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When Obamacare Fails, How Will Market-Based Reform Succeed?

When Obamacare Fails, How Will Market-Based Reform Succeed?. Tom Miller American Enterprise Institute February 4, 2013. Positive Alternatives?. WHEN OBAMACARE FAILS The Playbook for Market-Based Reform BY THOMAS P. MILLER DECEMBER 2012. Silver Linings Playbook?. Basic Building Blocks.

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When Obamacare Fails, How Will Market-Based Reform Succeed?

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  1. When Obamacare Fails, How Will Market-Based Reform Succeed? Tom Miller American Enterprise Institute February 4, 2013

  2. Positive Alternatives? WHEN OBAMACARE FAILS The Playbook for Market-Based Reform BY THOMAS P. MILLER DECEMBER 2012

  3. Silver Linings Playbook?

  4. Basic Building Blocks Defined contribution financing (all subsidies) Retarget, protect most vulnerable HRP $, continuous coverage incentives Information, incentives, innovation Mutually assured accountability Alternative insurance regulation Beyond health insurance: the bigger picture

  5. What’s Not Enough It won’t work (rooting for failure) It costs too much (we’ve seen the graphs) Wait ‘til it self-implodes (who wins the crisis?) Trust the states The two Santa Claus theory of politics Hidden formula cuts Magical market thinking Trust your doctor Good riddance, ESI?

  6. The Fork in the Road

  7. Defined Contribution Deliverables Change the locus of decision making Public dollars start with beneficiary/patient Neutralizing misincentives Expanding positive incentives to: Seek and produce information Maximize value (beyond just health coverage) Reward better performers Customize & personalize, tradeoffs Information-based regulation Competition, entry, accountability, rewards Real connections -- willing buyers & sellers

  8. The Ordeal of Change:Getting under the Hood Unlock & rebalance: resources, roles, expectations Getting beyond a common rhetoric National goals, local trial & error Payment incentives can nudge Only practitioners deliver Beneficiaries choose agents & partners Admit what we don’t know Pay more OOP for what works better or is more wanted

  9. The Ordeal of Change:Tougher Calls Stop subsidizing the middle class Bring regulatory cross-subsidies on budget Adjustments add complexity & transition time Cost of Medicaid mainstreaming Slower path to coverage neutrality Defaults for disengaged Competition is disruptive Bleed out, or bandage? Public wants “real problems” fixed, w/o “real solutions”

  10. Incomplete: The Bigger Picture Improving health outside the doctor’s office (social determinants, self-help) Rebuilding human & health capital Beyond insurance: making care cheaper, better, quicker Supply-side expansion (scope of practice, telemedicine, competition policy) Reversing the dependency ratio Saving money, or improving value? Competing for efficiency, w/o bonuses Accountability: to patients or politicians?

  11. Answer “Why” Before “How”Supply A Larger Vision Opportunity for everyone to do better Reflect & reinforce values Improve health Patient-driven Accountable Balance with other needs

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