Implementing Health Reform – The Long, Hard and Twisting Maze

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.

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Politics of Health Reform: Selling Anger or Catharsis

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.…

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How Long is the New Health Law?

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.)…

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Regulating Insurance: States v. Federal Roles

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. …

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Health Reform’s Rock & Roll

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.…

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

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. …

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Playing Poker with Health Reform

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.…

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Historical Perspectives on Health Policy: Part 3

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. …

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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. …

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Making More Sense of Health Reform’s Politics

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. …

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Making Sense of Health Reform

After spending a week in Washington DC talking to lots of people, and reading all sorts of information, I’m still not sure how to simply explain the the current state of health reform legislation – except to say that it is unfolding pretty much as expected:

  • It is taking a lot longer than planned, i.e. the August deadline never seemed realistic
  • There are pockets of agreement, but no solid majorities for a single bill
  • The Senate and House are operating in parallel, with the Senate being more conservative and focused on issues important to rural communities
  • Costs and spending are defining the framework within which all the ideas and packages are bouncing – like a 1970s video game
  • And political motivations and calculations are the firmament for many – if not most – positions and actions

Politics with Elections on 12 Month Horizon
On the last point, there has recently been ample evidence. …

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Kennedy Legacies for Health Reform

In preparation for Congress reconvening today – and to spin up activits’ energy ahead of the President’s health reform speech on Wednesday – there was a rally yesterday on the Boston Common.  (See pictures below.)

Health Reform Rally Boston - September 6, 2009

Health Reform Rally Boston - September 6, 2009

Because this event was in Massachusetts, the speakers – and many of the hand-held signs – referred to Senator Ted Kennedy’s decades of work on healthcare, and invoked his memory to energize the reform efforts.  From an historical perspective, in addition to Ted Kennedy’s legacy the words and deeds of his brothers JFK and RFK may also be important for creating social momentum for improving healthcare in the US.…

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