Think Big? Think Small?

Note: I'm moving to a new policy blog site: http://frissepolicy.blogspot.com/

The New York Times recently posted two contrasting positions from Ezekiel Emanuel (National Institutes of Health) and Stewart Butler (Heritage Foundation). Emanuel's position is entited "Think Big" while Butler's is entitled "Think Small." The articles are a wonderful, cross-referenced exposition of this critical issue. Both resonate

• Follow this link to the Emanual posting
• Follow this link to the Butler posting

First, Emanuel's major points:

1. Think big. "In health care, big plans are necessary not only to motivate people but as a matter of sound policy." It's about a system of care, or, as he says "reform must include changing the delivery system and how we pay for care. "
2. Health policy is fiscal policy. "Forget Social Security or defense, health care costs are the long-term driving force in federal and state budgets." He points out that Orzag and rumored candidates for new positions (Summers, Cooper, and Furman are mentioned) all get health care. (Certainly this fan of Jim Cooper's believes he does like few others).
3. Comprehensive care is cheaper care. "One of the secrets of health care reform that has not yet sunk in, is that bigger changes to the system actually cost less. " Emanuel references a previous blog posting about a Lewin Group Analysis.
4. Institutionalize tinkering. Arguing that no plan is perfect, Emanuel believes that "good reform will make addressing these issues easy by not requiring major legislation for each adjustment."
5. Everything is connected. He is persuasive, arguing that "health care is so big — $1 out of every $6 in the economy, dwarfing automobiles and all other economic segments. Everything is affected by health policy, and every decision should be examined for its impact on health care reform." It works both ways, every issue affects health care and health care policies affect every other issue. He identifies this relationship through example "Similarly, every favor to a constituency should be linked to support for the health care reform agenda. If the automakers want a bail out, then they and their suppliers have to agree to support and lobby for the administration’s health care reform effort."

Butler's pragmatic advice is equally pursuasive. He makes four points:

1. Make a strong commitment to bipartisanship. Citing bipartisan proposals and state-led initiatives, Butler urgest the President-elect to "tell the more triumphalist liberal supporters on Capitol Hill to chill, and that he’s looking for common ground."
2. Find better ways to use the money we are currently spending on health. He state that "rather than throwing tens of billions in new money at the health industry in an effort to expand coverage." and emphasizes on the critical need to reallocate the $200 billion tax expenditure on the tax exclusion. The Baucus proposal, released in white paper form last week "opens the door" to this possibility.
3. Allow states flexibility to redesign existing health programs and use money more efficiently to reach the goal of maximizing affordable coverage. This was covered in one of his previous posts entitled "States are Good Guinea Pigs."
4. Remember that Americans are very conservative about their health care. Given the President-elects own appeal to this conservative instinct when discussing Senator McCain's phase-out of the employer deduction, it would seem that this awareness is embedded. At the same time, we have a President-elect who often stated that he spent the last year of his mother's life contesting plan exclusions and other bureacratic issues. Perhaps our new President will be the first to have first-hand experience with the difficulties under our current system.

Both of these remarkable thinkers make sound points. Is there a chance to pursue both? Can Medicare be extended and stretch while at the same time allowing some experimentation and differentiation in the states? Is such differentiation even possible given the (as of this date) projected net decreases in State expenditures this year of over $66 billion?