Special Contributor | Health Care Reform: We’ve Really Only Just Begun
On March 23, President Obama signed the Affordable Health Care for America Act. This legislation will go down as one of the most significant pieces of social policy legislation that Congress has ever passed. Sure, the legislation isn’t perfect—no law ever is—but it expands coverage to 32 million Americans, makes the market for health insurance significantly more competitive, and provides help to millions of Americans who have struggled to afford their health insurance premiums. More significantly than that, the legislation represents a commitment to the idea that if an American wants to buy insurance, they should be ale to get a high-quality product at a reasonable price.
However, it’s vital to note that President Obama’s bill signing marked the beginning of health care reform, not the end. If international experience is any guide, now that the bill has been signed into law, the real arbiter of how the legislation will impact Americans will be how it is rolled out across the country. The process of implementation will be difficult and technocratic, but it will also be imperative to shaping the legislation. The rollout will be an opportunity for policymakers to translate the ideas articulated in the reforms, like the insurance exchanges, into tangible programs. From there, the new policy programs will need to be measured, analyzed, and constantly improved. There will certainly be portions of the legislation that don’t work or have unintended consequences. The key challenge for policymakers will be using the speed bumps along the way as an opportunity to improve the health system, rather than having it serve as ammunition to scuttle reform altogether.
What makes health care so fascinating for those of us who work in the field and study it—and also such a menace for politicians who try and pass legislation to reform it—is that unlike many other policy spheres, change in health care takes time to implement. It takes time to train new doctors and have them alter their behavior, time to create new financial incentives in a system where quality is so difficult to measure, and time for the reforms to produce tangible results that can inform future implementation and policy. Plus, nobody ever likes change.
In the Netherlands, it took almost 20 years to fully implement their market-based reforms. In England it was a similar story, with the process for reform taking the better part of a decade. The process of implementation in these two nations can certainly alert policymakers to the types of challenges that they’re going to face rolling out President Obama’s reforms and hopefully make the process smoother.
The rollout of England’s* National Health Service market-based reforms was littered with speed bumps, but in the long run, they’ve proven hugely successful. When policymakers in England began offering every NHS patient a choice of where they received care, a necessary ingredient was also creating a referral system that could accommodate this new policy shift. (We will need something similar in the United States for the insurance exchanges). In response, the government created “Choose and Book,” a paperless, electronic referral system where patients can book appointments by phone, with their general practitioner (GP), on the internet, or in person.
While the Choose and Book program has now proven successful, initially it was a debacle. The company that the government contracted with to create the system missed several key deadlines and ran into a bevy of technical challenges. More significantly, doctors were slow to embrace the change. They complained that the new system was clunky and inefficient and refused to use it. As a result, the government missed their self-imposed targets for use. One central lesson that emanates directly from this experience in England is that the policymakers who implement the reforms need to do so in direct consultation and engagement with the users who interface with the reforms, be they doctors, insurers, or patients.
In England, it also proved vital to measure performance as the reforms were rolled out. The British government made huge efforts to collect ongoing data on performance that policymakers used to refine the policies and, if necessary, shift directions. In their campaign to shorten waiting times, which have long been the bedbug of the NHS, the government measured waits and used that information to performance-manage hospitals. The constantly flowing data became a barometer to see how policies were progressing. Crucially, the data also added an element of accountability to the reforms. The public could hold politicians accountable for their ability to meet their stated ambitions; politicians could hold policymakers accountable for implementation and results. While there were certainly moments when politicians would have been happier if their performance was not measured, these data drove the reforms forward.
We will need similar data in the United States. As the reforms are rolled out across the country, the federal government should encourage benchmarking progress and make data available for academics and analysts to measure their performances. Those measured may not always like the scrutiny, but it will produce better results.
Finally, there’s the need to recognize that portions of the legislation that President Obama signed simply will not work. In legislation this complicated, there are bound to be unintended consequences and good ideas that in practice just don’t work, and good policymaking and good implementation will actively react to impediments as they arise. With that point in mind, consider another example from England that might be instructive: The U.K. government decided to rework family doctor’s contracts in an effort to reward clinical performance. Part of the new contract included a clause that allowed doctors to take a several thousand-pound pay cut in exchange for not working nights. The government thought this would improve overnight coverage in England, which had always been patchy.
The government got it wrong. Almost every GP decided to forgo money and stop working nights. As a result, overnight coverage got far worse, not better. Now, to be sure, this policy hiccup led to ridicule and political consternation; it was embarrassing to the government, and it was splattered across newspapers. Nevertheless, policymakers used this unintended consequence of a well-intentioned idea as an opportunity to improve the policy to encourage overnight coverage, rather than simply succumbing to calls to scrap the new contract altogether.
Without a doubt, whenever elements of President Obama’s legislation lead to unintended consequences, there will be calls to scrap the whole reform. This is where level-headed policymakers need to be a voice for reason and implore politicians to work on fixing the problems, rather than simply throwing the baby out with the bathwater. There will be negative headlines, and there will be very public setbacks, but policymakers must keep in mind why so many pushed for reforms in the first place.
In addition to looking at experience of other nations, I would be remiss if I didn’t mention the experience of Massachusetts. For the last several years, Massachusetts has wrestled and succeeded at implementing insurance reforms signed into law by then-Governor Mitt Romney. In many ways, the reforms that President Obama just signed into law are modeled on what was implemented in Massachusetts. As American policymakers focus on the process of turning legislation into tangible policies and programs, they need to focus on what worked and did not work in Massachusetts, speak with the policymakers who implemented the reforms, and use them as an opportunity to avoid making the same mistakes twice.
The next several years will be a fascinating time in American health policy. No one knows precisely what impact the sweeping new reforms will have on price or quality. The arbiter of how these reforms perform will be dictated almost as much by how they are implemented as by the actual underlying legislation itself. In the years ahead, my hope is that legislators can suspend the bickering and partisanship and focus on sound implementation. Unfortunately, experience in other nations again suggests that is unlikely.
* The British NHS was divided into separate health care systems in England, Scotland, Wales, and Northern Ireland. Only England has pursued aggressive market-based reforms.
Special Contributor Zack Cooper is a research officer with the London School of Economics. His monthly column for the Health Policy Forum considers health policy from the international perspective. “Special Contributors” are regular contributors to the Health Policy Forum who pose their own opinions and policy positions in the realm of health care and health policy. As a leading nonprofit health care research and consulting institute dedicated to improving human health, Altarum encourages open discussion and debate about the many challenges in health care today. All postings to the Health Policy Forum (whether from employees or those outside the Institute) represent the views of the individual authors and/or organizations and do not necessarily represent the position, interests, strategy, or opinions of Altarum Institute. Altarum is a nonprofit, nonpartisan organization. No posting should be considered an endorsement by Altarum of individual candidates, political parties, opinions, or policy positions. Read more.
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