David Frum for HHS Secretary

For ten years now, David Frum has wowed me with the clarity of his critiques of Republican extremism, notwithstanding the craziness of some of his own policy prescription (most in foreign policy; he is, after all, Mr. Axis of Evil).  He's been a hero dissecting and crying out against emerging U.S. authoritarianism for the past year. And in fact, he was doing that too back in 2009/10. Here's from his famous post-mortem on the passage of the ACA in March 2010:

I’ve been on a soapbox for months now about the harm that our overheated talk is doing to us. Yes it mobilizes supporters – but by mobilizing them with hysterical accusations and pseudo-information, overheated talk has made it impossible for representatives to represent and elected leaders to lead. The real leaders are on TV and radio, and they have very different imperatives from people in government. Talk radio thrives on confrontation and recrimination. When Rush Limbaugh said that he wanted President Obama to fail, he was intelligently explaining his own interests. What he omitted to say – but what is equally true – is that he also wants Republicans to fail. If Republicans succeed – if they govern successfully in office and negotiate attractive compromises out of office – Rush’s listeners get less angry. And if they are less angry, they listen to the radio less, and hear fewer ads for Sleepnumber beds.

So today’s defeat for free-market economics and Republican values is a huge win for the conservative entertainment industry. Their listeners and viewers will now be even more enraged, even more frustrated, even more disappointed in everybody except the responsibility-free talkers on television and radio. For them, it’s mission accomplished. For the cause they purport to represent, it’s Waterloo all right: ours.

Back then, Medicaid expansion was a bad thing from Frum's conservative point of view -- something Republicans could have avoided had they negotiated the ACA in good faith:

 Could we have leveraged [Obama's] desire [for Republican votes] to align the plan more closely with conservative views? To finance it without redistributive taxes on productive enterprise – without weighing so heavily on small business – without expanding Medicaid? 

Now, though,  he's out with some startling clarity on our healthcare conundrum. First, he effectively writes off the notion that the best way to control healthcare costs is to shift more of them to consumers as the shibboleth it is, and then...emphasis mine:

Loathe to tangle with providers, Republicans have fixed their hopes for cost reduction on customers. “Patient-centered medicine” sought to transform the user of health-care services as the system’s decisive cost-controller.Confronted with the full cost of medicine, the patient would consume care more prudently—or forgo it altogether.

That hope is listing badly. When and if it finally sinks, Republicans may notice something else. The other advanced countries with universal coverage manage to buy significantly better outcomes at the expense of 11 or 12 percent of GDP instead of America’s 16 percent. That extra increment of GDP could pay for a lot of military spending and a lot of tax cuts. Once politics has eliminated coverage reduction as a means of forcing economy, other possibilities open before a center-right party—and indeed have opened for center-right parties across the rest of the English-speaking world. Perversely, the effort to keep government out of health care has empowered health care to consume more and more government dollars. Where government has been deployed more effectively than in the United States, health care has consumed less.

That's it. Where there's no rate-setting -- single payer, all payer, hybrid -- there's no cost control. It's the sine qua non. There's one wealthy country where it's every payer for itself -- ours.

One way to incrementally extend government discipline over healthcare pricing is not to cap Medicaid spending, but to expand it. Medicaid is the most cost-effective healthcare delivery system in the country, though the rates it pays providers would be unsustainable if made uniform for all payers. If Medicaid-like programs -- perhaps paying providers Medicaid + 20%, like New York's Essential Plan -- were extended to all who lacked access to employer-sponsored insurance, perhaps another 20 million people would could gain access to healthcare paid at affordable rates.

Remake the ACA marketplace as something like a managed Medicaid market (or, somewhat more expensively, like Medicare Advantage). That would actually be in keeping with Trump's rhetoric, though not with his actions or his alliances.

I'll expect a move in this direction when Frum is named HHS Secretary.