Three unpopular parts of Obamacare should stay

As Republicans consider repealing President Obama’s health care law, what bits should they be looking to keep?

To my mind, the most important and unobjectionable bits of Obamacare are payment reform, comparative-effectiveness research and the tax on gold-plated health-care plans.

These are not, you will notice, the most popular bits of Obamacare, the one that President-elect Donald Trump seems to favor. Nor are they the most famous.

But all three attempt to tackle the biggest problem with our health-care system: its exorbitant cost.

Obamacare tried to tackle the cost problem in three ways.

First, it levied the “Cadillac tax” on extremely generous health-insurance plans. It is, to be sure, an awkward and inefficient way to approach the problem. It would be much more logical to cap, or eliminate, the business tax deduction for those benefits, but that isn’t going to happen. At least this curbs some of the worst effects of keeping the deduction.

The second portion of Obamacare that Republicans should consider keeping is some of the payment reforms. These attempt to tackle the problem from a different angle.

Right now, Medicare will pretty much pay for any fool thing your doctor wants to do to you, as long as you’ll sit still for it. This system, known as “fee for service,” encourages doctors to perform lots of services. The idea behind various payment reforms is that they’ll pay the doctor for health (or at least, for having patients), rather than for doing a bunch of stuff to those patients.

If the doctors save money, they get a bonus; if hospitals readmit too many patients after they’ve been discharged, they get hit with a penalty.

As long as we’re going to have Medicare (and we are), we have to structure payments somehow. And on balance, there’s a decent argument for keeping the new structure rather than reverting to the old one.

The third thing that Republicans should consider keeping is the Independent Payment Advisory Board, otherwise known as the “death panel.” Its lethal reputation is considerably exaggerated; IPAB will not be considering the fates of individual patients, and it doesn’t even have the legal authority to deny treatments. What it can do is look at the evidence and recommend payments based on cost effectiveness.

I have real concerns about whether the IPAB will end up stifling innovation in the name of keeping costs down. But a government agency that evaluates the current state of medical knowledge, and disseminates that knowledge to doctors, is a good idea.

So that’s what Republicans should think about keeping. That’s a very different question from what they will consider keeping.

This story was originally published January 9, 2017 at 5:03 AM with the headline "Three unpopular parts of Obamacare should stay."