Health reform is a journey, not a destination. Nothing will have as much impact on defining the destination and accelerating the journey in America as the passage of the Accountable Care Act (ACA) of 2010. The language of the ACA owes much to bipartisan policy efforts over many years, including the 1990 Pepper Commission, of which Senator Durenberger was vice chair, and the 27 members of the U.S. Senate, including Durenberger, who made up a “mainstream” effort to bridge the gap between the Clinton Health Security Act of 1994 and its Republican opposition. While policy reform efforts have been quite partisan since 1994, a great deal of policy recommendations from the health policy community and from organizations such as the Medicare Payment Advisory Commission, of which Durenberger was also a member for six years, are incorporated in the ACA.
The implementation of the ACA is interesting. There are parts of the task that federal officials must undertake. Then there are important parts that must be implemented as state initiatives. Partisan political opposition is only too well-known. Lobbying will be intense. Journalists will be busy reporting. There will be court tests and new legislative policy initiatives. The NIHP will endeavor to provide you with the resources you need to keep up with the health reform journey.
As we know it today, the term has a long history and a variety of definitions. I have been learning from health reformers for more than 40 years that health reform is what the health professions are trained to do – constantly learn to do better at what they have learned to do well. Minnesota has a proud tradition going back to the late 19th century when two brothers named Mayo from Le Sueur, Minnesota, took over a small clinic in Rochester; and when a Benedictine nun from her order’s new St. Mary’s Hospital in Duluth sold health “insurance” for a dollar a month to northeastern Minnesota loggers.
It includes raising the performance bar on the practice of medicine, which today we call health care, as well as leadership in population health improvement by attacking addictive behaviors and some of the substances that cause them. It includes community support for persons with mental and behavioral illness and with disabilities of birth, accident or aging. It includes national leadership in health education and medical technology research and development, and in health systems and behavior change to enhance incentives for responsible behavior and accountability.
Unlike most other developed nations, the United States has never made healthy people a goal of its national health policy. We have focused our investment capital instead on health care. We have focused practice on individual professionals, small group practice and, with the rapid growth in new information and new technology available to health care professionals, on the specialization of health care services. Insurance became the vehicle for spreading the increasing costs of new health care across populations of healthy and unhealthy persons. Employment became the favorite source of risk-spreading group purchases of insurance. And the national, and some states’, governments were enlisted to make the benefits of affordability of health care available to all. As is the assurance to citizens of most every other developed nation because national governments have made it national policy to do so for political reasons. So we might more appropriately call this HEALTH CARE POLICY REFORM.
In 1954 it became U.S. national policy to subsidize health insurance through tax deductions and exemptions. In 1965 Congress amended the Social Security Act of 1935 to add titles 17 and 18 and private insurance models to tax and fund Medicare and Medicaid for the elderly, disabled and low-income mothers and their children. From then on the nation has periodically engaged in a public policy debate involving the relative merits and priority of more and better health care for all vs. containing the cost growth, as though it is an “either-or” proposition. So long as we ask health care professionals, hospitals, and other entities to take all comers they will allow insurance companies to play by whatever rules they prefer, prices expressed as premiums there never will be a measure of concumer value. POLICY is the statement of a problem and an agreed course of action designed to reduce or eliminate the problem over time. Where this requires a role for government we call it PUBLIC POLICY.
It is one thing for a private entity to see a problem and take action to change course. It’s quite another for a representative government such as ours in the U.S., where public officials are elected to represent a distinct constituency, not a liberal or conservative or whatever variant political party. At this point I refer you to a more extensive paper entitled Understanding Health Policy . Because most elected officials belong to one of two major parties which are liberal or conservative or variants. Because building support for the definition of the problem even before debating alternative solutions runs into strong professional interests expressed in state and national associations.
In health care especially, the tradition of the doctor-patient relationship implies great power, influence and persuasive ability to the health professional’s presumption of expertise. Because we live in an environment which is increasingly dominated by conflicting opinions, conflicting “facts” and conflicting interests, only some of which are financially powerful. Because the environment for public action contains other issues which may have greater priority to those in position to set or to influence public action. System 2009 Report