The Path Forward for National Health Reform

January 31, 2010 / Michael D. Miller MD / Delivery of Healthcare, Health System Reform, Medicaid, Medicare, Politics / 2 Comments

The path forward for health reform is becoming clearer now that the dust from the Democrats losing their 60th vote in the Senate is settling. While a freestanding, comprehensive law now seems very unlikely, achieving the core goals of health reform are possible via the regular order of a Reconciliation bill, demonstrations and pilot programs, waivers, existing authorities, and the appropriations process.

It’s the Stupid Economy
First, the President has appropriately reraised jobs and the economy to be his highest priority. This shift may both help defuse the hyperpartisaness that has enveloped health reform, and increase action to improve the economy and create jobs since they are the source of the public’s ongoing angst and frustration. …

Health Reform’s Rock & Roll

January 21, 2010 / Michael D. Miller MD / Federal Healthcare Reform, Health System Reform / 1 Comment

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.…

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

January 6, 2010 / Michael D. Miller MD / Federal Healthcare Reform, Health System Reform, State-Level Healthcare Reform / No Comments

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. …

New Year, New Decade, New City, New Health Reform

January 4, 2010 / Michael D. Miller MD / Health Policy and Communications Blog, Health System Reform / No Comments

For the new year and new decade I’ve relocated back to Washington DC to be more directly engaged with the implementation of health reform and related initiatives.

Packing, moving and unpacking took longer than expected – sort of like passing health reform legislation – and I apologize for my infrequent postings. Being back in more direct contact with policy makers, national advocates and others here in DC, I’ll be writing more frequently and in greater detail about the implications and expectations of health reform legislation, law(s), and implementation.

On the horizon is the development and passage of legislation combining the House and Senate health reform bills. …

Playing Poker with Health Reform

December 16, 2009 / Michael D. Miller MD / Federal Healthcare Reform, Health Policy and Communications Blog, Health System Reform, Politics, State-Level Healthcare Reform / 3 Comments

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.…

Historical Perspectives on Health Policy: Part 3

December 4, 2009 / Michael D. Miller MD / Comparative Effectiveness, Federal Healthcare Reform, Health Policy and Communications Blog, Health System Reform, Miscellaneous / 1 Comment

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:

Creating and Executing Health Policy
Minimum Health Insurance Benefits
Caring for the Disabled Elderly
An Overview of Rural Health Care
Effectiveness Research and the Impact of Financial Incentives and Outcomes
Changing Provider Behavior: Applying Research on Outcomes and Effectiveness in Health Care
Health Care Cost Containment
Redesign of Delivery Systems to Enhance Productivity
Medical Malpractice
Prolongation of Life: The Issues and the Questions
Challenges for Health Services Research

The observant ready will notice one critical issue from today’s debate missing from this list… Information technology. …

End of the Beginning for Health Reform

November 29, 2009 / Michael D. Miller MD / Federal Healthcare Reform, Health System Reform, Politics, State-Level Healthcare Reform / No Comments

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. …

Cost and Coverage c. 1989-91: Part 2 of Historical Perspectives on Health Reform

November 17, 2009 / Michael D. Miller MD / Access to Healthcare, Delivery of Healthcare, Economics & Financing, Health System Reform / 2 Comments

As I mentioned in my last post, in going through old files I found many memos and articles about health reform. Some of them from 1989-91 illustrate the long history of the challenge of controlling costs and providing care for more people – and eerie similarities to the current debate:

For example, below are some pieces of text from articles and commentaries published in the New England Journal of Medicine from January 1989 – October 1990:

“A Consumer-Choice Health Plan for the 1990. America’s health care economy is a paradox of excess and deprivation. We spend more than 11 percent of the gross national product on health care, yet roughly 35 million Americans have no financial protection from medical expenses.

…

Making More Sense of Health Reform’s Politics

November 5, 2009 / Michael D. Miller MD / Federal Healthcare Reform, Health System Reform, Politics / 1 Comment

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. …

Making Sense of Health Reform

November 2, 2009 / Michael D. Miller MD / Access to Healthcare, Federal Healthcare Reform, Health System Reform, Politics / No Comments

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. …

Morphing Medical Homes into Advanced Primary Care Model

October 18, 2009 / Michael D. Miller MD / Delivery of Healthcare, Health System Reform, State-Level Healthcare Reform / 4 Comments

The concept of patient centered medical homes (PCMH) has been evolving since it was first presented by 4 primary care medical societies, (AAFP, AAP, ACP & AOA), in March 2007. Since then, the PCMH concept has been endorsed by many other medical societies and interest in PCMHs has grown. Some of the significant steps forward have included:

The National Committee for Quality Assurance (NCQA) created specific requirements and a certification procedure for PCMHs
Several states are moving forward with PCMH pilot projects
Congress passed a law for Medicare Demonstration projects and the Department of Health and Human Services created draft guidelines for these projects – however, these guidelines haven’t been finalized although the demonstrations were scheduled to start in 2010

Steps Sideways
Along with all the interest and activity related to medical homes, there has been a blurring of the definition about what constitutes a medical home. …

Shakespearean Health Reform

October 12, 2009 / Michael D. Miller MD / Health System Reform, Politics / No Comments

With the expected passage of legislation by the Senate Finance Committee this week, Federal health reform prepares to move into the next phase, i.e. merger of bills in the House and Senate followed by a Conference Committee to meld those two versions. While this “process” may seem very straight forward, it probably will have subplots as intriguing and complex as many of Shakespeare’s plays. So below, are some highlight of what may unfold in the coming weeks, (and months), as health reform legislation is finalized and then implemented… perchance.

To Reconcile or Not to Reconcile, That is the Question
The Senate Democrats had set a deadline of October 15th, after which they may use the rules of Reconciliation to pass health reform legislation. …

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