After the Court & Election Decisions: What’s Next for Health Care?

Tom Miller

American Enterprise Institute

November 8, 2012

Story Lines to Pursue

• Cross-pressures on exchanges

• Recalibrating Medicaid expansion Metabolic disorder or fiscal bulimia?• State-level politics• Setting the table for the 2014 “stress test”• Transparency without real prices

Primary Political Scenarios:Ratification, Rejection, or Equivocation?

Post-November playing field scenarios• Re-election w/o full congressional control From “rope a dope” to “survive & advance” Reality-based revision or fuller strength

dosage? Pottery barn rules

Primary ACA Political Equations:Blame Shifting

• States – branch offices, handle dirty work• Keep full costs off-budget

The Ordeal of Change:Politics vs. Markets

• Strategic & tactical repositioning• Getting beyond a common rhetoric• National goals, local trial & error• Scalability, replication, adaptation

Pilot Program Prototypes?

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Pilot Program Prototypes?

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Pilot Program Prototypes?

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Don’t Just Look under the Street Light for Lost Keys

• Social determinants of health• Broader portfolio of investments• Scope of practice• Competition policy• Telemedicine• Broader use of self-insurance

Choke Points & Leverage

• Exchanges (state v. fed)• Medicaid expansion• Renegotiate & rewrite vs. repeal & replace

The Secret Plan for Health Delivery Reform,

ACA Implementation, & Affordable Entitlements

Predictive Modeling: Probabilities, Possibilies & Implausibilities

• Centripetal, not centrifugal, forces• But changing permanent law alters frame of reference• Accountability: to patients or politicians?• Macroeconomic overrides

Bonus Rounds

• Six Picks for Post-Election Health Policyhttp://www.realclearmarkets.com/articles/2012/11/07/six_picks_for_post-election_health_policy_99976.html

• When Obamacare Fails: The Playbook for Market-Based Reform (AEI, November 2012)• Beyond Repeal and Replace (AEI project)•http://www.aei.org/issue/health/healthcare-reform/beyond-repeal-and-replace-series