As health reform legislation moves forward, (having been passed by one of the two Senate Committees and two of the three House Committees last week), the tension between policy and politics is increasing. This political process can make it hard to maintain the practical functionality of the legislation, i.e. not sacrificing the substantive policy goals to the political realities.

One of the great challenges in making these trade-offs is to retaining reasonable functional relationships among the many necessary financing and delivery system changes to actually improve the healthcare system.

Keeping the Implementation of Health Reform from Getting Jammed Up
An analogy for this challenge came to mind when I was in DC last week.  At a friend’s house, I was fixing a lock on one of their bathroom doors – the door’s latch wouldn’t catch in the door jam because the strike plate had been improperly aligned.

The options for this situation are:

1. Doing nothing – leaving the door so it doesn’t latch or lock.
2. Removing the strike plate and expanding the hole in the wood of the door jam.  This would enable the door to latch, but also would have worn out the wood of the door jam, and made it so the door could be locked from the outside because the latch wouldn’t be compressed enough against the jam to unlock the door as it was being closed.
3. Moving the strike plate. But this would require chiseling out wood from the door jam, drilling new holes, and then repainting the door jam.
4. Moving the latch and locking mechanism on the door. But this would have required cutting into the door, making new holes, filling the old holes and spaces, and repainting the door.
5. Enlarging the height of the hole in the metal strike plate so that the latch catches.
6. Enlarging the height of the hole in the metal strike plate and the door jam so that the latch catches, AND the latch deploys outward enough so that door’s locking mechanism can be activated from the inside, but the strike plate is close enough to the edge of the door so that the door can’t be locked from the outside.

Clearly these different options vary in how much effort, time, and resources they require, and how well they improve the situation. (I went with #6 for my friend’s door.)  Similarly, in health reform, how the different parts of the legislation interact and how many resources they require for implementation are important considerations.

As I’ve written before, healthcare delivery and financing are closely interconnected, and making changes in one can have profound effects on the other.  Therefore, as health reform legislation is shaped to accommodate political considerations – such as support for access to care in rural areas, financing without unacceptable tax changes, mandates to achieve near universal coverage paired with insurance market reforms, and promotion of certain technologies and preventive interventions – it will be a tremendous challenge to make sure that the moving parts of the financial systems latch correctly with the delivery system’s strike points in ways that promote better efficiency, quality and access.  An additional challenge will be for the legislation to provide enough time and resources for each of the changes so that they don’t get jammed up in their real world implementation.