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Policy prescription: States' fights

| Tuesday, April 24, 2012, 4:26 p.m.

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

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.

A Page of Books, written and compiled by Alan Wallace, appears on the last Sunday of each month.

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