With a few weeks to go before the President’s March 26th deadline for agreement on a comprehensive health reform bill, the likelihood of that occurring is diminishingly small. However, even without a comprehensive bill, or even several incremental Federal laws passed this year, health reform will be happening in the States and the private sector, while the Federal government may also pull a few of the strings it has available to shift the operation of our healthcare system:
State Level Health Reform
“State-Level Health Care Reform” is the title of an article in the Feb. 20th issue of the National Journal. This article discusses various initiatives states are considering and how their national organizations, (such as the NGA and the NAIC), are supporting these efforts. Of course, States face significant challenges for making investments in health reform because of their legislative calendars and budgetary pressures. To help states’ fiscal problems, the Department of Health and Human Services announced on February 18th that they were providing states’ Medicaid programs with $4.3 Billion in relief over 2 years.
In assessing how states might try to create health reform based upon Medicaid, it is also important to remember that Medicaid is not one program – and not even 50 separate uniform state programs – but that states have hundreds of waivers for the operation of different parts of their Medicaid programs. For example, Massachusetts has 6 waivers – one of which is the basis for the state’s health insurance expansion program – and Arizona has 2 waivers, the first one approved in 1982 as the basis for the state’s entire Medicaid program.
Private Sector Initiatives
Private companies are continuing to try and reform healthcare from the both the cost and quality perspectives as both purchasers and sellers. A friend who works for a large company with a significant footprint in healthcare, and a very large and diverse workforce, told me that they are addressing healthcare cost and quality on both ends. First they are shifting their entire health benefits system to high-deductible type options, and they are also developing products and services to improve the efficiency and quality of healthcare delivery. Other companies are doing similar things and working through coalitions such as the Leapfrog Group, the National Business Group on Health and the Pacific Group on Health to work collaboratively, (and perhaps corrosively), with health plans and large providers to control costs and improve quality.
Federal Initiatives
Without new sweeping laws, the Federal Government has significant administrative tools for changing how healthcare is paid for and delivered. Beyond rule-making in programs such as Medicare and Medicaid, the government can use its purchasing power to change how private companies operate. This lever was the focus of a February 26th New York Times article, the first two sentences of which may be heavy foreshadowing: “The Obama administration is planning to use the government’s enormous buying power to prod private companies to improve wages and benefits for millions of workers, according to White House officials and several interest groups briefed on the plan. By altering how it awards $500 billion in contracts each year, the government would disqualify more companies with labor, environmental or other violations and give an edge to companies that offer better levels of pay, health coverage, pensions and other benefits, the officials said.” [emphasis added]
Conclusion – Pluralism, Federalism, & Individualism
The individualistic nature of US society has long shaped government and social programs, and the role of individual decision making – going back to the Constitution – has been reflected in preferences for local control and charitable-community actions rather than government programs. The challenge for government officials and lawmakers at all levels is to create health reform in a manner consistent with this fundamental societal philosophy. This conundrum may have been summed up by Vice President Biden at last week’s health summit, which CNN reported: “Vice President Joe Biden says the philosophical debate over whether health care should be mandated is similar to debate in the 1930s regarding Social Security. He also says after being in Washington for 37 years, he’s ‘reluctant … to tell people what the American people think. I think it requires a little bit of humility to be able to know what the American people think, and I don’t. I can’t swear I do. I know what I think. I think I know what they think, but I’m not sure what they think,‘ he says.”
I’m not sure I’ve heard a clearer explanation of the quandary policy makers have in deciphering the desires of the American people for comprehensive local solutions that provide uniform individualized options that are simple and efficient while eliminating waste, fraud, and abuse without excess government intrusion, spending, or taxes so that costs are reduced and quality improved while maintaining personal choices of doctors, hospitals, and therapies and incentives for creating better treatments and cures.
