Health care reform

The GOP's Health Reform Anxiety

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There are two things to note about the health care portion of the Republican party's 2012 platform. The first is how much it differs from the 2008 platform, which, as The Washington Post's Sarah Kliff has noted, devoted only about 200 words to the subject and proposed no major reforms. The new document is far more expansive, with subsections devoted to Medicare and Medicaid, and an acknowledgment in the budgeting section that Medicare "is the largest driver of future debt."

Overall, it's reasonably strong statement from a party that has traditionally been loath to discuss major health entitlement reforms. But it still leaves the party plenty of wiggle room. That brings us to the second point, which is how  awkward and opaque the party's position on health care remains. You can see a clear desire to appease the base by pursuing those reforms, but you can also see a deep-rooted anxiety about how those reforms will actually play with the public, and seniors in particular.

The foundations are reasonably strong: The platform notes that both Medicare and Medicaid are fiscally unsustainable and elaborates on the way both have come to dominate the health system and public budgets:

Medicare has grown from more than 20 million enrolled in 1970 to more than 47 million enrolled today, with a projected total of 80 million in 2030. Medicaid counted almost 30 million enrolleesin 1990, has about 54 million now, and under Obamacare would include an additional 11 million. Medicare spent more than $520 billion in 2010 and has close to $37 trillion in unfunded obligations,while total Medicaid spending will more than double by 2019. In many States, Medicaid's mandates and inflexible bureaucracy have become a budgetary black hole, growing faster than most other budget lines and devouring funding for many other essential governmental functions.

In response, the platform recommends converting Medicare into a premium support system and pursuing state-based block grants for Medicaid. Those aren't the best solutions, but relative to the current situation, those are both promising reforms — reasonable and plausible ways to start transforming the U.S. health care system. But as Kliff notes, it avoids touching the larger and more difficult issue, which is the way the health system has been distorted by the tax deduction for employer sponsored insurance. That's not entirely surprising given the slew of political attacks suffered by Sen. John McCain, the last Republican presidential nominee to broach topic. But it still suggests a lingering reticence to even mention one of the biggest flaws in the country's health policy infrastructure.

There's a similar anxiety at work in the platform's Medicare and Medicaid reforms. The GOP platform seems to see its preferred entitlement changes as an end, not a beginning, framing these reforms as ways to preserve and protect both programs. It's a limited approach that assumes the centrality of these entitlements rather than questioning them, one that acknowledges that way both Medicare and Medicaid have overtaken so much government spending and activity, but promises to further entrench embed both programs into the firmament of American public policy.