Is the Political Terrain Shifting on Health Reform?

The politics of health reform, naturally, was a big topic at the annual conference of the Association of Health Care Journalists a few weeks ago. Speakers included both Don Berwick, the chief of the Centers for Medicare & Medicaid Services (CMS), and Francis Collins, director of the National Institutes of Health (NIH). I thought I’d report some of what I heard and observed there, and take stock of where we are, in reality, under all the Affordable Care Act (ACA) sound and fury.

As of this writing, since taking control of the House in January, Republicans have tried to repeal the ACA, strike out large portions of the law, defund it, and weaken some of the regulations of health reform. Some were willing to shut down the government over health reform.

Yet as of now, the main changes on the federal level are the repeal of the 1099 tax filing provisions (which was bipartisan) and cutting some, but not all, of the funding for states to set up coops as an alternative to the (gone but not forgotten) public option.

Not a mortal blow to health reform.

Not even a mortal blow, necessarily, to co-op formation.

Obviously, the ideological and fiscal and political battles about the ACA are not over. Dozens of other bills are floating around, ranging from changing how brokers are treated under the medical loss ratio to repealing Community Living Assistance Services and Supports (CLASS) and gutting the Independent Payment Advisory Board (IPAB). That’s not going to evaporate overnight, and we’ll probably hear some of the ACA repeal/defund language again as part of the debt ceiling debate.

But it’s not center stage.

At the federal level, the attention for the moment is shifting to the future of Medicare (premium support/vouchers) and Medicaid (block grants.) The state politics and the decision making about setting up exchanges is intense right now, but remember that a state that opts out of establishing its own exchange isn’t opting out of health reform, it’s paving the way for the federal government to set up that exchange. Plus there’s some wiggle room – states don’t have to have everything lined up as their legislatures wrap up sessions this spring. There’s still time next year, although of course the states that get an early start may well do a better job as it’s a technically difficult task.

The courts are unpredictable. We can all imagine a scenario where the mandate is upheld, and we can all image one where it is struck – and we can imagine it before the 2012 elections and after. It’s a lot less likely that the Supreme Court will uphold the Florida ruling and just throw out the entire statute.

On a panel discussion about health politics, Noam Levey (an LA Times reporter whose work I respect a lot) pointed out that he is just beginning to hear a new word on the Hill. Not repeal. Not replace. But “fix”. It’s not the new mantra, and it’s certainly not the new political order. But he has begun to hear some Republican lawmakers say they want to “fix” this or that provision. That’s a change.

Without overinterpreting the language, the semantic shift Levey cited does seem to suggest that at least some conservatives understand the ACA is not only the law of the land but a law that will begin to put down roots, affect people’s lives, and become part of the socio-legal-economic fabric, just like Social Security and Medicare did.

One clear indication that we’re on shifting political terrain: Berwick’s sudden [relative] outspokenness and availability to the media. That was of course characteristic of Berwick’s pre-government life at the Institute of Healthcare Improvement. He likes to talk to writers, and I mean that as a compliment; many of us have learned a great deal from him. (Apparently, when he spoke to AHCJ a few years ago, he ended up hanging out and watching March Madness basketball with some of the reporters.) But he didn’t say all that much in his first months as CMS head. His speech to the health journalists certainly kept “on message,” as the president himself had already said similar things. But it was much more pointed than I’d heard Berwick since he joined the government.

“They are untested, they are hazardous,” he said of the Medicaid block grants. Rather than give states that vaunted flexibility, they could actually tie states’ hands in hard times. “What happens if we issue a block grant to a state and then there’s a flu outbreak or the recession comes back? Well, you’re on your own.”

He said the Washington battles over Medicare too often got boxed into “cut providers” or “cut benefits” (aka rationing). “You are seeing a lot of talk today about cutting,” he said, referring to the House budget. “I don’t like that plan. I don’t think cutting is the best way.”

He said he has a better idea: save money by improving care. Stop the infections. Stop the mistakes. Stop the duplication. Stop the unnecessary readmissions.  Improving care while cutting costs is “kind of the secret weapon of the American health care economic crisis.”

“The best way to make health care affordable and sustainable,” Berwick said, “is making it better.” Health reform, he said, gave him tools, like the Center for Medicare and Medicaid Innovation, to do that.

Politically, however, the national focus (and Wisconsin town hall meetings) does seem to have shifted away from ACA per se  over to entitlements – Medicare being more politically potent than Medicaid. The Obama administration had a hard time explaining health reform and “bending the curve”, and I’ve often noted that when Americans hear “delivery system reform” they probably think it has something to do with whether they will still get mail on Saturdays. It will be interesting to see how Republicans and Democrats explain how “premium support” will affect the next generation of aging Americans.

Language will matter a lot, suggests a recent “data note” from the Kaiser Family Foundation, examining why public opinion polls on Medicare have been all over the place:

Surveys conducted by five different polling organizations in the last two months have attempted to gauge the level of public support for such a plan, and their results have varied widely, ranging from strong support for keeping Medicare as is, to a roughly even split, to a leaned preference for changing the system. These polls also show that support for both changing Medicare and for keeping the current system can be driven even further up or down when respondents are exposed to arguments typically advanced by those on either side of the debate ….

There is often no right way to ask a poll question, and variations in question wording can make a big difference in observed levels of support for a given policy proposal. Two things, however, are clear from the analysis above. The first is a reminder that it is important not to place too much emphasis on the results of any single poll question, particularly when it comes to complex policy debates, the details of which are still largely unfamiliar to the public. In these cases, it is often helpful to look at the results of various questions asked in different ways in order to gain a more nuanced understanding of how the public might react as a debate unfolds

… In Washington, the debate over whether and how to change Medicare as part of efforts to reduce the deficit is just beginning and the various survey findings shown here suggest that whichever side does a better job getting its arguments across to the public may ultimately gain the upper hand, at least from a public opinion standpoint.

Television images of angry voters at Republican town hall meetings may also have an impact. Local television in Wisconsin (click here for report) described, but apparently didn’t capture, images of Rep. Paul Ryan slipping out a side door with police to avoid protesters surrounding his own car. If someone with a cellphone video camera got it, it may well introduce millions of seniors to YouTube.

A final note: For those of you who are wondering about how NIH’s Francis Collins weighed in on all this – he talked science, not policy to the journalism conference. Stem cell research, gene therapy, and even the opportunities to change the science of prevention. And he conveyed a lot of excitement about the state of biomedical research in the early 21st century. Once, when someone asked a highly technical question about cellular proteins or something along those lines, Collins half-jokingly asked the reporter if he had a Ph.D. in microbiology (He did!). But as a writer, I loved how Collins made the connection between his laboratory and our journalism. “Stories,” he said, “are what we humans migrate to.”


Contributing Writer Joanne Kenen writes monthly news features for the Health Policy Forum discussing health policy innovation and “what works” in our health care system, as well as the politics of health policy and reform. 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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