‘A Fundamental Debate about Power and Control’.

Healthcare reform has dominated American politics and elections for decades, and the 2020 presidential election is no exception. The landmark enactment of the Affordable Care Act in 2010 only widened the gap between voters who embrace liberal ideals of a single-payer model, and those who espouse a limited-government, consumer-driven plan.

No matter the ideological divide, voters are united in a belief that high insurance costs and inequitable access to health care remain top concerns.

“Americans are very clear on what they don’t like: high cost, deductibles, premiums, out-of-pocket, bureaucracy, and paperwork,” says Robert Moffit, senior policy fellow in Domestic Policy Studies at The Heritage Foundation, a conservative-leaning think tank based in Washington, DC. “But if you ask them what they want, the answers you get are fundamentally non-ideological. The public says, ‘My neighbor lost his job and he doesn’t have health insurance. That’s wrong and somebody should fix that.’”

On Monday, October 28, Moffit will join a panel of health policy experts at the School of Public Health for the Dean’s Seminar “Single Payer Health Care: Aspirations and Realities.” The seminar will examine the political, economic, and practical benefits and challenges associated with the single-payer proposals of progressive candidates, including the Bernie Sanders–backed Medicare-for-all plan.

The division in Congress on healthcare reform “comes down to a fundamental debate about power and control,” says Moffit, who held senior positions under the Reagan administration in the Office of Personnel Management and Health and Human Services, and whose current research focuses on Medicare. “Do you want centralized power in the system or decentralized power in the system? That’s a political science question, not an economic question.”

Ahead of the event, Moffit spoke more about consumer-driven healthcare policies, his opposition to Obamacare, and how to achieve bipartisan legislation.

You coauthored the book Why Obamacare Is Wrong for America. Can you explain the main aspects of the ACA, as well as the Bernie Sanders–backed Medicare for all plan, that you disagree with?

Laws have mixed consequences, and the Affordable Care Act is the largest piece of social legislation ever enacted in the United States. Concerning health insurance, the law’s greatest regulatory focus was on the individual and small group markets, and the purpose of that was to make sure people had expanded access to coverage in the individual insurance market, and to control cost, quality, and access to care.

What the law actually does is transfer an enormous amount of centralized regulatory authority from the states over the regulation of insurances in the individual market and the small group market, while it greatly expanded Medicaid. The effect of these markets has not been good, in terms of the functioning of either one of them. In the individual market, there was a high plateau of health insurance costs, which was exactly the opposite of what President Obama and his congressional allies projected. There was an explosion of health insurance costs right away. In 2014, the first year that the individual market opened up under the Affordable Care Act, you had a 54-percent jump in the cost of premiums in the individual markets. Between 2013 and 2017, there was a 105-percent total increase in premium costs. That continued through 2017 and 2018.

It is only now that we’re starting to see a leveling off, but the steady rise in health insurance costs has reached an unacceptably high plateau. If you make more than $50,000 a year, you don’t qualify for any of the premium or cost-sharing subsidies. So instead of insurance market enrollment growth, we’re seeing a decline and flattening out of insurance coverage, particularly among the middle class.

The broader issue with Medicare for all is whether or not we’re going to have an insurance monopoly run by the federal government, or whether we’re going to have alternatives. That is the fundamental issue. What happens if you’re in a single government insurance program, but there are no alternatives for coverage or care? We have some experience from some foreign countries that people often find themselves in a very difficult position.

The Heritage Foundation supports the Health Care Choices Proposal. Can you explain how this plan would reduce premium costs?

In the individual and small group markets, we have to both lower the cost of coverage and expand the choices, and the only way to do that is to reignite the competition in these very diverse markets. Under the Affordable Care Act, competition has collapsed in many states. Today, 77 percent of US counties have only one or two insurers. This is the very opposite of what President Obama promised in 2010 when he said the enactment of the Affordable Care Act would create robust competition in the state health insurance markets.

What we’re suggesting is that Congress take three big steps: First, maintain the existing level of protected federal funding for the coverage—and transform the funding into equitable block grants to the states with certain key conditions. The states must use the funds to provide direct financial assistance to low-income persons who would not otherwise be able to afford health coverage, and they must also use the funds to offset the cost of persons with preexisting conditions.

The second step is that while Congress would retain existing federal law to protect people from exclusion from coverage for preexisting medical conditions—that’s a key element of the Affordable Care Act, and we would keep that, but we would liberalize the regulatory system. The bulk of insurance rules governing the individual and small group market—health benefit requirements, age ratings, risk pooling—would be restored to the states; the people of the states would be able to regulate their own markets. Under Section 1332, which was enacted as part of Obamacare, the law gives state officials the opportunity to opt out of certain Obamacare regulations. Several very diverse states, from Maryland to Minnesota, have been very successful in reducing health insurance costs and expanding enrollment. Every state is different, and you have to give states the authority to do what is best in each market.

As the third condition, every person would have the choice to get the coverage that they want. If you’re enrolled in a government program like Medicaid and you like it, you can keep it. But if you think a private plan would give you superior access to physicians or better care, or if you have access to an employer plan, we’re proposing that Congress allow you to redirect the funds that would go to Medicaid into your private program. We’ve had the total proposal scored, and it’s projected that the average premium reduction nationally would be 15-32 percent.

How can conservatives and liberals learn to work together to create bipartisan legislation that benefits all constituents?

The worst thing that has happened to our discourse is our inability to talk with each other with respect. The problem is polarization. If you’re not going to talk to your fellow citizens about problems they have in common and with respectful disagreement, that is a serious issue. It’s poisoned the legislative process, and it’s not just “the era of Trump”—it’s been going on for a while, post-Reagan. It happened during the Clinton period, where you had a serious breakdown of comity in Congress, and I think the consequences have been very bad for the country. You shouldn’t demonize people because they disagree with you—they might actually have a good idea. When I was in the Reagan administration, we had real disagreements with House Speaker Tip O’Neill and the Democratic leadership, but we did not have the kind of poisonous polarization that characterizes our current political environment. As a congressional relations officer, I spent almost all of my time dealing with Democratic staffers, some of whom became very good friends. When I left the administration, some even wrote letters or called on my behalf. Today, I think that would be unlikely. Polarization is the issue, and the question is how do we turn it around? It’s not a political problem, it’s a moral problem. We can follow the old hymn, “Let There Be Peace on Earth and Let It Begin with Me.”

Click here to register for Think. Teach. Do. New York on Febraruy 4, 2020 where Dean Galea and Dean Delva will discuss “Politics and Health”.

—Jillian McKoy