affordable health insurance without being discriminated against based on pre-existing conditions.

Equips states with tools like auto-enrollment programs and high-risk pools, so affordable health coverage can be accessed by all.

Addresses health care’s growing strain on small businesses, by allowing them to pool together nationally to offer coverage to their employees.

Encourages the adoption of health information technology and assists states in establishing solutions to medical malpractice litigation.

Seems like I've heard a lot of this before...

The American Health Policy Trap

The American health policy trap: a costly and complicated system that has left a growing minority of Americans without financial protection in sickness but has nonetheless satsfied enough people to make it difficult to change. The key elements of the trap are a system of employer-provided insurance that conceals its true costs from those who benefit from it; targeted government programs that protect groups such as the elderly and veterans, who are well organized and enjoy wide public sympathy and believe that, unlike other claimants, they have earned their benefits; and a financing system that has expanded and enriched the health care industry, creating powerful interests averse to change.

Paul Starr, Remedy and Reaction: The Peculiar American Struggle Over Health Care Reform

Mitt Romney's Health Care Dilemma

Tonight, Mitt Romney promised his Iowa supporters that as president, his first act would be to pursue the repeal of "Obamacare." Romney's dilemma is plain: The Affordable Care Act  is also modeled after the Massachusetts Act Providing Access to Affordable, Quality, Accountable Health Care championed by then Governor Romney. In particular, Romney opposed mandated participation by employers in health insurance, insisting on individual mandates.

Romney's reasoning followed what was then traditional Republican logic: Requiring individuals to take responsibility for their health care eliminated free riding whereby the costs of uncompensated care are absorbed by the insured. Now, to be sure, there is plenty of free riding in American health care, and it goes beyond uncompensated care. For example, large companies use bargaining power to negotiate more favorable rates with insurers, who then pass the loss onto small businesses, the self-insured, and the uninsured. Moreover, since the self-insured do not receive a health insurance tax break, they subsidize the insurance of people with employer-provided insurance.

Senator Charles Grassley (R-IA) introduced employer mandates as an alternative to the Clinton attempt health care reform. According to Paul Starr in his book Remedy and Reaction, many Republican politicians supported individual mandates as recently as 2009. Since then, the party's desire to defeat President Obama and the ascendance of its libertarian wing has trumped a policy that has roots in the Eisenhower administration. As a result, Mitt Romney has been forced to repudiate a policy that he successfully effected in Massachusetts and that he once believed would help him run for president. If he can thread that needle, more power to him.

Are We Patients or Consumers?

"[There is] no difference between men, in intelligence or race, so profound as the difference between the sick and the well." 

F. Scott Fitzgerald, The Great Gatsby

"Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick." 

Susan Sontag, Illmess as Metaphor

Advocates of consumer-driven health care contend that patients are consumers of health care and that choice of insurance plan forms the basis of a successful health care model. In their seminal book Redefining Health Care, Porter and Teisberg argue that CDHC champions err by focusing on consumer choice rather than value-driven care as the primary economic driver of competition in health care.

The question of whether we are patients or consumers need not be considered in such binary fashion, writes George Annas in The Rights of Patients: The Authoritative ACLU Guide to Patient Rights. The word "patient," Annas says, "...is the best term to describe an individual who is sick or injured and in need of medical care." Annas recognized the paternal implications of the term and agrees that it requires refining.

However, he also finds "consumer" wanting, writing that it best applies to healthy people physically and psychologically able to contemplate a choice of plans or elective procedures. An important reason why there has never been a sustained, effective, widespread consumer movement in health care is the when we are sick or injured, our first priority is to become well, and we are willing to cede rights that we might otherwise take for granted in order to regain health.

Moreover, public attention lies elsewhere: Advances in medical technology that delay death and increase the curative power of modern health care, costs, access, patient rights, and matters as basic as adequate time with physicians.

In short, we are consumers when well, and patients when sick.

(Source: The Rights of Patients: The Authoritative ACLU Guide to Patient Rights, 3rd ed.)