I’ve been complaining for some time that Republicans have been big on the “repeal” part of “repeal and replace” but light on the “replace” side. So I’m reluctant to be too harsh in my criticism of the Choice in Healthcare Act introduced by Rep. Devin Nunes (R-CA) and described in the Wall Street Journal and the Nunes website. Therefore I’ll start with the two things that are good about it: it starts soon and it addresses Medicare and Medicaid.

The substance of the plan is naive and simplistic. Here’s how Nunes describes it:

[T]he Choice in Healthcare Act… will create a voluntary, 10-year pilot program for a new health-care delivery system, beginning in June 2013.

Geared toward low-income individuals and seniors, this simple plan will replace participants’ Medicare and Medicaid benefits with roughly equivalent funds put on a debit-style “Medi-choice” card. Participants can then use their card to buy the health insurance of their choice on the open market and to pay for out-of-pocket expenses such as co-payments and deductibles. In succeeding years the card’s funding level will be adjusted for inflation, and any unused funds will roll over to the next year.

This plan will streamline health-care delivery by replacing hospital insurance, Medigap, prescription-drug programs, Medicare and Medicaid with a simple debit card. Instead of dealing with the notorious restrictions, exclusions and red tape of government-provided health care, participants will be empowered to control their own health care and force insurers and providers to compete for their business. Medicare and Medicaid beneficiaries will be freed from these failing, regimented programs, and they will gain the same access and choice in health care enjoyed by other Americans.

He goes on from there to describe how great it is and how simple, and how the ripple effects will be profound.

Here are a few questions right off the bat:

  • The plan is voluntary. Won’t that lead to adverse selection?
  • It’s a 10-year pilot. Why 10 years? Does that mean it will be 2023 or later before we have something we can scale up?
  • Why does a Medicaid recipient need a debit card to buy health insurance? Does Nunes realize that historically co-payments and deductibles for Medicaid have been trivial or non-existent? Is part of his “choice” a way to add these expenses and complexities into the mix? Does it really simplify matters to go from no co-pay to a co-pay paid by the feds and state and put it all on a debit card?
  • What if the “open market” doesn’t want to insure one of Nunes’ constituents due to a pre-existing condition?
  • If choice is so important and a mandate to buy insurance so bad, why not just let the recipient cash the card in for real money?
  • How will these poor people “force insurers and providers to compete for their business?” Will these consumers really have more negotiating power with managed care than the federal government or the State of California? Somehow I doubt WellPoint and Kaiser are quaking in their boots at the thought of facing off against individual debit card holders!
  • Won’t the removal of “restrictions, exclusions and red tape” and introduction of the “same access and choice in health care enjoyed by other Americans” drive costs up rather than down?
And my final question:
  • Why did Nunes propose such a ridiculous plan in the first place?