Inside National Health Reform

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Welcome to Politics Bites, where every afternoon at It's A Free Country, we bring you the unmissable quotes from the morning's political conversations on WNYC. Today on the Brian Lehrer Show, John E. McDonough, DPH, MPA, professor at Harvard School of Public Health and the first Joan H. Tisch Distinguished Fellow in Public Health at Hunter College, CUNY, discusses his new book, Inside National Health Reform, which takes a close look at the development, passage and enactment of the Affordable Care Act.

The Federal Affordable Health Care Act offered tax breaks to help people afford policies. The Massachusetts Act offered subsidies for insurance coverage for those who cannot pay. Though the first act was commandeered by a Democrat and the second by a Republican, both share a notable element—the individual mandate.

John McDonough helped write both those pieces of legislation. He led the advocacy group “Health Care for All” and has written a new book.  He said that governor Romney proposed the individual mandate as a way to satisfy the Bush administration. Tommy Thompson, the head of the Department of Health and Human Services (DHHS), threatened to withhold the federal government waiver unless the mandate was created.

The state in 2004 was facing the loss of a significant portion of that money [from the waiver], so Governor Romney and the late Senator Kennedy went to the Bush administration arm-in-arm and said let  us hold on to this money, and if you let us… we will create a form of universal health care in one state, tied to an individual mandate, and you, the Bush administration, will get credit for creating universal health care in one state and it won’t cost you anymore than you’re already paying right now.

He clarified that it was not a federal mandate, but a request from Massachusetts for help from the federal administration.  He said it became an agenda item for the administration after that point, and that Bush praised the law through the DHHS.

Romney himself touted the plan as creating competition and options. McDonough said his advocacy group was not enthusiastic about the individual mandate or the entire package.

We had to be drawn to the table. We were very supportive of employer responsibility and very suspicious of individual responsibility.

He said the individual mandate was an idea created and promoted by Conservative policy advocates.

Between the Clinton plan and the Obama plan it was kind of just accepted truth among Conservative circles that the way to address trying to expand coverage was tying it to an individual mandate.

He said it wasn’t until summer of 2009 that the individual mandate underwent a dramatic withdrawal of support from Conservatives.

The value behind Conservative support was.. individual responsibility. .. That it shouldn’t be about big government setting something up, that it shouldn’t be about putting responsibility on others.  Individuals need to take responsibility and we need to create a way for people to be able to buy insurance and then make sure that they actually do so…. The difference was Mitt Romney didn’t just talk about it, Mitt Romney actually did it, and that’s why he’s in such hot water now.

McDonough said premiums continue to go up despite these affordable care acts in part due to the political make up of the policy-makers. In Massachusetts, for example, Romney faced a lot of political opposition from Democrats, which shaped the final form of the act.

He wanted a mandate for much skinner coverage with much higher deductibles and cost sharing.

The act, he said, was not designed to control health care spending but to enforce universal coverage.  Yet the Act does seem to be controlling costs.

Over the last roughly 12 to 15 months, we’ve seen a significant drop in the rate of  increase in the Medicare program.

A large part of that savings has been due to increased crackdown against fraudulent operators.

When a lot of those see that the federal government is getting serious, it actually dissuades people from getting in and committing that type of fraud.

This crackdown seems to be helping move momentum toward a better control of health care costs. McDonough is optimistic that that movement will continue.

There’s not a magic bullet, there’s not a single answer… but I think the news in the years ahead on healthcare spending is going to be significantly better than people are expecting.