Health Affairs
May/June 2008
Politics
Prologue: The Politics Of Health Reform: A Collection Of Perspectives
Does politics for all translate to health care for all? In a long and surprising year of primaries and caucuses, with unprecedented numbers of new voters, will health care reform claim top spot on a new president’s domestic agenda? Will all of the energy displayed this year be transformed into real legislative action in 2009?
The following Perspectives on the politics of health care reform start with hope for the future in the form of the Healthy Americans Act, a bipartisan proposal by Sen. Ron Wyden (D-OR) and Sen. Bob Bennett (R-UT) that is gathering steam and cosponsors in the Senate. The senators posit that different, new, and fertile conditions for health care reform exist, marking this point in time as different from the 1990s.
The pollsters who follow, Celinda Lake and colleagues (Democratic pollsters) and William McInturff and Lori Weigel (Republican pollsters), render a somewhat more split verdict on whether we are witnessing a period of historic change. They both note the deep desire of the public for change, for an American solution that encompasses the view of health care as both a societal right and a personal responsibility, but it is unclear whether deep partisan divides in the electorate and a worsening economy will allow for anything other than incremental change.
The last group of Perspectives by Joseph Antos; Christine Ferguson, Elizabeth Fowler, and Len Nichols; and Jacob Hacker all use the Clinton reforms as a template for what went wrong and what is both possible and needed in 2009 to pass major reform legislation. The authors represent several political viewpoints, but they all suggest that the failure of the Clinton reforms was a failure of politics, not of policy. They all find the seeds of failure in the partisan nature of how the Clinton administration went about the reform business. As Hacker notes, instead of building a bridge to compromise, a transparent process with congressional input, the Clinton administration burned the bridges behind it. Health reform, major or minor, needs broad bipartisan support. It needs leadership from the executive branch and active participation from the legislative branch to muster the support to implement changes.
Senators Wyden and Bennett claim that their bill and their colleagues have learned these lessons. The bill has bipartisan support, and it is a model of clarity and brevity compared to the Health Security Act of the 1990s. Is this the moment? Will all of the political engagement of this year’s historic campaign translate into path-breaking legislation? Or are we headed back to the future?
http://content.healthaffairs.org/cgi/content/full/27/3/688
Compromise
Prologue: Formulas For Compromise
The system must change. The system cannot change. These seem to be the lessons of policy analysis and policy initiative, of repeated recommendations and oft-frustrated efforts to improve access, moderate cost, enhance quality, and encourage innovation in health insurance. The political imperative is to ascertain how much can be reformed with the least disruption of existing institutions and expectations.
The following papers describe the elements they interpret as essential for health insurance reform while leaving as much as possible of the larger system remain in place, at least for now. Cathy Schoen and her colleagues at the Commonwealth Fund, which is focusing much of its work on promoting a “high-performance health system,” advocate a combination of individual insurance mandate, modest employer tax, expansion of public programs and tax credits, and a “connector” structure that offers individuals and small firms a choice of coverage between private insurance and a Medicare-sponsored plan.
Katherine Baicker of Harvard University seeks a “formula for compromise” that would uphold the cultural importance of individual choice but channel it toward forms of care and coverage that offer the best combination of cost and performance; for Baicker, as for most economists, it’s all about trade-offs.
Bruce Bodaken, chairman, president, and chief executive officer (CEO) of Blue Shield of California; and Paul Ginsburg, president of the Center for Health System Change, focus attention on the roles of insurers and employers, respectively, in the debate over and creation of a reformed health care system. Both emphasize the willingness of these stakeholders to cooperate in system reform and take leadership positions in reform efforts, to the extent that the new system builds on the strengths of the current structure and focuses change on its weaknesses, rather than throwing everything into the air and provoking a backlash of political fear and economic self-interest.
A Perspective by Andy Stern, president of the Service Employees International Union (SEIU) since 1996, follows the Ginsburg paper. He and Safeway CEO Steve Burd have worked closely with Sen. Ron Wyden (D-OR) and Sen. Bob Bennett (RUT) on the bipartisan Healthy Americans Act, which is the subject of another Perspective in this volume by Senators Wyden and Bennett.
http://content.healthaffairs.org/cgi/content/full/27/3/645
The Triple Aim: Care, Health, And Cost
By Donald M. Berwick, Thomas W. Nolan and John Whittington
Improving the U.S. health care system requires simultaneous pursuit of three aims: improving the experience of care, improving the health of populations, and reducing per capita costs of health care.
If we could ever find the political nerve, we strongly suspect that financing and competitive dynamics such as the following, purveyed by governments and payers, would accelerate interest in the Triple Aim and progress toward it: (1) global budget caps on total health care spending for designated populations, (2) measurement of and fixed accountability for the health status and health needs of designated populations, (3) improved standardized measures of care and per capita costs across sites and through time that are transparent, (4) changes in payment such that the financial gains from reduction of per capita costs are shared among those who pay for care and those who can and should invest in further improvements, and (5) changes in professional education accreditation to ensure that clinicians are capable of changing and improving their processes of care. With some risk, we note that the simplest way to establish many of these environmental conditions is a single-payer system, hiring integrators with prospective, global budgets to take care of the health needs of a defined population, without permission to exclude any member of the population.
Whether or not the Triple Aim is within reach for the United States has become less and less a question of technical barriers. From experiments in the United States and from examples of other countries, it is now possible to describe feasible, evidence-based care system designs that achieve gains on all three aims at once: care, health, and cost. The remaining barriers are not technical; they are political. The superiority of the possible end state is no longer scientifically debatable. The pain of the transition state–the disruption of institutions, forms, habits, beliefs, and income streams in the status quo–is what denies us, so far, the enormous gains on components of the Triple Aim that integrated care could offer.
http://content.healthaffairs.org/cgi/content/full/27/3/759
An archived webcast of an event coinciding with the release of this issue of Health Affairs, which focuses on health reform (the panel excludes representatives of single payer reform):
http://www.kaisernetwork.org/health_cast/health2008hc.cfm?hc=2596
Comment:
By Don McCanne, MD
Ouch! In this special issue of Health Affairs, we hear once again that the politics of reform requires compromise. The current political dynamic moves forward with the assumption that a single payer national health program represents an uncompromising position on health policy that ignores political realities. That may be true, but does that warrant the exclusion of consideration of policies that would improve the efficiency, equity and affordability of health care merely because the political alignment is not yet optimum?
It is notable that the editors did allow one almost parenthetical sentence mentioning, “with some risk,” the simplicity of achieving goals of reform through a single payer system.
Politics alone is not a reason to exclude superior health policies from consideration, but when the political process does have that result, it is our obligation to do everything that we can to change the politics. Politics is a dynamic, and it is malleable.
New York Times columnist Thomas Friedman, in a tribute to his mother this weekend, wrote, “…every time life knocked her down, she got up, dusted herself off and kept on marching forward, motivated by the saying that pessimists are usually right, optimists are usually wrong, but most great changes were made by optimists.”
Optimists, get up and change the political dynamic!
