"The aim of public policy should not be to stop people spending their own money on their health care," said Stuart Butler, a top health policy expert with the conservative Heritage Foundation. (While the new Massachusetts plan limits what public programs spend, it does not require private payers to do the same.)
Tanden, the former White House aide, says she thinks budgets and negotiated payments will be less threatening and more politically acceptable than giving people a voucher-like payment and sending them into the marketplace. Medicare would share in the benefit if costs can be checked for the country as a whole.
"We think of this as the answer to 'premium support'," said Tanden, referring to the term Republicans prefer for the Romney-Ryan Medicare plan. "What this is really enabling is a private sector negotiation. Under premium support what will happen is consumers will pay more."
In Massachusetts, the new cost control law has its share of skeptics, but it doesn't seem to have provoked a backlash.
"These global budgets are going to be negotiated between health insurers and providers," said Jay Gonzalez, the state's secretary of administration and finance. "They are agreeing to pay for services in a different way. It isn't rationing. It isn't capping."
Massachusetts enacted its original health care overhaul under then-Gov. Romney in 2006, expanding coverage to an estimated 98 percent of state residents. Obama's law covering the uninsured could still be repealed if Romney wins the White House. The main cost controls in the president's plan — a board to restrain Medicare spending and a tax on high-cost private health insurance — wouldn't start to bite for another few years.
The White House has had little to say about the new ideas from Obama's former advisers. That could change if Obama is re-elected and plunges into budget negotiations with Congress.