Predicting the future is easy. Accurately predicting the future is hard. While some people make a living by predicting the future, most will not admit to this truism. But the difficulty of accurately predicting the future of legislation and politically driven processes is what makes it important for policy makers to be prepared with contingency plans.
“Be Prepared” is the Boy Scout motto. As a boy scout many years ago, I learned that this was more than just a saying, it was really used to guide planning and decision making for all sorts of activities: camping, cooking, first aid, sporting events, community service projects, etc., because by preparing for all contingencies, when something unplanned happened it wasn’t a “crisis,” it was just a detour that wasn’t part of the “original plan.”
Being prepared is important for the success of health reform as the debate intensifies this month, because there are many, many things that could influence the outcomes. Some of these factors are intrinsic to healthcare and the legislation – such as how to pay for health reform – while others are extrinsic to healthcare and the specific legislation. (I’ve made a list of the extrinsic derailing possibilities, but it is too long to include here.)
What contingency planning means for health reform is that not only does there need to be a multi-year implementation plan for the specific provisions of any new health reform law, but there also needs to be preparation for the unexpected – but inevitable – hurdles that will get thrown into the path of the development and passage of any legislation.
59 Days Until Reconciliation
While the legislative process is complex enough – and has been characterized as herding blind and deaf seagulls – such contingency planning is crucial because as of Monday, June 8th, there are 59 scheduled legislative days, (including Mondays and Fridays), before October 15th, which is the deadline Congress has set to pass health reform without the Senate resorting to using the Reconciliation process.
Passing health reform legislation via Reconciliation has some significant implications for the content of health reform – which is why it should concern stakeholders of all types. While the Reconciliation rules are somewhat complex, the gist is that provisions which don’t influence Federal spending can be excluded from Reconciliation bills. Therefore, if the bill developed this summer includes provisions to reshape the healthcare delivery system or improve quality, but which don’t change Federal spending within a ten-year period, then they can be dropped from the legislation. (This budgetary analysis is conducted by the Congressional Budget Office, which is another reason why their “scoring” of legislation is so crucial.)
Focusing on Immediate Symptoms v. Actual Problems
This could mean that substantive provisions for transforming healthcare delivery to improve long-term quality and cost control may be dropped from health reform legislation, resulting in a bill focusing on more immediate cost cutting and not addressing some of the fundamental forces driving increasing costs.
I have characterized the difference between issues such as increasing costs, and the forces driving the increasing costs as being similar to the difference between medical problems and the symptoms they produce. In this case, the symptom is increasing costs, while the actual problems are misaligned incentives and the resulting warped structures of the healthcare delivery system.
Legislative “fixes” have for many years focused on the symptoms – particularly short term cost reduction measures that some have characterized as rearranging the deck chairs on the Titanic. This year presents the opportunity for some real reforms to the underlying problems that have become embedded in the healthcare delivery and financing systems. Whether that can be accomplished in the next 59 days remains to be seen.