Few health care experts are more intimidating or effective than Gail Wilensky. An economist trained at the University of Michigan, Wilensky served as director of Medicare and Medicaid under George H.W. Bush. Later, she became chairperson of the Medicare Payment Advisory Commission, a highly respected, blue-ribbon commission that advises Medicare on what to pay for medical services. Since that time, she’s held multiple positions in the advocacy and nonprofit worlds. It’s no exaggeration to say she knows as much about health care policy as anybody.
Wilensky is also a Republican who holds genuinely conservative beliefs. She’s skeptical of welfare-state liberalism and has advocated for converting Medicare into what liberals, like me, would call a voucher program. And she argues that efforts to cover the uninsured play a disproportionate role in our health care debate—often going out of her way to note that 85 percent of the country has insurance, and, for them, cost is a much more important issue.
These are not unusual views on the right, to be sure. But, precisely because she has run the government’s largest public insurance programs, her warnings about Washington’s approach to health care resonate. When she says, for example, that Medicare does a lousy job of paying for physician services, you know that she’s speaking as somebody who has signed the checks and, afterward, audited the books.
I’d put a handful of other conservatives in the same category as Wilensky, starting with Mark McClellan. Like Wilensky, McClellan used to run Medicare and Medicaid. He’s an economist as well as a physician who used to be on the faculty at Stanford. Stuart Butler, from the Heritage Foundation, probably qualifies as well (though his specialty is the welfare state generally, not health care per se). Both men have solid conservative bona fides, McClellan having served as a top domestic policy adviser to President George W. Bush and Butler having been an early advocate for Social Security privatization.
And yet, as the health care debate continues, with the right seeking to block or at least stymie the implementation of ObamaCare, this trio of intellectually formidable conservatives hasn’t been all that vocal. Butler has been the most prominent of the three, but he has been far less visible than many of his counterparts of equal stature on the left. McClellan and Wilensky, meanwhile, have even lower public profiles. The two do speak with Republican lawmakers, and Wilensky was an unpaid, outside adviser to the McCain campaign. But it’s not as if they are ghostwriting the GOP’s legislative agenda, let alone defending it on Fox News.
Is it because they don’t have strong feelings? Because they don’t have much to add? Or because their sophisticated and, yes, ideologically nuanced approach to health care is of no use to the Republican Party and its supporters right now? I recently put the question to Wilensky, the one whom I know best. She’s too loyal to say anything negative about party leadership. But it was clear to me that her views on health care reform have diverged sharply from GOP dogma. And that’s not because Wilensky’s ideas have changed.
To be clear, Wilensky is not a fan of the Affordable Care Act. She starts with its most controversial and least popular feature: the requirement that everybody obtain health insurance. The small financial penalty, she says, probably won’t discourage healthy people from opting out of coverage altogether; as a result, insurance companies, newly prohibited from refusing coverage, will end up raising rates. “It’d be hard to construct a more screwed-up combination of a wimpy penalty and constraints on the insurance companies,” Wilensky says. “I understand what you were trying to do, but could you have done a worse job of it?”
Wilensky is also skeptical that the Affordable Care Act will control health care costs in the long run. The law includes a bevy of payment experiments within Medicare, like paying some providers flat sums based on diagnosis rather than fees for every service performed. But Medicare has a long history of pilot programs that, even when successful, rarely evolved into broader reforms. And Wilensky says the Affordable Care Act doesn’t provide a way to fix this problem. It’s “unlikely these ideas will make it from successful pilot to law of the land,” she argues.
Like most economists, Wilensky supports ending the tax preference for employer-sponsored insurance, a proposal that was the centerpiece of John McCain’s campaign plan. The Affordable Care Act has a version of this reform, called the “Cadillac tax,” which would effectively remove the tax break for more generous insurance policies. But the change won’t take place for several years, and, at first, it will apply only to the most expensive policies available. “What started as a Cadillac tax ended up as a Maserati tax,” Wilensky quips, adding that she thinks it is likely that future lawmakers will push the date it goes into effect even farther into the future-if they let it stand at all. Yet another source of frustration for her is the lack of serious malpractice reform.
But, if you listen carefully to these and other criticisms of the act, you’ll notice something: Many of the law’s supporters would agree with them. That’s particularly true on the center-left, where experts and the politicians who heed their advice have been making similar arguments all along. During the run-up to heath care reform’s passage, you had Jon Gruber, an economist at the Massachusetts Institute of Technology, arguing for a stronger individual mandate, and David Cutler, an economist at Harvard, pushing to make cost-control more ambitious. Within the administration, then-Budget Director Peter Orszag made the Cadillac tax a personal obsession, while one of his subordinates, Ezekiel Emanuel, pushed for changes in malpractice law.
More important, perhaps, is what Wilensky doesn’t criticize. In our interview, for example, she readily conceded that her problem with the mandate was its execution, not the idea. “I’m not against requiring insurance, in principle,” she says. “We’ve already made the commitment to not having people die in the streets.” She also recognizes that the uninsured, although less central to her thinking than to that of her liberal counterparts, will require real resources to address. “If we’re going to fix the problems of the uninsured,” she says, “we have to put money on the table initially.”
Despite my prodding, Wilensky wouldn’t denounce Republican efforts to repeal the Affordable Care Act. But she also wouldn’t call for the undoing of the expansion of insurance to approximately 95 percent of Americans. “There are a lot of bad things about the law, but it provides a lot of extensions of coverage,” she says. “I’d go about changing the stuff I don’t like.” I suggested that, if she were locked in a room with, say, McClellan, Gruber, and Cutler, they could hammer out a compromise—and that it would probably include an insurance marketplace, with regulations and subsidies, much like the ones included in the Affordable Care Act. She agreed. “We have major areas of overlap,” she told me. “We have differences over how to get there, but they are the kinds of differences reasonable people can resolve.”
Twice since this debate began, Wilensky has taken public positions at odds with Republicans. The first came late in the summer of 2009, when the controversy over “death panels” was peaking, and more extreme conservatives like commentator Betsy McCaughey were twisting the writings of Emanuel to suggest he supported government-sanctioned euthanasia. Wilensky denounced the charges, noting that the supposed death panels were merely a sensible, much-needed provision to pay for end-of-life counseling. “This ‘panel of death’ characterization is just untrue,” she said at the time. “I was shocked about the comments about [Emanuel].”
More recently, Wilensky has defended the embattled nomination of physician Don Berwick for her old position at the helm of Medicare and Medicaid. Berwick’s favorable comments about the British health care system, which limits access to advanced treatments more substantially than most developed countries, have subjected him to the same kinds of criticisms that hounded Emanuel. Wilensky has called the charges “ridiculous.”
McClellan has joined Wilensky in defending Berwick. He has also spoken favorably about the Affordable Care Act, telling The Washington Post’s Ezra Klein that “it’s an important step” and praising its coverage expansions, while still calling for amendments that would control costs more aggressively. Butler’s case is a bit more complicated: In 1992, he put forward a widely circulated Republican alternative to the Clinton health care plan. Butler’s scheme turned out to bear more than a passing resemblance to the Affordable Care Act’s coverage expansions. Like Wilensky, he spoke up on behalf of Emanuel. Recently, Butler has been a more forceful critic of the Affordable Care Act, calling for its outright repeal. Still, he eschews incendiary rhetoric to make a more sober case against the law. He thinks it tries to do too much, too quickly and would prefer to let states design their own reforms, even if those schemes end up having a lot in common with the Affordable Care Act.
The conservative orbit, it seems, no longer has much use for the complicated takes on health care reform that were promoted by this trio for so long. Today, Wilensky seems too busy with her other endeavors, like working on global health, to care whether Roger Ailes has her on speed dial. “It’s not like I don’t know how I could look more attractive to the loudest voices in the Republican Party right now, in terms of making more extreme statements,” she says. “I just don’t think that’s ultimately how to be most helpful in trying to solve issues.”
She doesn’t sound particularly disappointed, partly because she doubts anything significant will happen before the next presidential election. “There’s a lot of noise now,” she says. “The real question will be what happens after 2012, what kind of attitude people adopt.” If attention turns from “replacing” the Affordable Care Act to, as she says, “repairing” it, then I expect she, McClellan, and Butler will become more influential again. That would make the left’s debates with the right more intellectually challenging-and more productive, as well.
Jonathan Cohn is a senior editor at The New Republic. This article originally ran in the April 7, 2011, issue of the magazine.