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Pulling It Together: Keeping the Health Reform Coalition Together

We could be headed for a new schism in the debate about health reform. Not the familiar gulf between advocates of the market and government, or the predictable one between deficit hawks and spenders, but a new one that crosses traditional partisan and ideological lines between advocates of long-term reform of the health care delivery system, and immediate help for the uninsured and insured struggling with health care costs.  This new rift is most likely to develop if tight money and a crowded agenda force the focus to shift from comprehensive to incremental reform and choices need to be made about what goes into a smaller, cheaper legislative package. It’s a rift that could stand in the way of progress on health reform if care is not taken to avoid it.

For one group, I will call them the “Delivery System Reformers,” true health reform lies in making the actual delivery of care more cost effective over the long term. Delivery System Reformers champion health IT, comparative effectiveness research, practice guidelines, and payment incentives to encourage more cost-effective care such as pay for performance.  They believe that only if we can weed out unnecessary care, promote more cost effective and scientifically proven therapies, and distinguish between new technologies that produce new benefits and not just new profits will we be able to get a handle on health care costs and produce value for the health care dollar. The recent op-ed in the New York Times by baseball executive Billy Beane, Newt Gingrich, and John Kerry exemplified the delivery system reform movement, and notably did not mention the uninsured once.  Indeed some delivery reformers believe it would be a mistake to put more money into the current system through expanded coverage until more fundamental changes in the system are made.

The other group, I will call them the “Financing Reformers,” is focused on an entirely different set of problems. Its major concern is the problem of the 46 million Americans without health insurance coverage and the serious problems all Americans are having today paying for health care and health insurance. For these reformers the health care crisis is fundamentally a problem of economic security and ensuring that everyone has access to affordable health care.  Financing Reformers may differ on solutions — tax credits, expanding public programs, building on the existing employment based system, single payer — but their primary objective is to fix what they see as a growing crisis in the health insurance system that harms people’s economic well-being and access to care.

Obviously many in our field advance both agendas simultaneously, but there are also two very distinct camps.  They think about different problems and often attend different conferences. The health reform field is like a Venn diagram with circles that intersect (though not by a lot).

The two agendas clearly fit nicely together in almost any comprehensive health reform plan and in fact elements of each were included in virtually every candidate’s plan and are advanced by many organizations. If major health reform legislation becomes the subject of serious debate next year, there’s no doubt that it will include expanded coverage for the uninsured, financial relief for many of the middle-class insured, and efforts to make the delivery of health care more efficient and improve quality.  Over the long term both financing reform and delivery reform are needed.

But, let’s assume that money is very tight in the new Congress and that choices have to be made about the makeup of an incremental health reform package.  For example, assume that the President and Congress operate under so-called “pay go” rules where every new program has to be tied to a way to pay for it.  Assume that the Congressional Budget Office will not score savings for delivery reforms in the short term, which will make it tougher to pay for a health reform plan. And assume that Congress will have to find money for other health care priorities too such as to reauthorize SCHIP and restore Medicare physician payment cuts. It is in a tight money environment like this where the focus shifts to an incremental health reform package that the schism could develop. Delivery System Reformers might advance an incremental package that focuses on their long-term agenda. They would have an advantage in pressing their case because the reforms they favor are much cheaper than expanding or subsidizing coverage. But Financing Reformers would be completely unsatisfied with a plan that did not offer coverage expansions and substantial help to consumers struggling with health care costs.  Elected officials might be tempted to go with the delivery reform agenda: it’s critical to do; it could be sold as a first step; and its price tag will be very appealing compared to the much higher costs of coverage subsidies. But politicians would have to worry that such an agenda responds more to the interests of health care experts than of the public, which is mostly worried about its own costs and the affordability of health care and not the quality of care.

We deal with similar tensions in other areas of health. One example is HIV, where it has long been a challenge to keep those who champion HIV treatment and those who champion HIV prevention under the same tent when resources are being allocated. When I was a state welfare commissioner I dealt with a similar tension in poverty policy between advocates for the poor who favored services strategies – providing job training and child care for example  – and those who favored direct income transfers. These differences in social policy are not unique to health reform and always emerge when it comes down to allocating money through legislation when money is scarce.

The old gulf between left and right on how to reform health care, about government vs. the market, has not gone away and will remain a challenge in crafting health reform legislation.  But now that Democrats are in control of the White House and the Congress and will be trying to advance a health reform agenda in an environment where new money will be scarce, the health community needs to be on guard for this new rift which could undermine the chances for action.  If it does come to an incremental effort it will be important to preserve elements of both health reform agendas to keep the health reform coalition together and to advance the twin causes of short term consumer relief and longer term delivery reform in tandem.   And if it comes to it, it will also be important to plan an incremental effort carefully and not stitch it together as a last minute fallback if more comprehensive legislation collapses. Little attention seems to be directed to that challenge today for fear of undermining a broader effort, but that’s a subject for another column.