Policy prescription: States’ fights

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If the U.S. Supreme Court — where oral arguments begin Monday — overturns  ObamaCare, states should become laboratories for reform; if it’s upheld, states’  design of their insurance “exchanges” still will be important and should reflect  each state’s demographics and health care shortfalls.

That’s the thrust of the independent, nonpartisan Pioneer Institute’s new  book, “The Great Experiment: the States, the Feds and Your Healthcare.” The dean  of Harvard Medical School wrote its introduction and its chapter authors include  a former Office of Management and Budget associate director and a Tufts  University School of Medicine professor.

Following are excerpts from the Trib’s phone conversation with  editor/co-author Josh Archambault, the institute’s director of health care  policy.

On ramifications of the Supreme Court case and presidential  election:

If the Supreme Court strikes down some … of (ObamaCare), then the November  election takes on even more of an importance from a policy perspective …  long-term. If you see the president win re-election and the law’s upheld and you  end up with … Republicans having control of both the House and the Senate, or  even just the House … the Obama administration … (is) not going to get any  money that they need (for implementation) … so I think you’ll see it grind to  a halt legislatively … . Now, let me put on my optimist hat … . (If) the law  is upheld or … one section’s struck down and it’s still sustainable in theory  — that’s a big “what if” — and the president wins re-election, 2013 offers …  a rare opportunity for some sort of major deal to be struck, bipartisan, on tax  reform. You’ll have the Bush tax cuts expiring … just after a presidential  election, the debt ceiling will need to be raised again and something will have  to happen with health care, whether it’s Medicare, Medicaid or something  directly related to (ObamaCare). There may be an opportunity there in which …  Congress actually is having to make tough decisions on … a major tax-reform  bill in which there could be undertones of health care, (providing) the cover  for some sort of adjustment to happen at the federal level, either on  entitlement reform for … Medicare and Medicaid … or on … ObamaCare.

On how to empower states:

What we’re proposing … is not … “Oh, just hand it down to the states, let  them take care of it,” because frankly … we’ve seen states haven’t been able  to crack this nut just yet. … (W)hat’s really important is that … we look  back to the last major entitlement reform — it was in 1996, welfare reform —  (and) how (we went) about getting some sort of settlement and some sort of  competence at the state level. It was through waivers. The federal government  had in essence … said, “We want to see more people working, less people on the  rolls, and that they won’t be on the cycle of dependency.” … And then they  said, “We’re not going to grant waivers because you ask for them. We want you to  have a waiver.” That was kind of their innovation strategy … . I think there  were 43 waivers … . We learned what things worked, what didn’t. We had an  empirical basis to make recommendations, and by the time we got to the 1996  reform … everybody in the states was pretty familiar with … what other  states had tried, so that they could move forward with some sort of meaningful  reform. … (T)hat’s what we would like to see on health care.

On what roles Uncle Sam and the states should play:

First, the (federal government needs) to deal with the tax treatment of  health insurance. This has been the primary reason why states have been somewhat  hindered (in) dealing with health care costs. So … we’re advocating for a  refundable tax credit because … this is one way you get to a place where  individuals start to become a little bit more of a consumer instead of having it  be purely tied to your employer. We’re not against employer(-provided)  insurance, we just think the current system … ends up helping the wealthiest  … . (O)ur goal is … to get as many people (as possible) affordable coverage — at all income (levels). … (I)t’s our hope that the federal government would  encourage these waiver programs, specifically in the Medicaid program, saying,  “We have these overarching policy goals. We want you to get there (in) the best  way that you think is appropriate for your state. Here are the ‘guardrails’  which you must keep within and here’s some money to be able to do it, but we’re  going to hold you accountable for outcomes and if you’re not working, then we’re  going to require you to fix things.” … The states’ role in all of this is  often an administrative function, (with Washington) saying, “You need to work  with your citizens to help them get enrolled, to help them get access to the  refundable tax credit.” It’s not that (states) have to be … driving a  systemwide reform. … The state government role would be helping facilitate  this movement more toward reform.


The Boston-based Pioneer Institute considers what’s in place today so  different from the health care reform plan that Massachusetts passed in 2006  that it shouldn’t even be called “RomneyCare.”

Legislators overrode Republican Gov. Mitt Romney’s veto of some key  provisions, and since then, the law’s been implemented largely by Democrat Gov.  Deval Patrick’s administration “in ways that conflict with Romney’s original  vision,” the institute says.

Its director of health care policy, Josh Archambault, says the Patrick  administration has:

• Raised the minimum coverage required under Massachusetts’ individual  mandate from the original catastrophic-care level to what “would probably be  considered a ‘gold-plated’ plan” in other states, increasing both what  individuals pay and public subsidies.

• Made it more difficult for small businesses to avoid paying penalties for  not offering coverage.

• Undercut personal responsibility by letting anyone whose income is up to  150 percent of the poverty level pay?nothing for coverage, instead of  the original requirement that they pay?something — “even a dollar …  so they felt a sense of ownership.”

• Established “tiers” that limit the number of unsubsidized plans offered  through Massachusetts’ insurance exchange to small businesses, hindering market  competition and consumer choice.


With gasoline prices near $4 per gallon locally and even higher elsewhere,  pain at the pump is both a pocketbook issue and a political issue for Americans  in this presidential election year.  But there’s little any individual — president or not — can do about those prices. They’re tied to the global market  for oil produced by the global industry that has arisen since Edwin Drake  drilled his pioneering well in Titusville in 1858.  For a deeper understanding  of the history of the oil industry and the market forces that set oil — and  gasoline — prices, turn to these titles, selected especially for A Page of  Books readers by manager Karen Rossi and her staff at Carnegie Library of  Pittsburgh’s Downtown & Business branch.

Understanding Oil Prices: A Guide to What Drives the Price of Oil in  Today’s Market by Salvatore Carollo (Wiley, 2012)

The Age of Oil: The Mythology, History, and Future of the World’s  Most Controversial Resource by Leonardo Maugeri (Praeger,  2006)

Oil: Anatomy of an Industry by Matthew Yeomans (New  Press, 2004)

Oil on the Brain: Adventures from the Pump to the  Pipeline by Lisa Margonelli (Nan A. Talese, 2007)

The Prize: The Epic Quest for Oil, Money & Power by  Daniel Yergin (Simon & Schuster, 1991)

Over a Barrel: The Costs of U.S. Foreign Oil  Dependence by John S. Duffield (Stanford Law and Politics,  2007)

The Big Rich: The Rise and Fall of the Greatest Texas Oil  Fortunes by Bryan Burrough (The Penguin Press, 200

The Teapot Dome Scandal: How Big Oil Bought the Harding White House  and Tried to Steal the Country by Laton McCartney (Random House,  200

The Russian Rockefellers: The Saga of the Nobel Family and the  Russian Oil Industry by Robert W. Tolf (Hoover Institution Press,  1976)


Mr. President: How and Why the Founders Created a Chief  Executive by Ray Raphael (Knopf)

Americans could be voting for teams, not individuals, in this year’s  presidential election — if not for Gouverneur Morris, who represented  Pennsylvania at 1787’s Constitutional Convention and persuaded fellow Framers  that one person should head the executive branch and have greater powers than  some preferred. He overcame newly independent Americans’ wariness of one-man  rule “with amazing political savvy and not a little bluster and deceit,”  according to the publisher. The author, who already has 15 books — many on the  shaping of America — to his credit, has produced what various reviewers call a  “wholly surprising history,” “a fascinating and fresh narrative” that has  “something new to say about the most powerful office in the world.”

The Crusader: The Life and Tumultuous Times of Pat  Buchanan by Timothy Stanley (Thomas Dunne Books)

Even more timely due to its subject’s recent ouster from MSNBC, “The  Crusader” draws on interviews with the controversial conservative columnist and  others who’ve known him. Its British author, a columnist and former Labour Party  candidate for Parliament who wrote a book on the 1980 Democrat nomination battle  between Sen. Ted Kennedy and President Jimmy Carter, traces Pat Buchanan from  his D.C. boyhood through his roles in the Nixon and Reagan administrations, his  runs for the presidency and his work as a writer and commentator. Buchanan’s  supporters and detractors will find plenty of interest here; as someone who’s  witnessed much history and prompts strong reactions, his is a life worth  examining in depth.

Sarah Palin and the Wasilla Warriors: The True Story of the  Improbable 1982 Alaska State Basketball Championship by Mike  Shropshire (St. Martin’s Press)

Here’s a different take on the former Alaska governor — one that focuses on  then-Sarah Heath, known as “Sarah Barracuda” for her fierce point-guard play on  a team that had never finished better than 3-18, yet became an underdog  state-title winner. Mike Shropshire, who’s written for newspapers and magazines  and penned the book “The Last Season in Hell,” describes what life’s really like  near the Arctic Circle, where high schools and their teams are hubs of activity.  Whatever one thinks of Sarah Palin today, this book provides insight into the  community and culture that shaped her long before politics did — and thereby  provides insight into a woman who continues to fascinate Americans.

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