| 摘要 | Key Points
Government spending on health care and health insurance as a share of total health spending will likely continue to grow.
Recent legislation and policy changes have made total health spending more “market-like,” as federal and state health programs rely increasingly on private-sector administration.
Shifting the share of any increased total public subsidies (explicit and implicit) to become more market-like can potentially provide some operational efficiencies and make balancing political demand and private supply more feasible.
Read the PDF.
Executive Summary
Government spending on health care and health insurance will likely continue to grow despite recent Republican efforts to slow it. Public funding for care and insurance does face longer-term fiscal limits, but initial fiscal pressures have been largely met not by budget cuts, but by changes in how this spending is administered. Recent legislation and administrative changes have made total spending (whether financed by taxpayers or consumers) more “market-like,” often taking the form of de facto vouchers. The trend lines for the sources of funds (increasingly public) for health care and insurance and how they are delivered (through private insurers and other intermediaries in less-intensively regulated markets) move in the same direction: Both increase over time. Shifting the share of any increased total public subsidies (explicit and implicit) to become more market-like can potentially provide some operational efficiencies and make balancing political demand and private supply more feasible, at least until the sources of funding approach much tighter limits.
Introduction
After two years of Republican control of the presidency and both houses of Congress, it seems appropriate to consider the paths health policy and health care markets will likely follow for the remainder of President Donald Trump’s term and beyond. Future political events will influence some of this path’s direction, but much of it will follow a trail already in place.
A complete repeal and replace strategy for the Affordable Care Act (ACA) failed to garner sufficient Republican support in the Senate, but other administrative and legislative changes (e.g., the individual mandate, Cadillac tax, cost-sharing-reduction subsidies, risk corridor budget neutrality, Medicaid expansion, and insurance coverage requirements) have chipped away at pieces of Obamacare, and more efforts (e.g., association health plans, short-term insurance, and more permissive Medicaid waivers) are underway.1
Each Trump administration effort to alter various ACA provisions was cited by ACA defenders and critics alike as a potential crippling blow to Obamacare, but the law’s basic structure limps on. However, Obamacare supporters have recently expressed pleasure that the Republican attacks and changes appear to have actually led to a stabilized, if not increased, government role in health care.2 Similar sentiments were expressed by the former Democratic insurance commissioner of Pennsylvania: “Republicans have inadvertently strengthened the hand of Democrats like me who prefer richer subsidies to a mandate and welcome the expanded federal role that will come with those subsidies.”3 More recently, the November 2018 congressional elections demonstrated a clear shift in public sentiment, with greater popular support for retaining the ACA than for repealing or revising it extensively. Many campaigns by vulnerable Republican incumbents who had once supported ACA repeal and replace measures displayed notably greater defensiveness in retreating from their past positions to limit the law’s protections for coverage of individuals with preexisting health conditions.4
The accuracy of further near-term forecasting may depend on how each wing of the health care process (finances versus operations) is actually configured. Even as the dollar amount of taxpayer-funded subsidies for health care continues to increase, the rules for how they are spent may continue a less-noticed trend of becoming more determined through private, market-like mechanisms, to such an extent that the final destination may be altered or at least more unpredictable.
Read the full report.
Notes
1. Thomas P. Miller, “Whiplash: The Affordable Care Act’s Twisted Path Through Implementation, Litigation, and Reinterpretation,” American Enterprise Institute, July 9, 2018, http://www.aei.org/events/whiplash-the-affordable-care-acts-twisted-path-throughimplementation-litigation-and-reinterpretation/. 2. Robert Pear, “Years of Attack Leave Obamacare a More Government-Focused Health Law,” New York Times, December 26, 2017, https://www.nytimes.com/2017/12/26/us/politics/republicans-trump-affordable-care-act-obamacare.html. 3. Pear, “Years of Attack Leave Obamacare a More Government-Focused Health Law.” 4. Thomas P. Miller, “Rip Van Health Policy,” AEIdeas, November 2, 2018, http://www.aei.org/publication/rip-van-health-policy/. |
