End of the Beginning for Health Reform

This week’s Economist has an article titled “The beginning of the end” about the coming Senate debate.  But I think they have it exactly wrong.  The passage of legislation through the Senate – and then ultimately through a Conference Committee and by both houses so it can be signed by the President – would be the end of the beginning for health reform.

In contrast to the many, many hours of work by Members of Congress, many more by their staff, and probably even more by interest groups and activists across the country, the implementation of a new set of laws will be the real beginning.  Implementing a new law reforming the insurance industry – and myriad other parts of the healthcare delivery and financing systems – will require drafting of many rules and regulation, reviewing and commenting on the drafts, digesting those comments, issuing final rules and regulations,  drafting RFPs for contracts to run various new entities, (such as insurance exchanges), awarding those contracts, and possibly hiring employees for new functions such as a Medicare Advisory Board. Whew.

It now seems that the likelihood of a new health reform law being enacted during this Congress (probably sometime in February or March) has tipped into the greater than 50% category – but just barely. (National Journal has 2 great articles about the current precarious situation – one about the process and politics in the Senate, and the other about eight key stakeholder groups and their issues and concerns.) However,  even if the political and substantive issues can be tweaked into good-enough alignment that would enable enactment today, many different events and scenarios that are too complex and numerous to list here could still derail the process.

If the legislation fails to pass at this 715th minute, then there will still be followed by a vast outpouring of activity.  But instead of being focused on a specific law, it will be about how to address access and cost at the state level, in the private sector, and via more pilots, demonstrations and other variations within the existing authority of Medicare and other government programs. However, without a new law these activities will be much less focus and contained – and much of the effort will be discussion and analysis about what should be done and where limited resources should go, rather than focused on implementing new initiatives.

These two options remind me of a question someone asked me at Thanksgiving dinner, “Don’t they [Congress] have to do something since we can’t continue the way things are?” The presumption that if no legislation passes, then nothing will change is a false assumption.  With no major health reform laws for the last 20-30 years, the healthcare system has changed dramatically – both through private sector and government actions.  Clearly those actions have been imperfect and temporizing rather than addressing fundamental problems, but they have resulted in change.

Which scenario will be “better” depends upon who you are and how the current situation is benefiting or hurting you and your family.  Certainly, for the majority of Americans, having a new law would be better because it would improve their security for having insurance that they can depend on and know is stable – a theme that has persisted since the early 1990s and was reemphasized this summer by David Kendall and his colleagues at Third Way.

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