"Repeal And Replace" With...What?...

Okay, The New Majority has had its fun...

In a largely partisan vote, members of The New Majority in the U.S. House have kept faith with the people who elected them by passing the "Repeal The Job-Killing Health Care Law" Act (in a gesture of The New Civility, House Speaker Boehner referred to the bill as the "Repeal the Job-Destroying Health Care Law" Act...a nicety perhaps too subtle for us here in the grass roots of America).

There will be no action on the bill in the Senate, where Democrats hold a narrow majority.

So...NOW what happens?...

The New Majority has set itself on a course to block key funding provisions related to Obamacare...but that, too, faces the prospect of a pesky Senate .

In reality, the stage is set for establishing "Reforming Health Reform" as a plank in the Republican platform for 2012.

Now, I'm not a Washington insider, but it would seem to me that the Republican strategy would have a little more...intellectual and political heft...if they were a little more forthcoming about what they're FOR.

It's not like we haven't been here before. Republican Congresses have been responsible for the last two quixotic attempts at "health reform:" The enactment of HIPAA in the mid '90's was supposed to increase access to health coverage for small businesses and individuals, as well as reduce the rapid rise in health insurance costs; it did neither, largely because the law and attendant regulations were written by insurers. And of course, there was that exercise in fiscal irresponsibility known as Medicare Part D.

So let's stipulate for the moment that the republican party has not recently demonstrated either much fiscal restraint of any particular expertise in health system reform.

And let's pretend that there really IS a desire on the part of The New Majority to do something constructive...to fix parts of the new law which are broken(or easily breakable) while not messing about quite so much in the private market...and creating incentives for people voluntarily to sign up for health insurance.

First, let's recognize a fact: In Medicare, Medicaid, The Veterans Administration and other programs, government is the biggest purchaser of health care services in our country. If I were advising The New Majority, I'd place priority #1 on improving the clinical and administrative efficiencies produced by the health plans currently under the direct oversight of the Congress.

Second, let's recognize that the private health insurance market is currently four markets: the market for large, self-insured employers (which have been quite aggressive in seeking exemptions from some of the plan design provisions of the new law, primarily to enable them to continue offering high-deductible health plans to their employees); and within the fully-insured market, companies with more than 50 employees; companies with 2-50 employees, and individuals and the self-employed, who are currently precluded by federal law (and most state laws) from obtaining group coverage.

Because large self-insured employers' health plans are currently regulated by the federal government under ERISA, it's appropriate for Congress to reinforce its oversight of these plans.

For the rest, Congress needs to own up to the fact that federal "assistance" in the fully-insured market has largely exacerbated problems faced by small employers and individuals in obtaining affordable coverage (there are a few exceptions, in my opinion...although many of the "consumer protections" being touted in the new law are actually statutory attempts to UNdo some the provisions under HIPAA which have created problems in the non-group market). So here, perhaps the key for Republicans is to do less, not more.

A key element of the Republicans' health reform platform for many years has been to repeal all tax preferences for the purchase of health coverage. That ain't going to happen. Instead, let's go the other way, and make sure that the tax preference follows whoever the purchaser is. Make health insurance premiums fully deductible for both companies and individuals.

There seems to be agreement that even Republican leaders are reluctant to do away with the health insurance exchanges incorporated into the new law. But there are some legitimate concerns that exchanges could adversely affect competition in the small group and individual markets. That's largely due to the fact that the new law tied new subsidies for premium costs exclusively to participation in the new exchanges.

So once again, let's go the other way, and create incentives for the formation of private Small Business Health Plans. This would enable small employers and individuals to band together in the private sector, in the voluntary marketplace, to purchase health coverage jointly. Give these private entities access to the same subsidies as are available through the exchanges, encourage them to use IT and other tools to increase administrative efficiencies, and create powerful private entities, governed by purchasers, to compete with public exchanges.

And put the mandate off till way, way in the future. Only two constituencies support a mandate: health policy wonks who believe, but can't prove, that mandating the purchase of health coverage will somehow subsidize the cost of coverage for those currently excluded for health reasons; and insurers, who both see the opportunity to capture a few million new customers, and know that once a mandate is enacted, there won't be any further need to worry about cost controls, because you'll have to buy coverage, no matter what it costs.

Throw in some tort reform, and you've got yourself a "replacement" for Obamacare.

Both the benefit and the problem with this approach is that many of these ideas have been part of the Republican playbook for a couple of decades, and even when they held firm majorities in Congress and control of The White House, the ideas have gone nowhere.

This is why it's highly unlikely you'll see a real "replacement" bill introduced in this Congress. Because for a couple of decades, Republicans have proved themselves unwilling to take much of a lead in health reform. It'll be much more fun to holler about liberty, obstruct the proceedings, and wait till 2012...