It's a pleasure to appear at this Health Affairs conference on health reform implementation as a "biblical outlier" after being described earlier by Susan Dentzer as "Doubting Thomas." I confess that I have not yet seen convincing evidence of the resurrection of health reform that is effective or sustainable.
The original premise for my article was to explain how political factors shaped the evolution and final nature of this massive health care law. This latest two-year legislative enterprise resulted in a rather messy "just-in-time" late-term delivery of what we might term "health reform" with multiple political birth defects.
Despite the best efforts of some energetic cheerleading squads in town, and even in this room today, there's still some uncertainty, if not serious doubt, as to just how sustainable this legislative edifice may turn out to be. I've analogized the longstanding political and policy battles over what's called national health reform as the equivalent of our own Hundred Years' War, which started with Teddy Roosevelt's first Bull Moose presidential campaign proposal near the beginning of the last century. Except that the original Hundred Years' War, from 1337 to 1453, to determine which royal house could claim the French throne, was resolved more clearly and in a slightly less medieval manner than our modern-day struggles over health reform.
My primary mission today is to provide a rapid fire overview of the key points in my article about health reform politics--relying on the old standbys of oversimplification, exaggeration, and parody--and then pretend to link this up to the topic of concern to the rest of this panel--the opportunities, challenges, and burdens that states will face under this newest iteration of health reform proposals that actually became law, and not just political theater.
Because I'm on the clock, I'll resort to the adage that a picture is worth a thousand words, and a motion picture delivers tens of thousands more. So here are five recurring images of various inter-related political strategies and factors behind the final sale of this legislation by late March.
Perhaps the most urgent and important political objective was to make national health reform appear to be less costly--particularly in a government budget sense--and to be less disruptive both to current health care arrangements and to many Americans' traditional views (at least outside this room and this city) of the limited role of the federal government.
Hence, the need for various smokescreens that could obscure or portray more appealingly the underlying fiscal and economic features of the proposed health reform plan.
(Here's the depiction of the naval origins of that term, as we see the USS ObamaCare steaming out to a town hall meeting near one of the coastal cities.) Some key elements included coming to an initial truce with employer-sponsored health insurance plans, at least to keep more "private" money on the table during the first installment of required insurance coverage growth. Insurance coverage mandates could enlist the money of employers and individuals to help fund additional health spending that would not be fully counted as spending, or taxes, in the federal budget.
Relying on expanded Medicaid eligibility through state channels could operate as a less expensive "Hamburger Helper"
to accomplish about half of the total targeted coverage goals by allowing federal dollars to be stretched further, given Medicaid's very low reimbursement rates for health care providers.
Even without donning the more politically flammable wardrobe of a "public plan option" that hinted at the designer house of Single Payer, the architects of the final law were able to combine vastly expanded "public plan" Medicaid coverage with much tighter political regulation of "private" insurers in subsidized health insurance exchanges of the (near??) future to accomplish most of the larger political objectives of increased dependency on politically-brokered health care.
Another essential part of the political strategies and tactics was the need by the respective political sides in Congress either to "beat the clock" or "run it out."
The strategy of Hill Republicans--particularly given their minority status and the procedural delaying tools of the Senate--was to urge a "go slower" approach while grassroots concerns about the health reform bill grew across the countryside. Meanwhile, the tyranny of the shortening congressional calendar in the fall of 2009 left congressional Democrats scrambling to get their health reform plans into law before their sizable majorities, and the public's limited patience, might fade away in the November 2010 election cycle. This political time pressure worked in several swirling directions as the health care bill moved closer to enactment. And even when the political clock seemed to strike midnight in Massachusetts in January, it turned out to be a false alarm.
Because it turned out that President Obama and his congressional allies were determined to bet it all on red (not red state, but red ink) and stake his presidency on winning enactment of some less refined version of their original health reform plan by whatever means it took.
Each side ultimately resolved to go for broke and "just win, baby," as Al Davis used to say before his Raiders embarked on their lost arc. The result is the legislative child before us today; whose parents tell us is going to grow up to be better than it looks, as the unfortunate offspring of single-party partisan cloning.
Before we close the book on this political short story, what about the states and rest of the Three Stooges of health reform?
Well, one of the early political strategies of the Obama White House was to co-opt potentially hostile groups, by cutting deals that protected them against downside political risks of the uncertain future, in return for commitments of up front support. That may have worked in the near term for several more politically adroit sectors that gave at the office early and often. But other groups just played the role of political stooges--with some kept hanging on a political leash with no tangible political benefits in return (Larry still has his AMA membership card, but its growth looks less sustainable) and with others serving as political foils when the White House marketing campaign switched from health reform to health insurance reform and needed a private sector villain (Curly's still waiting to make up his premium rate losses on increased customer volume at AHIP). The state governments, facing unprecedented fiscal pressures yet expected to make silk purses of health coverage out of the sow's ears of overstretched Medicaid programs, are supposed to hang on without changing eligibility or benefits until enhanced federal matching funds and more made-in Washington mandates arrive in 2014. Some of them are feeling like the last stooge Moe, as in "Maintenance Of Effort."
But we can at least remain confident that the folks behind the wheel, driving this latest version of health reform, know what they are doing and will keep us on the road to better health at a lower cost, at a safe speed. Then again, it may be a bumpy ride with a more abrupt ending.