What Will The Government Have to Do to Make Health Care Reform Work?
I'm glad to see columnists and reporters who cover health care turn to the question of how reform, once it's passed by Congress and signed into law by President Obama, will actually be implemented by the federal government. None of the spate of stories and columns on the importance of the Massachusetts model or of a mandate to purchase insurance discuss the formation of a new agency or division to handle implementation and oversight. But at least they're asking the right questions about implementation. For example, Alec MacGillis at the Washington Post dives into the question of how an individual mandate might work (and how it has worked in Massachusetts' reformed health care system). He writes:
The record of mandates is mixed, according to research done by Sherry Glied, a Columbia University professor of health policy who has been nominated for a position in the administration. The rates of people buying car insurance, for example, vary among states and do not correlate directly with the size of penalties for going without insurance. Overall, she found, mandates work best when compliance is relatively easy and affordable, when penalties are "stiff but not excessive," and when enforcement is prompt and routine.
But he also describes a massive community organizing effort that enlisted a wide array of public, private, and non-profit entities, ranging from churches to supermarkets, to spread the word about the mandate to purchase insurance. Massachusetts is a small state. Organizing such an effort would be vastly more complicated, both logistically and politically, on a nation-wide scale. Giving whatever federal office is tasked with that responsibility the resources it will need to accomplish it will be critically important to the success of health care reform. Paul Krugman is optimistic about the potential success of national reform efforts. I'd be curious to see him grapple with the organizational issues at stake.
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Unless the penalty for not buying insurance is huge, most people that don't feel they need it or that it is expensive at any price will not comply. They rightly feel that in an emergency they will get satisfactory treatment and otherwise they don't care/want it and doubt that there will be any inforcement unless there is an emergency and then it is irrelevant. The comparison with auto insurance is similar. Those who don't want of care just don't do it and assume they won't have an accident.
Ken Baumann Posted Monday, October 26, 2009 4:13 PMwe need to discuss mandated insurance not only for those who must buy insurance but also for those who can be covered by a government program. As new york has experienced having the potential to be covered versus actually enrolling are separate issues. New York has 2.7 mil uninsured with 1.3 mil having the potential to be covered.why do we think all these people will magically be enrolled?..especially when the state budget already has issues..these are the patients who would rather use an emergency room and have charity care then go through an enrollment process. As we know emergency care is not the best care. assuming (like ken does above) that people's behavior will not change as long as the emergency room is avialable, we need to allow providers to enroll patients at the point of service. The systems are available and so is the patient. I don't think we can keep our fingers crossed on this one..
notmd Posted Tuesday, October 27, 2009 12:03 PMMost people do not recognize that the reform is not instantaneous, but has a very long implementation period. It's not even like ARRA where the monies are taking a while to be awarded. The timeline for this is years, and I would be very surprised if it doesn't take over a decade for this to unfold fully (with several legislative adjustments in out years).
Drew Altman, President of the Kaiser Family Foundation, has an interesting blog discussing implementation with a timeline graphic at:
http://www.kff.org/pullingittogether/100909_altman.cfm
Lots of interesting info on health reform and what it will take can be found at several websites:
http://www.academyhealth.org
http://www.commonwealthfund.org
http://www.rwjf.org
http://content.healthaffairs.org
And the timeline discussed by Dr. Altman is only the planned timeline. I think the organizational challenges to this are tremendous. As a health services researcher, I consider this to be a full employment stimulus package for the foreseeable future ;-)
Dave B. Posted Thursday, October 29, 2009 11:38 AM