Health reform is now the “law of the land,” and “written in law.” However, as people are quickly realizing, after a year of campaigning and more than a year of legislative action, implementing the new law will require navigating a long, difficult, and twisting path – even before any amendments are considered in this or subsequent Congresses.
Navigating the fast and slippery route to successfully implementing all the provisions of the PPACA will be daunting. Three relatively recent laws are examples of the time and steps required for such implementation – and each of these was much simpler than the PPACA:
- The Medicare Part D law was signed in December 2003 and the new benefit started in January 2006. This gave the Federal government about 2 years to develop the rules, sign up providing plans and facilitate enrollment by creating an exchange-like website and other resources, while the plans conducted the actual enrollment.
- The Massachusetts health reform/insurance expansion law was enacted in April 2006. This was followed by a long series of staggered implementation steps. For example, insurance reforms, (on top of the state’s pre-existing significant insurance regulations), became effective in January 2007, and the new individual mandate started in July 2007.
- The Federal stimulus law was signed in February 2009, and the HITECH Act part of the law included significant provisions and funding to boost the development and adoption of information technology by healthcare providers. At the end of December 2009 a key draft rule on “meaningful use” was released, and it is expected to be finalized soon. In the meantime, the Department of Health and Human Services has distributed funding to start the adoption of specific types of health IT. (The April 2010 Issue of Health Affairs has a series of articles focusing on the implementation of the HITECH provisions of the stimulus bill.)
Written in Law – Not Written in Stone
The implementation of these laws illustrates how it takes months and years after a law is signed to create the implementing rules and regulations, and to contract with organizations to actually carry out significant parts of the new law – and this is before any modifications are made by subsequent laws.
In the coming weeks and months, many entities will continue combing through the final law – which because of the circuitous path it took to Congressional passage is much more difficult to read and understand than most other new laws. Some of the most challenging aspects of implementation will be in the states, where government agencies will have many new responsibilities and/or will need to be created. Federal and state governments, and many private organizations, will also probably need to hire people to carry out this implementation – and hiring government employees can be a lengthy process.
In addition healthcare companies – particularly health plans and insurers – will be working to determine how their business operations will be affected by new state and Federal regulations, despite the fact that those regulations haven’t been written yet. And all but the smallest businesses will be seeking to understand how they will comply with – and possibly benefit from – the new insurance rules and financial incentives.
Overall, it is clear that the implementation will be the hardest part in taking health reform from a concept and a campaign position, to reality for individuals and society. I know that many people in Washington DC – particularly Congressional, HHS and related health reform staff – worked very hard for many, many months in an exhausting process to get the law passed. For Congressional staff at least, the implementation will be the responsibility of others, while Congress’ work will be to ensure that this implementation is consistent with their intent, and to work with HHS to adjust provisions according to the real-world bumps and detours in the road from here to there.
The cartoon below summarizes the expanding and complicated challenge of implementing health reform through the inevitably twisting and complicated path better than any combination of words could… I’ll have more about specific provisions and implementation in the coming days, weeks, and months….