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Implementing Health Reform - The Long, Hard and Twisting Maze

By Michael D. Miller MD
April 13th, 2010

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.

Conclusion
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….

MAZE-Man

Posted in Federal Healthcare Reform, Health System Reform, HealthPolCom Blog, Politics, State-Level Healthcare Reform | 3 Comments »

Politics of Health Reform: Selling Anger or Catharsis

By Michael D. Miller MD
March 22nd, 2010

With the health reform legislation process winding up, it is clear that going forward politics are - and will be - front and center, with the divide between the Democrats and Republicans as wide as the orbit of Pluto…… the planetoid, not the Disney character. This divide is depicted in black, white, and red in the National Journal’s March 13th Insiders Poll question, “If Congress enacts something close to President Obama’s latest health care reform plan, how would that affect your party in the midterm elections?”  87% of Democrats thought it would “help a lot” or “help a little,” and 100% of Republicans thought it would help them.

They can’t both be right.

Each party is banking on their ability to sell health reform their way:  Democrats will present it as a significant step towards fixing many of our healthcare system’s and country’s problems.  Conversely, the Republicans will characterize it as fundamentally evil and something that will end individual freedom and civilized progress because of “government takeover of healthcare” being run by a “healthcare czar.”

These sentiments and strategies are clear in the quotes accompanying the National Journal’s poll:

Republicans:
“The tax increases, the wild spending, and the backroom deals and threats will shock voters of all parties, producing a GOP revolt.”

“Passing the bill will help the GOP by fueling voter (especially senior) anger at an arrogant majority that knowingly ignored popular opinion.”

Democrats:
“It will help a lot of people, show that Democrats can act, and get the ’sausage making’ off the news.”

“If it passes, people [will] see it’s not the end of the world and learn more about its benefits. The more they know about it, the more supportive they are.  Best of all, we can begin talking about something else.”

However, one Democrat in the 9% who thought enacting the law would “hurt a lot” said, “The Right hates it, the Left is not satisfied, and the middle is scared.”

Majority v. Minority - Catharsis v. Anger
 Without dissecting the merits of their positions, these divergent perspectives are due to the parties’ different roles in our two-party democracy:  The majority needs to present their actions in a way that fosters catharsis in people, (particularly in voters), by actually improving some problem. Their goal is to turn that catharsis into positive feelings about the majority party, leading to votes in future elections. Conversely, the minority party needs to create anger about what the majority party is doing or proposing, with the goal of turning that anger into….. (no surprise here)…… votes in future elections.

Thus the key for the party leadership, individual elected officials, and their communications and campaign staffs, is how to best create catharsis or anger - depending upon which side of the fence they are on.

An old friend, Dan Wasserman, the political cartoonist for the Boston Globe, in his March 2nd cartoon depicted this very nicely:

Dan Wasserman Political Cartoon - 03-02-2010 Romeny Anger
[This cartoon was also reprinted in the March, 6th issue of National Journal]

Challenges of Political and Policy Communications
How people, (i.e. voters), perceive the issues and problems - and potential solutions - is strongly influenced by how they are presented and described.  It is this communications process that builds or derails political and policy initiatives and campaigns.  No matter the long-term success or failure of the health reform law, the road from now until the November elections will be filled with messaging to instill voters with either catharsis or anger - particularly swing voters in key states and CDs. For the Democrats, creating cathartic feelings will be much, much easier as specific provisions of the law become effective.

For Republicans, creating anger will be possible from the outset. In the near term having a new law will give them a focal point for anger, with proposed regulations and rules being easy and rich targets.  In the longer term, as the new law actually improves many people’s lives, it will be harder to accomplish that goal.  However, by that time, if they can use the near term anger they’ve created to take control of one or both houses of Congress, or the White House, as the majority party they will be the ones trying to create catharsis - so some successes via implementation will be to their benefit.  In addition, if that happens, for political reasons Republicans will not want to repeal or significantly unravel the new law since continued implementation of health reform - without dramatic alterations - will deny Democrats one of their main campaign issues that they have historically used to generate anger among their base and swing voters.

—————————————————————–

Post Script: Turning Anger Into Productive or Destructive Action
[Omitted for space considerations.]

Posted in Federal Healthcare Reform, Health System Reform, Information & Communications, Politics | 1 Comment »

How Long is the New Health Law?

By Michael D. Miller MD
March 21st, 2010

With the House of Representatives passing the Senate’s version of the health reform legislation tonight, it can now be signed by the President.  An historic step by any measure. While one of the criticisms leveled against the bill has been its length - typically cited as 2,409 pages - I recently pointed out to someone that the 2,409 page length is because the bill is printed to make it easy to read by using a large font, leaving lots of space between the lines, and sequentially indenting subsections to make the overall structure clearer.  (Below is one page from the printed version of the bill.) However, by changing the font and reformatting it, I was easily able to make the entire bill fit on 60 pages.

So how long is the bill? It all depends.  But certainly the 2,409 page length “fact” - and similar figures - will be tossed around as pseudo-quantitative arguments that the new law is too complex, which will be another example of fun with facts in support of political positions.

Page 448 of Health Reform Bill

Posted in Federal Healthcare Reform, Health System Reform, Information & Communications, Politics | 1 Comment »

Regulating Insurance: States v. Federal Roles

By Michael D. Miller MD
March 18th, 2010

One of the fascinating issues within the health reform debate is how to improve the insurance market by changing government regulations.  While large employers who self-insure are except from state regulations, (and must only conform to limited Federal rules under ERISA), individuals, small groups, and others who actually purchase insurance have their policies regulated by individual states.

Both Democrats and Republicans agree that the current system of insurance regulation creates job lock and other socially undesirable effects, and that insurance companies should be able to sell policies across states lines.  However, their solutions are quite different.

Democrats favor national regulation to create a single playing field, and Republicans prefer permitting insurance companies to sell in multiple or all states if they are licensed and regulated in any state.  The insurance industry’s trade association (AHIP), doesn’t seem to take a firm position on this issue - at least from looking at their website.

However, I was surprised to see a full page ad from an individual company on the back cover of a recent issue of National Journal advocating for national rules to replace state insurance regulation.  This interesting ad included the following phrases:

“Something’s wrong when…. innovation surpasses…. insurance regulation.”

“Here’s something to bristle at: the regulatory system that shapes our…. insurance policies hasn’t changed much in the last century.  Yet everything …. has changed dramatically…… Chrome and steel have given way to thermoplastic and fiberglass.”

And the company’s recommendations for solutions focus on increasing national regulations:

“Today there are 50 different sets of insurance regulations in 50 states.  This makes it difficult to introduce innovative new products.  But with a modern system of national regulation, consumers would get to choose from the best products available nationwide.”

“National regulation would help spread risk more fairly across similar geographic areas.”

“Modern regulation is the kind of protection Americans deserve.”

However, the caveat here is that this ad is talking about regulation of car insurance and not health insurance.  In fact, the specific company doesn’t even sell comprehensive health insurance - so they don’t have a dog, cat or Cadillac plan in that fight.

What is also interesting is the parallel developments and history in the State of Massachusetts with health and auto insurance. Everyone following the debate about health reform has certainly heard what Massachusetts has done with health insurance reform and mandates to achieve near universal coverage.  However, in roughly the same time-frame the state also reformed its auto insurance regulations to enable national insurers to enter the market.  This increased competition resulted in dramatic decreases in premiums - but the insurance plans are still regulated by the state.

How changing the regulation of selling health insurance would change costs and affect consumer protections is open to debate.  Unfortunately as an “issue” it has been overshadowed in the health reform discussions by other aspects such as the so-called public option, abortion coverage, coverage of immigrants, costs to individuals, effects on the Federal deficit, and mandates for having insurance. Thus Federal v. State insurance regulation - which is really a core part of health reform - hasn’t been a big part of the national political debate, even though changing insurance company practices has been a large part of the Democrats’ messaging.  Despite that, there are several interesting points to consider:

  1. Insurance companies operate on a business model very similar to financial institutions, such as banks, in that they seek to manage risk and they make most of their money on the “float” - or interest earned - based upon having large amounts of money for a period of time between collecting premiums and having to pay for covered benefits… and deductibles also adds a delay to these payments, which creates a cushion to the float.  Therefore, because their revenues are tied to their interest earnings, the lower the prevailing interest rates the lower their earnings - and thus the more they need to raise premiums… and vice versa.  (I did an analysis several years ago showing that premium increases were directly correlated with interest rate fluctuations, but delayed a year or two.)  This parallelism with banks raises the question about why it is OK to Federally regulate banks, but not health insurance companies? How much more important is it to protect people’s money than their health insurance coverage?
  2. National insurance regulation would help address both job lock for individuals within companies that purchased insurance directly, and location lock for small businesses and entrepreneurs - particularly those operating service businesses where location may not be as crucial as manufacturing or retail operations.
  3. Permitting the selling of insurance across state lines based upon licensing in one state would probably result in reduced consumer protections since some states have less oversight and requirements than others about marketing, coverage guarantees, etc.
  4. And neither national rules from the Federal government or allowing selling across state lines would significantly affect the growth in health case costs or insurance premiums, i.e. they wouldn’t really bend the cost curve.  Although allowing selling across states lines could reduce premiums in certain higher cost states, but that would be due to people being able to by insurance policies with less coverage or intrinsic protections.  In some ways this would follow the old saying, “you get what you pay for.”
  5. And since the consensus is that bending the cost curve will require changing how health care is actually delivered to patients, (which makes sense since ~80+% of health care spending goes to pay for health care goods and services), this discussion makes me wonder how differential state regulation of doctors and healthcare providers fit into this equation?  While laws and legal procedures may vary among states, presumably the practice of medicine shouldn’t vary dramatically…. Although many studies have shown that it does so in ways that can’t be explained by demographic differences or regional variations in disease states such as Lyme disease. I’m not certain how changing the way clinicians are licensed would improve healthcare delivery or costs, but it is another aspect of State v. Federal regulation that is becoming an increasingly contentious issue - as was pointed out in an article in today’s New York Times.

Posted in Access to Healthcare, ERISA, Economics & Financing, Federal Healthcare Reform, Private-Employer Based Health Insurance, State-Level Healthcare Reform | No Comments »

Health Reform’s Rock & Roll

By Michael D. Miller MD
January 21st, 2010

With the Democrats losing their 60th vote in the Senate in Tuesday’s special election, the political and health policy worlds are astir with angst about the fate of health reform legislation.  Everyone in those arenas has at least one perspective about what would be the best course of action… including MoveOn, which stated in an email today, “Tuesday’s election was a shock. But the aftermath was even worse:  President Obama and some Democrats in Congress are now considering scaling back health care reform. That would be a huge mistake.”

However, given that MoveOn was one of the leading organizations declaring that the public option was the most important part of health reform, I’m not too inclined to put much stock in their understanding of the fundamental policy or political forces in the US right now.

Despite MoveOn’s proclamations, it seems clear that health legislation in 2010 will be smaller than either the House or Senate bills.  Whether that occurs in a bipartisan way (unlikely), via reconciliation (more likely, but limiting the scope of the bill), or through some other mechanism, remains to be determined by the political officials looking toward the 2010 elections - with perhaps some input from policy people. In addition, it is likely that HHS (and possibly some states) will get much more active with demonstrations and pilot programs, and the Federal government may look to the investments in Health IT and Comparative Effectiveness Research made in last year’s stimulus law as more fundamental cornerstones to build from.

Regardless of what comes next, some rock and roll lyrics seem very prescient for what has happened with the health reform legislation:

Sometimes the lights all shinin on me;
Other times I can barely see.
Lately it occurs to me what a long, strange trip it’s been.

 

But still they lead me back
To the long winding road.

 

You can’t always get what you want
But if you try sometimes you might find
You get what you need.

These images may also be illuminating for the path ahead, and are consistent with some of my predictions:  A year ago I wrote about the long and convoluted path health reform legislation would likely travel. And in a post last June I stated that many factors could change the course of the legislative process.

“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.”

So, as always, keep your seat belt fastened and the tray tables in their upright and locked position.


Posted in Federal Healthcare Reform, Health System Reform | 1 Comment »

Healthcare as Part of the Social Safety Net - Policy Implications for Health Reform

By Michael D. Miller MD
January 6th, 2010

Researchers at the Urban Institute have recently released a book about the forces and values that shape the social safety net in the United States. (Repairing the U.S. Social Safety Net.)

Yesterday, they held a briefing to discuss their book and solicit comments from other experts. Demetra Smith Nightingale, one of the authors, described how different parts of the social safety net interact, and how societal values and assumptions shape the creation and evolution of individual safety net programs. One of their fundamental conclusions is that society’s trust in government is reflected in how safety net programs are structured.  When there is more trust in government the programs can be national in scope and administered by the Federal Government, such as with Medicare or Social Security.  But when there is less trust in government, then programs are created which may be funded or supported with government dollars, but the programs are administered by state or local governments or even by private entities.

It is clear that today’s society is in a trust the government less mode, and this is reflected in the movement of the health reform legislation towards state and private entity implementation. Why this is important is that the Urban Institute researchers also looked at how well various types of social safety net programs work, and they noted that those with more local implementation also have much greater variability of effectiveness and penetration.

Two other conclusions from the discussion may be important for the implementation of a new health reform law.  First, food stamps are really the most fundamental part of  the social safety net in the US since they are the most easily obtained and food is the most basic of human needs.  And second, the social safety “net” is probably more like a series of lines that may or may not productively insect.  This situation might be like two fishing boats:  One using a net can very efficiently and productively catch lots of fish, while another using a number of individual lines may be able to use a variety of baits, but will surely miss catching many fish.

Below are two of the charts from the book which were distributed at the briefing.  These are very informative because they summarize how the different parts of the social safety net interact and the policy framework which connects societal values, goals, program structure and implementation.

Urban Institute - Deciphering the Conflicting Values Shaping the U.S. Social Safety Net Figure 1

Urban Institute - Deciphering the Conflicting Values Shaping the U.S. Social Safety Net Figure 1.2

Posted in Federal Healthcare Reform, Health System Reform, State-Level Healthcare Reform | No Comments »

Playing Poker with Health Reform

By Michael D. Miller MD
December 16th, 2009

The National Journal’s December 5th issue has a very interesting article comparing President Obama’s approach to key issues to his poker playing style.  (The issue cover states, “Obama as Poker Player.”)

Having played poker for over 45 years, I find the article’s discussion of his cautious approach and preference for standard games very enlightening. For many people today, poker is about Texas Hold’em, a game that is great for TV but rather simplistic in some ways because each player only has 2 cards and shares 5 others.  The National Journal discusses the intellectual, strategic, and personality difference between this game, and more sophisticated games such as five-card draw and seven card stud - as well as more “wild” games such as baseball, although it doesn’t mention my crazed favorite, midnight baseball.

What the National Journal doesn’t discuss is the difference between playing poker on-line versus in-person, and the difference between playing with a bunch of strangers and playing with people you know and might interact with professionally.  These differences are very significant, since playing on-line is all about the odds, and “reading” people can only be done via their betting behaviors.  However, playing in-person enables a player to physically read the opponents, (i.e. see their “tells”), and playing good poker is primarily about playing the other people, and secondarily about playing the cards in your hand and on the table.  And reading the other people becomes even more important - as well as possible - when playing with people you know and have interacted with in other settings, such as negotiating legislation.

So for the President, applying lessons and strategies from poker to health reform, Iran, and other key issues may work well, but I also hope that he remembers that great players don’t win every tournament, and the key to long-term success is knowing when to fold, when and how to bet, and perhaps most importantly how to see around the table to what is likely coming up in future deals so one can be in the game and optimally positioned for future hands.

Healthcare Reform’s House of Cards
For the current health reform efforts, it seems that the cards are being reshuffled and new hands dealt at a time when the legislative house of cards should be getting its final touches and glued together.  Instead, the house of cards seems to keep collapsing - although Senator Reid, (and the President), are doing their best quick-handed action to keep rebuilding it for another try before minor or major political quakes send the cards scattering again. From a fundamental process level, the pulling in and pushing out of new ideas - such as a allowing some younger people to join or buy-into Medicare - is what might have been expected in April, May or June, but not December, and this is not a good sign for enactment of a law anytime soon.

The Substance of Health (Insurance) Reform Without a Public Optio
At this point, it seems that a public option is out of the equation, and some House Members are signaling that they could pass such a bill, but some on the left are arguing that no bill is better than a new law without a public option.  Despite these loud protests, not having a public option isn’t the end of the world, (sorry HD), and I’ll soon write why insurance reforms and coverage expansion are much more important, (sorry MoveOn.org), based upon my past experience with health reform legislation, my time in Massachusetts, and my very recent and ongoing ground-level experience in getting new health insurance in the District of Columbia as I prepare to move there from Cambridge, MA. (Preview - Community rating and guarantee issue by non-profit insurers v. medical underwriting by for-profit minded insurers.)

Posted in Federal Healthcare Reform, Health System Reform, HealthPolCom Blog, Politics, State-Level Healthcare Reform | 3 Comments »

Historical Perspectives on Health Policy: Part 3

By Michael D. Miller MD
December 4th, 2009

I just found my copy of the book “Improving Health Policy and Management” edited by Stephen Shortell and Uwe Reinhardt.  The book’s eleven chapters address many of the hot-button issues in today’s health reform debate:

  1. Creating and Executing Health Policy
  2. Minimum Health Insurance Benefits
  3. Caring for the Disabled Elderly
  4. An Overview of Rural Health Care
  5. Effectiveness Research and the Impact of Financial Incentives and Outcomes
  6. Changing Provider Behavior: Applying Research on Outcomes and Effectiveness in Health Care
  7. Health Care Cost Containment
  8. Redesign of Delivery Systems to Enhance Productivity
  9. Medical Malpractice
  10. Prolongation of Life: The Issues and the Questions
  11. Challenges for Health Services Research

The observant ready will notice one critical issue from today’s debate missing from this list… Information technology.  That is because this book was published in 1992… and actually the titles of the first and last chapters also included “in the 1990s.”

What this points out is that the fundamental issues of controlling costs, defining benefits, and improving efficiency in care delivery and through financial incentives are not new to the health care debate.  Reinforcing this historical reality, I recently ran into Professor Stuart Altman from Brandeis - who is one of the most insightful and clear thinking non-ideological health policy expert I’ve ever had the pleasure of talking to and hearing testify before Congress. And he told me on a rainy NYC sidewalk that he has been talking to people across the country about how the current debate is both similar to and different than the early 1990s, the 1980s, the 1970s….. and back to even the 1930s…and despite the ongoing delays he is hopeful that legislation will be enacted this time.

So while the issues haven’t changed, and likely won’t change no matter what legislation is enacted in the coming months, (and years), the hope is that this time around progress will be made so that health care becomes less of a national obsession, (and drag on the economy), and people and politicians can focus on life, liberty, and the pursuit of happiness, rather than illness, accessing needed treatments, and financial uncertainty.

Posted in Comparative Effectiveness, Federal Healthcare Reform, Health System Reform, HealthPolCom Blog, Miscellaneous | 1 Comment »

End of the Beginning for Health Reform

By Michael D. Miller MD
November 29th, 2009

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.

Posted in Federal Healthcare Reform, Health System Reform, Politics, State-Level Healthcare Reform | No Comments »

Making More Sense of Health Reform’s Politics

By Michael D. Miller MD
November 5th, 2009

As expected, it appears that Tuesday’s elections are clarifying the political thinking for some Member of Congress.  Specifically, the losses of Democratic gubernatorial candidates in VA and NJ are blamed on independent voters shifting from the Democratic column - where they predominantly voted last year - to the Republican column this year.  While some appear surprised by this movement, it seems very natural - after all, that’s why they’re called “independents.”

The implications of this shift for health reform legislation are that Democratic Members of Congress from more moderate districts - where they depend on more independent voters to get reelected - are probably feeling increasingly nervous about the contentious issues in health reform.  Conversely, Democratic Members from more liberal districts - where they depend upon their base of Democrats to turn out for the election - are feeling more convinced about the necessity of passing health reform legislation which will appeal to their Democratic base.

With the Democratic leadership in the House apparently looking to pass a bill this Saturday, it will be interesting to see how the increasing political pressures in different parts of the Democratic caucus are reconciled to find 218 votes for passage.  Having a Saturday vote is also a somewhat high-risk strategy because its passage or failure will provide immediate fodder for the Sunday morning news/political talk shows and newspapers. In addition, since Senate majority leader Reid recently indicated that the Senate may not vote on health reform legislation until next year, a quick vote by the House also raises the question of whether their passing a bill will put pressure on the Senate to act - sooner or later - or if it will put politically vulnerable Democratic Representatives out on a limb that they may not be able to carve into a paddle for next year’s elections? As the lyrics say:

  • Time keeps on slippin’, slippin’, slippin’
    Into the future
  • Don’t stop, thinking about tomorrow,
    Don’t stop, it’ll soon be here

Posted in Federal Healthcare Reform, Health System Reform, Politics | No Comments »

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