The greatest lesson of the failure of comprehensive health reform in the past is that politics comes first. If real estate is about location, location, location, health reform is about politics, politics, politics. Again and again in American political history, well-intentioned reformers brimming with statistics and policy ideas have argued that change must finally come. And again and again, reformers have run headlong into a wall of ideologically charged opposition that has thrown exorbitant resources and energy into convincing Americans and their leaders that they will be made worse off by change.

Can it be different this time? I believe so-if reformers learn the right lessons from the past. When President Clinton was running for office in 1992, a three-slogan agenda was famously taped on the wall of his war room: “The economy, stupid,” “Don’t forget health care,” and “Change vs. more of the same.” With apologies to James Carville, the lessons for today’s reformers are “The politics, stupid,” “Don’t forget fear,” and “Changed politics vs. more of the same.”

The politics, stupid. Even the best-laid policy plans are worthless if they lack the political support to pass. Putting politics first means avoiding the overarching mistake of the Clinton reformers of the early 1990s: envisioning a grand policy compromise rather than hammering out a real political compromise. Read more…

This week we will post essays from historians, political scientists and health policy aides who worked on legislation to expand coverage of the uninsured in the US. I look forward to their thoughts and yours about lessons to apply as President-elect Barack Obama, Senator Ted Kennedy, Senator Max Baucus and others try not to repeat history.

Martha Bebinger

On January 12th I participated in a media briefing sponsored by the American Benefits Council, a national trade association whose members are primarily large employers concerned about federal legislation and regulations affecting all aspects of the employee benefits system. The briefing unveiled the Council’s plan for national health care reform, which in many aspects bears a striking resemblance to the Massachusetts health care reform law. I was invited to participate in order to share my experience, and that of the Massachusetts employer community, with our state’s initiative.

The Council’s proposal, like our reform, builds upon the existing employer-based system through which the majority of working Americans receive health insurance coverage. It requires all individuals to obtain at least a basic level of care (individual mandate) accompanied by income-based premium subsidies for lower-income workers (sounds a lot like Commonwealth Care). The plan calls for the establishment of a broad multi-stakeholder advisory panel (kind of like a Connector) which would establish a minimum standard for quality, affordable health coverage (we call this minimum creditable coverage). All of this sounds awfully familiar to those of us in Massachusetts who have been living and breathing health care reform for the past several years.

The Council does go further than we have in attempting to tackle a range of cost and quality issues in addition to expanding access. Read more…

Pioneer Institute is pleased to release its latest policy brief, Massachusetts Healthcare Reform: A Framework for Evaluation
which lays out our view of the metrics that should be used to evaluate whether or not healthcare reform in Massachusetts is a success, a failure, or something in between.

There has already been impressive work done on the level of access to health insurance through reform and financing is receiving a great deal of attention currently. This brief seeks to identify specific metrics for these measures, plus administration and cost-effective quality.

The metrics themselves are listed below. I encourage you to read the paper, then give us your feedback – either here, or direct to me (spoftak@pioneerinstitute.org)

The paper identifies some sources (and some proxies) for the data behind each metric. Our next task will be to incorporate your feedback, then go out and run the numbers. Let us know what you think and what we’ve missed.

Reform Scorecard

Access

1. Number of uninsured over time, and the rate of change in this figure.

2. Size and growth of the Commonwealth Care program over time Read more…

As a new year is launched, our state and the nation stand on the threshold of monumental challenge to fix a broken economy that offers daily and dire reports of rising unemployment and unprecedented fiscal calamity. Mixed into the mess is the challenge to keep healthcare reform on track.

It’s easy to say that runaway healthcare costs are the main problem. While it is essential that everyone who provides, pays for or receives care has a responsibility to do more to manage healthcare costs, we need to first find a common agenda for action. I propose stakeholders focus on three specific challenges within our faltering healthcare system: reducing clinical variation, payment reform and administrative simplification. These three challenges, which I like to call the “three-legged stool” of healthcare improvement, must be addressed simultaneously and with equal vigor in order to succeed. Equal pressure on each leg will bring down healthcare costs concurrently on multiple fronts, which is far more practical and likely to succeed than simply putting hospitals – or any other healthcare stakeholder – on an externally imposed budget and hoping for a better system to emerge.

There is universal agreement among all Massachusetts stakeholders Read more…

America imprisons more people than any other nation – more than 2 million people are behind bars at any one time, and 12 million go through our prisons and jails each year. In a study in the April 2009 issue of the American Journal of Public Health, we found that many of these prisoners have serious chronic illnesses, and get little care.

Most shocking was the high rate of serious mental illness like schizophrenia, and the fact that most of those with serious mental illness were off treatment at the time of their arrest.

This finding has grave implications for Massachusetts. The Governor has announced massive cuts to mental health services. We know from previous studies that mental health care prevents crime. With Patrick firing a quarter of the state’s mental health case managers, and forcing safety net providers like Cambridge Health Alliance (which provides one third of all indigent mental health care in the state) to slash psychiatric beds and services, many of the mentally ill will end up in jail – often for minor infractions like trespassing and disturbing the peace. And untreated mental illness can also lead to major crimes. We know that mentally ill people are NOT dangerous, if, and this is a big if, they get treatment. Read more…

A new, worldwide study by the Harvard School of Public Health shows that using a short checklist during major surgeries dramatically reduces deaths and complications.

The simple checklist requires doctors to pause during surgery and ask a few basic questions, such as: Are we about to operate on the correct body part? Sounds obvious, but Harvard researcher Alex Haynes says checking eliminates more than a third of deaths and complications.

“It is reflective of a change in the culture of the operating room,” Haynes said. “It requires an emphasis on team-based care, and the operating room traditionally has been very surgeon-led — the surgeon is the captain of ship.”

But Haynes, who is also a surgeon at Massachusetts General Hospital and lead author of a paper detailing the study, says that with a checklist, other team members are more likely to speak up if they see something going wrong.

The year-long study was done in collaboration with the World Health Organization, and it involved more than seven thousand patients at hospitals in eight cities around the world. A paper on the study was published online yesterday in the New England Journal of Medicine.

“The benefit of the checklist is manifold,” Haynes added. “Obviously if we can prevent complications, it reduces a great deal of suffering on the part of patients, unnecessary additional medical care and time in hospital. It reduces cost. And, finally…we can save lives.”

There are many demons in the popular lore on American healthcare – bean counting hospital administrators, greedy doctors and sleazy malpractice lawyers – but the most infamous evil doers of all are probably the heartless insurance companies who are criticized for denying needed services to their subscribers to feed the corporate bottom line. In reality, drawing the boundaries on what medical services to cover is a very difficult and thankless decision. Everyone knows the anecdotes – like saying no to a mom of three who has metastatic breast cancer when there is an expensive new protocol that might offer hope. But there are other variations on the theme – what “non-traditional” therapies ought to be “covered” by private or government payers: acupuncture, chiropractic therapy, infertility treatments may be ok but what about aromatherapy or cosmetic surgery or chelation?

The other challenge to coverage decisions is that the healthcare universe is constantly moving forward. Around the edges of current practice there are innumerable alternative approaches pushing to enter the mainstream, often backed by industry, specialty medical societies and patient advocacy groups. Many are advances or at least have the potential to be, and we want these new answers, sometimes desperately. The problem is we can’t afford them all and, if we could, many wouldn’t turn out to be worth the money.

The US public votes a split ballot when it comes to healthcare Read more…

There are a lot of good things beginning to happen on health care reform, including the first steps on hospital cost and quality transparency; more movement to save taxpayers hundreds of millions of dollars by having municipalities purchase through the GIC; and finally more media focus on the cost side of the equation as exhibited by the important Globe Spotlight team reports.

It is encouraging that public acknowledgement is growing about the need to fix the cost side of health care in order to save the access side. Yet, although I am pleased with the growing attention health care costs are beginning to get, I remain frustrated that the equally important issue of cost apportionment among payers and consumers remains ignored. Health care providers have long complained that government payers—Medicare and Medicaid—do not adequately reimburse the true costs for procedures, creating cross subsidization from private insurance subscribers. True enough. But what about cross subsidies within the ranks of private payers?

Some questions to ponder: If it is true that the GIC is saving the state and now municipalities hundreds of millions of dollars through their group buying efforts, isn’t it also possible that other payers are picking up the tab for those savings? If it is true that the Connector will be holding the line on rate increases at 2% for their Commonwealth Care plans (taxpayer subsidized), isn’t it possible that others will be paying more in order keep those increases in check? Read more…

With many of the societal problems we’ve conquered, from littering to smoking, the solution really came down to changing our collective individual behavior.

The same may be true for the health care challenges facing Massachusetts today.

Childhood obesity has become epidemic, one being attacked from several different angles. But the most effective ones — and here is the good news — may be the ones that cost the least amount of money.

The Governor proposed a workplace provision as part of the obesity initiative he launched this week. It didn’t get most of the attention. It won’t generate the most controversy. But it may be the most far-reaching measure of all. What better place to educate people about nutrition, exercise and other healthy lifestyle choices than the workplace, where most of us get our health insurance and spend most of our waking hours? Read more…