I'm trying to think of a politically feasible first step for moving our health care system in a more consumer-oriented direction.  Why not start with the government?  Health care costs for municipal employees are putting a major structural strain on budgets.  One possible way out of this is to get the government employees to contribute more in premiums or somethng, but that is only a band aid and only good unitl that particular public employee union's contract expires.  Why not try something more radical?  One alternative would be for the state government to enroll state and municipal employees in an HSA/catastrophic coverage plan like the one that Mitch Daniels implemented in Indiana - though it might have to be phased in as public employee contracts expire. If Daniels is right and HSA's reduced Indiana's health care costs for state employees by 11% at 70% enrollment, it would represent a huge savings to the taxpayer with no negative health outcomes for the employees.  This kind of plan seems to be popular with Indiana state employees, but I can see resistance from current employees who are attached to their own plans.  Thats okay.  Resisting unsustainable health expenses for government employeees and replacing the current system with one that will provide quality health care (and maybe put a few extra dollars in the pockets of those employees) while saving the taxpayers millions of dollars shouldn't be an unwinnable fight.

Ony one problem.  It might be be against federal law.  I think the Indiana HSA plan for federal employees is grandfathered in, but it seems like new rules on HSAs in Obamacare would involve complicated rules that would make HSAs much less attractive in any future plan.  For one thing, you wouldn't get to keep money left over at the end of the year, You would just roll it over for retirement costs or future payments to Cobra if you should lose your job.  You have to give Obama credit.  He can even turn HSAs into a form of comprehensive prepayment for health care expenses.

But thats okay.  It gives the Republicans in Congress something to do.  They can a push for waivers for the states to experiment with HSAs for government employees.  They can sell this as a bailout for struggling states and cities in which the taxpayers will actually save money. They can explain the refusal to grant waivers as Washington arrogance that is forcing towns and cities to raise taxes and cut back on government services.  That is also probably a winnable fight on the level of public relations.  And Obama won't be President forever. The first step is winning the argument.  I can see one seemingly insurmountable obstacle.  Even if, in 2012 or 2016, there is a Republican President and a Republican majority in Congress, it is very unlikely that Republicans will have the required 60 vote supermajority in the Senate.  The Democrats would have the ability to use the filibuster to resist changes that would push the American health care system in a more consumer-driven direction rather than further along the state-run path (and Obamacare is only the first step.).  I have one word for you: Reconciliation.