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On health care, Republicans move beyond ‘just say no’


When President Clinton proposed a sweeping reform of the health care system in 1993, Republicans in Congress mercilessly savaged it as socialized medicine. A dozen years later, Democrats returned the favor. When President Bush proposed a plan to shore up Social Security in part by creating private accounts, they denounced it as a sell-out to Wall Street.

In both cases the opposition was unified, ruthless — and totally lacking an alternative plan for addressing an important but politically thorny issue. So vital national interests were ignored in favor of convenient political demonization. The cardinal rule of mindless partisanship became: Don’t stick your neck out.

This is why it’s gratifying that congressional Republicans introduced a health care plan last week, even before the Obama administration and the Democratic majorities in Congress hashed out the details of their own proposal.

The Republican plan, a more detailed version of what Sen. John McCain ran on in his presidential campaign, is no cure-all, particularly for the problem of the 46 million uninsured. Nonetheless, it’s a serious proposal that merits serious consideration. More important, the simple fact that it exists might improve chances that the parties will negotiate.

The GOP plan relies on the deceptively radical concept of replacing the current unlimited exemption from taxes of employer-provided insurance with a refundable tax credit of $5,700 for a family, or $2,300 for an individual, that people get regardless of whether their health coverage comes through an employer.

The idea is to introduce market forces into health care to hold down costs that are soaring unsustainably. Here’s how it would work: The government would essentially pay for the first $5,700 in coverage for a family through the credit, and the family would pay the rest out of pocket. With the average family plan costing $12,700 now, that is a major cost. An employer could contribute, but with workers having to pay tax on the benefit, the employer might as well convert it to pay.

The upside is that having Americans pay for more of their medical needs with their own money would give people incentive to shop around when looking for insurance or having procedures done, putting pressure on providers to control costs.

The downside is that millions of people who are now covered through their employers could be left on their own.

The policy implications could be sweeping. And so might the political ones. On one level, this is just a group of staunch conservatives girding for a fight. Instead of having no plan, they have one that many Democrats, and potentially some moderate Republicans, see as a frontal assault on employer-sponsored health care.

But on another level, give the GOP credit. For all those who say the Republican Party is out of ideas, on the issue of health coverage, at least, its proposal is bolder than what the Democrats have offered an asset given the scale of the problem.

The Democratic approach — advanced by President Obama but still under construction in Congress — is to expand the system of employer-provided coverage through mandates and subsidies. Such a plan would insure more people, but its ability to control costs is dubious.

More radically, the Democrats are weighing whether to include an option for people to buy into a government-run health insurance plan that would compete with private insurers — a concept that is as intriguing and as controversial as the Republican plan. It would drive down costs through the government’s purchasing power.

Each side dislikes and fears the other’s most far-reaching ideas. Republicans say private insurers could not compete with the government plan’s prices and so would slowly be driven out of business, leaving people with just one option. Democrats say the Republican plan would leave more people uninsured and reduce quality of care. At bottom, however, the choice illustrates the two possible approaches to controlling runaway medical costs: dramatically increase the power of market forces or use government purchasing power more extensively.

A few other things can have a modest effect on the costs of medical service. The "low-hanging fruit" includes mandating electronic record keeping, limiting malpractice suits, paying for outcomes instead of procedures, and identifying the procedures and institutions that have the highest success rates.

Ultimately, the budget-breaking costs of the nation’s dysfunctional health care system are unlikely to be brought under control just by tweaking the existing one, as the Obama administration’s plan envisions. The two political parties have identified more groundbreaking ideas, and they are not entirely incompatible.

So let the debate begin. The only unacceptable approach is the status quo.

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