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With the election of Barack Obama in 2008, reform of the health system became headline news.

After sixteen months of intense public debate, Congress passed the Affordable Care Act. Jeff Goldsmith was an active participant in this debate, and an active commentator on ACA’s implementation over the next five years. This controversial legislation dominated the first eight months of the Trump Administration in 2017.

See Jeff’s writing on health reform, ACA and “Repeal and Replace” below.

Health Reform

Sep 5, 2019: Relatively Modest Health Reform May Create More Value than “Medicare-for-All” With the chorus of progressive voices advocating single payer and Medicare for All during the runup to the 2020 Presidential election, Jeff Goldsmith offers three strategies that would create more tangible payoff in improved health with a fraction of the cost and disruption. Read his thoughts in Health Affairs blog. Sep 5, 2019

Aug 1, 2017: The Great Trump Healthcare Trainwreck This posting provides a scorecard to evaluate President Trump’s performance in managing the multiple unsuccessful attempts to repeal the Affordable Care Act, and provide some clues to this political defeat. Aug 1, 2017

May 30, 2017: California’s Coverage Expansion: Fiscal and Political Risks This posting explores how California got the number of uninsured in its state down to 7% by dramatically expanding its MediCal progam and standing up Covered California, one of the most successful health exchanges in the nation. Can this expansion be sustained as Congress considers unwinding the Affordable Care Act? May 30, 2017

Mar 8, 2017:The Rust Belt is Burning This posting explores how legislation prompted by President Trump to repeal and replace ObamaCare would harm his own constituents in the troubled Appalachian and Midwestern states that provided his margin of victory. Mar 8, 2017

Jan 10, 2017: Oregon's High Risk, High Reward Coverage Expansion This posting explores how Jeff’s home state of Oregon dramatically expanded health coverage under the Affordable Care Act, and its effects on Oregon’s health insurance market and care system. Jan 10, 2017

June, 2015: The Pioneer ACO was certified this spring as the first new Alternative Payment Model to be expanded under the Affordable Care Act. A close look at the program’s performance, however, reveals the use of “Lake Wobegon” accounting. The program lost nearly half its participants, and those with the most managed care experience fared the worst. Read: Pioneer ACO: Anatomy of a Victory June 18, 2015

January, 2014: As Congress wrestles with how to end the Sustainable Growth Rate Fiasco, a bipartisan proposal has emerged which will probably make things worse than they are now. Read about Congress’ Inadequate SGR Solution. January 24, 2014

August, 2013: The most controversial and heavily hyped healthcare payment reform idea in the Affordable Care Act has been the Accountable Care Organization. Thirty two high performing health systems participated in the Pioneer ACO demonstration, which reported its first year results in the summer of 2013. The blizzard of hype and press releases concealed a lot of problems. Read about the Pioneer ACO’s Disappointing First Year. August 15, 2013

July, 2012: The Supreme Court unexpectedly affirms the constitutionality of the Affordable Care Act. In doing so, however, it invalidates a key piece of the law, rendering the expansion of Medicaid “optional” for states. Why the Supreme Court may have dealt a serious blow to health reform. July 7, 2012

July, 2011: Intense White House criticism of a McKinsey study predicting a large number of employers dropping coverage when the ACA is implemented begs a question. Suppose health reform actually foretells the end of employer based coverage? It might not be a bad thing. This posting is about Letting Go of Employer Based Coverage. July 11, 2011

June, 2011: Controversy rages over health reform. A Republican landslide in November, 2010 strips the Democrats of control of the House of Representatives, and brings into office a new wave of conservative Republicans committed to repealing the Affordable Care Act. Many of the newly elected Republican majority do not believe there is a problem of access to healthcare. This posting discusses the unbridgeable gap between Republicans and Democrats on health reform. June 8, 2011

Here is Jeff Goldsmith's review of Paul Starr’s excellent history of health reform in the United States, Remedy and Reaction: The Peculiar American Struggle over Health Reform (Yale Univ Press, 2011) which includes an extensive analysis of the Obama health reforms.

November, 2010: Republicans have set themselves the political goal of “repealing and replacing” ObamaCare. They are unlikely to succeed and face significant political dangers, as they confront the Swamp Creature called the Affordable Care Act of 2010. November 5, 2010

March, 2010: In his book on Presidential politics and health reform, Heart of Power, health policy analyst Dr. David Blumenthal offered eight rules for Presidential conduct of health policy. How did President Obama do? March 29, 2010


March, 2010: President Obama is running out of time and public patience in the health reform debate. Obama must move quickly or health reform will slip from his grasp. The political price paid for health reform will be steep. March 7, 2010

January, 2010: After Scott Brown’s shocking election to Ted Kennedy’s Massachusetts vacant Senate seat, the Democrats lose their filibuster proof Senate majority. Can health reform be saved? This posting advocated starting over with a stripped down, affordable new bill. January 24, 2010

December, 2009: The core of health reform is transforming a nearly $1 trillion private health insurance market. Health reform legislation will eliminate most of the health insurance industry’s risk management practices (medical underwriting, etc.) and restrict its gross margins and earnings. The Congressional Budget Office issues an astonishingly rosy forecast of how health reform will affect private health insurance markets. What is wrong with their forecast? What are the fiscal and policy risks of health insurance reform? December 14, 2009

December, 2009: Critical to health reform’s enactment is President Obama’s pledge that the bill will not increase federal deficits, already running at $1 trillion a year. Why no-one believes health reform will be deficit neutral, despite Congressional Budget Office assurances. December 1, 2009

September, 2009: Will divisions inside the Democratic Party doom health reform? Can the “safe seat” and “running scared” Democrats find a health reform plan both can support? This posting predicted that health reform could blow up in the President’s face and cost the Democrats control of Congress. September 3, 2009

August, 2009: A major component of health reform is how to change healthcare payment to make it less inflationary. Unfortunately, the most discussed idea in the debate, the so-called Accountable Care Organization, or ACO, isn’t ready for prime time. August 17, 2009

July, 2009: The White House decision to let the House of Representatives take the lead in drafting health reform legislation may have dealt a fatal blow to the process. The House Democratic leadership releases an inflammatory and highly partisan draft of health reform legislation, alienating Republicans and trapping moderate Democrats. This draft ignites the Tea Party summer. A Wild Pitch Brushes Back Health Reform. July 20, 2009

July, 2009: Squaring his campaign promises for health reform with political realities will be a difficult enough challenge for President Obama. But the real problem will be a shortage of bandwidth in Congress. Why health reform is "no country for old men". July 6, 2009

May, 2009: The so-called “public option”, a Medicare like publicly sponsored health insurance plan to be offered as part of health reform, is not worth the fiscal and economic risks. Why the public option will not be a part of health reform. May, 15, 2009

Here is Jeff Goldsmith's review of Blumenthal (and James Morone’s) book, Heart of Power: Health and Politics in the Oval Office (Univ of California Press, 2009).

November, 2008: Obama hits the ground running. Based on his reported transition planning, this posting inaccurately predicted an effort to enact health reform by mid spring, 2009, based on Tom Daschle’s policy blueprint. November 25, 2008

November, 2008: President Obama is elected. His three choices for proceeding on health reform: complete the New Deal by enacting an expensive new entitlement to complement Medicare and Medicaid financed by new taxes, take on the healthcare industry and carve the funding out of their existing payments, or wait and let the economy recover. What Will Obama Do? November 5, 2008

February, 2008: Do we want to reform health care by providing universal health insurance coverage, or by funding access to safety net health systems for those without insurance, e.g. direct access? The safety net is the reason the US could have 50 million uninsured without a revolution. It's the health reform debate we never had. February 2, 2008