News

Last week was a powerful and exciting week for anyone who cares about health care in this country.  Whether you agreed or disagreed with the specifics of this legislation, there was common agreement that the Patient Protection and Affordable Care Act of 2010 was momentous legislation. I do support the legislation, not because I think it is a perfect bill but because I think it is an important foundation to work from.

Despite the claims of critics, this is not radical legislation.  Indeed, it is a uniquely American piece of legislation: it works within the current structure of health care rather than replacing it.  Setting aside the rhetoric, this bill respects American traditions while making health care part of the social compact. The legislation is a mix of market approaches and public approaches: it is by no means a government takeover of health care (was Medicare a government takeover of health care? oops, I digress).  The legislation keeps in place provider choice, insurance choice, and the private delivery system of health care.  It doesn’t fundamentally change our drug development system, our medical education system, or our public health system; it does build on and modify all of those systems. Indeed, the criticism of many policy analysts is that the legislation actually doesn’t change enough about the current health system.  But even the most ardent advocates for radical changes to the system came to realize that simply wasn’t going be politically possible.

There were incredibly moving moments over the past week– especially the bill signing.  But, it was also a discouraging week as untruths about what was in the bills continued to fester in so many places.  Reporters asked me why so many people seemed so worried and upset by the bills.  Unfortunately, I think the answer to that question has more to do with the politics of the legislation than the policy.  While there are certainly many who have legitimate disagreements about policy issues, there are also many who oppose the bill because they a have fundamental philosophical disagreement with the idea that health care should be part of the social compact.  Rather than simply owning that view (a view that is certainly at odds with that of most Americans), some resorted to hyperbolic claims and false statements about what was in the bill, using language designed to breed fear.  And, those falsehoods come with a cost: they destabilize the public and de-legitimatize discourse.

Leaders have a responsibility to speak from truth and facts, not to frighten people with hyperbole.    The level of uncivil discourse has done a terrible disservice to the American people.  At a time of dislocation and insecurity, public officials should take pains to be thoughtful, honest and clear in their communications: to encourage meaningful and informed debate.  Instead, what we have seen has been inflammatory, confusing and playing to people’s basest fears.  This is the kind of discourse that led to the repeal of the Medicare Catastrophic bill of 1988 after Representative Dan Rostenkowski’s car was stoned by angry senior citizens.  While some who practice this type of rhetoric might hope for the same outcome in this case, they are misguided. Most health policy analysts believe the Medicare Catastrophic bill was actually a far better bill than the Medicare Prescription Drug, Improvement, and Modernization Act that passed in 2003, which took more than 10 years and an enormously complex approach to achieve less for millions of seniors.  Unbridled rhetoric has consequences: some, catastrophic.

The truth is, the bill signed by President Obama is neither perfect nor radical. It embeds the principle that health security should be a basic American right, while still embracing a market based system. These two goals have often been in conflict, resulting in the defeat of many previous efforts at health reform. This bill is big and complex and makes many compromises to balance those goals.

The truth is, this bill will help millions of Americans, and while it may not go as far as many would have liked on improving the cost and quality of the system, it goes further than ever before, further than the status quo was ever going to get us, and further than many predicted it could. So yes, there will be changes and fixes down the road.

But the truth is, we finally have a health policy in America to build upon. And that, in and of itself, is a good thing.

When the history of the 2010 health reform bill is written, it should include a shout out to Anthem Blue Cross of California for all of its help. What a lot of changes in a short period of time! Remember the ancient history of January 19, 2010? That was the day that Scott Brown of Massachusetts was elected to fill the late Senator Edward Kennedy’s seat. Here’s a sample of what the news reports said after the election:

“I think you can make a pretty good argument that healthcare might be dead,” said New York Democrat Anthony Weiner, a fierce advocate of the public option. Another New York liberal, Democrat Chuck Schumer, thinks discontent among Independents will force Democrats to de-emphasize healthcare to focus on what matters to voters — jobs. “Our focus must be on jobs, the economy and delivering for the middle class,” he said. (January 20 LA Times)

Newspapers around the country echoed those views, and in the weeks after the Brown election those views deepened: the voters had spoken, health reforms were deeply unpopular, and the House would never pass the Senate version of health reform (the only viable way to get health reform without a filibuster-proof majority in the Senate).

Well, lo and behold, it is just over two months later, and guess what? The House has passed the Senate bill and health reform writ large is now about to become the law of the land!

So, what happened to change the story? Was it that the President became more engaged, or the public more supportive * (or, at least, less negative)? Did the bi-partisan summit held in late February accomplish its desired end?

Well, yes, all of that is true. But even with all of that, I don’t think we would have seen the passage of this historic health care bill Sunday had it not been for Anthem’s announcement in early February that it was raising individual rates by 39 percent.

Assuming that Anthem was not adopting Machiavelli’s approach (i.e., actually trying to get health reform passed — which did cross my mind), then one has to wonder what they were thinking to announce those rate increases in the midst of this great debate about health reform. Until Anthem announced its rate increases, advocates were having a hard time explaining reform in ways that resonated with the public. The President and Congress spent a lot of time talking about health reform in a very technical way, focusing on the details of policy changes and broader systemic impacts. How many people are sick of hearing “bending the cost curve,” as I am? (And who even knows what that means??) Opponents of reform, on the other hand, had much simpler sound bites about “death panels,” Medicare cuts, and the like.

But Anthem’s proposed rate increase gave advocates a clear message to rally around. The message was important — not just to change public opinion, but to help wavering law makers and give them something they could use in their districts to run on. It is no coincidence that after Anthem’s rate increase announcement, the President really seemed to find his voice on health reform. This was a message that the public could understand: rates are going up, people can’t afford care, and health reform would help with that.

So, on this historic day and on behalf of all the advocates of health reform: thank you Anthem Blue Cross. It wouldn’t have happened without you.

* With regard to the polling data: the polls have moved slightly in a favorable direction since January. On January 20, the day after Scott Brown got elected, the Rasmussen poll had 40 percent favoring health reform and 58 percent opposed; on March 14, 43 percent were in favor with 53 percent opposed.

The White House is saying that we will have health reform enacted by next Sunday. While health reform is the term often used to describe the House and Senate passed bills, in fact a large part of what is called health reform is really focused on health insurance reform. And, a big piece of that reform is designed to deal with the fact that today many Americans cannot get health coverage because of their health status. Leave it to the British to coin the artful phrase in describing this problem: “lemon drops.” Lemon drops is their term for what we call, much less elegantly, those with “pre-existing conditions.” And, what an appropriate term it is: those who are sick are the “lemons” that no health plan wants to cover. As an effort to avoid “lemon drops,” insurers spend a tremendous amount of time and money on trying to “pick cherries” — that is, applying medical underwriting to try and avoid covering those who are most in need and covering instead those who are healthy and likely to stay so.

The health reform bills in Congress are as complex as they are, in part, because of the goal to reform the insurance market and eliminate pre-existing condition exclusions and medical underwriting in the individual market. For that to occur, mandating coverage has been described as a pre-requisite. Linking guaranteed issue and mandatory coverage in the individual market makes sense because unless everyone is required to purchase coverage, it is likely that people will do a rational calculation: only buying coverage if they think the cost of that coverage will be less than the cost they would otherwise spend on care. That means that only those who are sick or expect to get sick will likely spend the money for coverage, breaking down the fundamental insurance principle of pooling of risk and sharing of cost. Over time, an adverse risk spiral can develop with those at the lowest risk dropping coverage leaving behind a sicker and sicker population in the insurance pool. We have seen this occur in Michigan where only Blue Cross and Blue Shield of Michigan is required on a continuous basis to take all comers regardless of health status.

Some economists, however, have argued for a different structure for getting to universal coverage in the individual market. Rather than mandating consumers to purchase coverage and requiring insurers to guarantee issue, they suggest an incentive based system. They rightly note that the penalties for failure to purchase coverage are politically vulnerable and likely to be too low (as they are in both the current versions of the Senate and House bills) and that over time, the same adverse risk spiral will develop nationwide as exists now in Michigan (indeed, if you listen closely to what the insurance industry is saying, this is what they are really arguing when they say the bills aren’t strong enough). Mark Pauly has been the most elegant proponent of this concept. In his approach, rather than mandating coverage and requiring guarantee issue, there would be financial incentives for individuals to purchase coverage while young and healthy. That is, cost would increase later in life. This approach is taken in the long term care market. Though that market is small, there is some indication that this approach does work to encourage people to buy and keep coverage — without the added complexity and political volatility of mandating such coverage

Americans hate being told they have to do something. Much of the turmoil around health reform has really been about Americans’ dislike of being mandated to participate and feeling that they are subsidizing the costs of others. Of course, that is what insurance is all about, but that concept when applied to social insurance is in serious tension with apparent American values. Mark Pauly’s idea may not be perfect but it may, in fact, be the better method to approaching universal coverage consistent with what most Americans seem to want. If health reform does pass this week and maintains the current mandates coupled with insufficient sanctions to really make community rating work, then we will have a great experiment to look forward to. If this method of dealing with the “lemon drops” doesn’t work, however, then it will be well to consider the ideas Pauly has put forward in the next round of health care reforms.

Today we are releasing a survey of Michigan citizens’ views[CHRTS CM SURVEY 2010] on access to health care. The findings from this survey paint a picture that differs from some conventional wisdom and adds a different dimension to the debate on health reform in Washington. In particular, the survey makes it clear that having health insurance is important but no guarantee of access to health care or self-perceptions of health status. The survey tells us that those with Medicaid coverage are having difficulties finding providers who will care for them; that even those with health insurance delay needed care at times because of the cost of that care; and, that there is no difference in perceived health status based on insurance coverage. Instead, the survey points to the importance of socio-demographic factors in perceptions of health status and the ability to obtain needed health care: income, education, gender. An exception to that finding is that urban residents — though averaging the lowest income of the survey respondents — had an easier time getting access to health care than all but the highest income, suburban residents. That finding could be an indication that the safety net ‚ more evident in urban areas — is making a difference in providing access to health care.

The implications of the survey are important and relevant to current discussions on health care reform at the state and federal level. The focus of federal health reform today is largely on expanding insurance coverage. While there is some effort to deal more directly with access to health care (the President’s health reform proposal, for example does include $11 billion in additional funding for Federally Qualified Health Centers and the National Health Service Corps), the principal mechanism used to expand access for the poor is the provide Medicaid coverage to all citizens at or below 133 percent of poverty. As our survey shows, however, expanding Medicaid may be problematic at best. Indeed, though the President’s health reform proposal contemplates full federal funding of the Medicaid expansion, it does nothing to correct the underlying structural flaws in the Medicaid program.

Medicaid has historically been designed to pay less than the cost of delivering health care and those ratios have worsened over time, especially in Michigan where budget challenges have forced a choice between keeping coverage broad and avoiding further cuts in payments to providers. Michigan’s payments to physicians are particularly low [CHRT’S IB ON HEALTH CARE SPENDING BY COUNTRY, STATE, PAYER] relative to Medicare and to other states. So, while intending to improve access to care, as currently structured the health reform bills might actually worsen the situation for some. How could that happen? Isn’t some coverage better than none? Well, already today Medicaid covers approximately one out of every six Michigan citizens. If there is a significant increase in the numbers of Michigan citizens covered by Medicaid, more physicians may stop accepting Medicaid patients worsening the availability of providers to both those who currently have Medicaid coverage and those who might gain coverage under health reform. So, while some coverage might be better than none, providing coverage while doing nothing to make sure that coverage is meaningful certainly doesn’t solve the problem of making sure people can get the care they need when they need it.

While raising questions about the viability Medicaid (without changes to strengthen its financial model) as a vehicle to expand access to health care, the survey does help point policy makers to one possible solution: expansion of community health centers and other such direct care options. Thinking about access to health care in a different way — based on data like these — may lead to different types of solutions than those in the bills currently under consideration in Congress. It’s not that insurance reform isn’t important — it most certainly is — but it is simply not sufficient. Expanding direct service — to an even greater degree than now proposed or even contemplated — might be a fresh way to think about the problem of access to care, and may in fact have a bigger payoff in improvements to health of the population. Maybe it could even get bi-partisan support.

Wouldn’t that be something?

Much has already been written about President Obama’s Health Reform Summit and what we learned or didn’t learn (see in particular blog posts at the Wall Street Journal and the New York Times). On the same evening as the Summit, I had an opportunity to participate on a health reform panel sponsored by the University of Michigan college Democrats with my colleagues, Catherine McLaughlin, an economist with the U-M School of Public Health and Mathematica; and Matt Davis, a pediatrician and faculty at the Ford Policy School. The panel gave us the opportunity to reflect on the Summit in a more focused and local way. One of the students in attendance asked a question with particular relevance to some of the dialog at the Summit. His question was, is Blue Cross and Blue Shield of Michigan a role model, can other states learn from us in Michigan, and can reform happen at a state level?

My answer to this question goes to both the complexity of health reform and why it is so hard to sell it in a sound bite. Interestingly, over the past week or two, much has been written about the 39 percent rate increase planned by Anthem in California for their individual market. In almost the same breath, folks at the Summit and in the press have raised the 56 percent rate increase requested by Blue Cross and Blue Shield of Michigan (BCBSM) for its individual market. While these two situations have been equated, the facts behind each are unique to their local markets and the nature of these two insurers.

BCBSM is a non-profit insurer that is (and has been for the past 70+ years) the insurer of last resort in the state of Michigan. Anthem is a for-profit insurer, converted from what was Blue Cross of California. BCBSM is required by state law to provide guaranteed issue products in the individual market place, i.e., to take all comers regardless of health status and its rates for this segment are heavily regulated by the state’s insurance commissioner. Anthem is not required to guarantee issue and actively uses medical underwriting exclusions in its individual segment. BCBSM insures approximately half the state’s population while Anthem faces significant market competition in California.

In part because of its large market share, non-profit status and history, BCBSM is indeed a role model for many of the ideas embodied in health reform: innovative contracts with hospitals and physicians, a commitment to a social mission, and a role as the insurer of last resort. BCBSM can also be seen as a case study of why there is a need for health reform: because it is the only insurer in the state that must take all regardless of health status, the risk pool in the individual market has deteriorated over time, with healthier individuals either dropping coverage or finding cheaper coverage elsewhere, leaving BCBSM with a sicker and sicker population to cover and increasing financial losses in the individual pool. And, because rates are heavily regulated in the individual market for BCBSM and BCBSM alone, rate approvals take a long time, leading to lagging rate adjustments out of sync with rising health care costs and “shock value” rate increase percentages when they are finally approved (the actual rate increase approved for this segment was ultimately 22 percent — not the 56 percent requested).

This is a very different situation than the one in California. The factors leading to the rate increases for Anthem are also complex but unique to the situation in that state and market — in fact, Anthem may have a different problem from BCBSM because it faces more a more challenging provider contracting environment than the one in Michigan.

Nationally published data tell us the rate of increase in health care spending in Michigan has been less than the national average[CHRT REPORT HEALTH CARE SPENDING BY COUNTRY, STATE AND PAYER] for over 20 years and I think much of that can be attributed to the innovations implemented by BCBSM in its relationships with providers. But, can health reform be solved at the state level? Despite what some politicians say, the research and data is pretty clear: to really address insurance reforms and substantially expand coverage, reforms have to be made at the federal level. There are many reasons why that is so (the New England Journal of Medicine has an excellent article on this as well). Expanding coverage and ending pre-existing condition exclusions and the like means that people cannot pick and choose to be covered based on their own health status: the healthy and the sick must both be in the pool in order to avoid an adverse risk spiral. And to accomplish that, there needs to be a mandate or tax subsidized system of some kind. And, that has to be accomplished at the federal level. So, the bottom line answer to the student’s question is: yes, other states and the country can learn a lot from what has happened with BCBSM and in Michigan: BCBSM shows both what can be accomplished and why reform is so needed at the federal level.

The fact that presidents have been trying to get some form of universal, government supported health insurance for almost 100 years now has been well publicized. What is less known is why — with the exception of the passage of Medicare and Medicaid in 1965 — almost all of their efforts have failed to produce substantive change. It’s instructive to look back in some detail to better understand the issues involved and what went wrong in each case. Such an exercise is essential to understanding both the forces that continue to shape public policy in America and the tactics that can affect those forces.

A review of history and even our current situation tells us that that the issues really haven’t been about whether or not Americans want some form of government help with the costs of medical care. In polling data going back to the 1930s, Americans have almost always responded favorably to the idea of the government playing a role in providing financial support for health care. For example, in a 1937 Gallup poll (cited by Hazel Erskine in 1975), 73 percent of respondents said “yes” when asked if the federal government should provide free medical care for those unable to pay. Even today, despite the debate and negative feelings around the proposals that passed the Senate and the House at the end of 2009, 63 percent of Americans still say they want Congress to pass comprehensive health care reform. So, the problem is less about whether or not people want health care reform than it is what “reform” really means to them, and also, fear of change.

From 1912 to 1916, the Progressives thought that they had strong support for government funding of health care and believed it would be easier to get “social insurance” than it was to get workers’ compensation or other such initiatives. In 1931, I.M. Rubinow wrote a fascinating article about the failure of health reform in 1916. Rubinow’s analysis provides a vivid picture of interest group politics and American values. Who knew, for example, that the inclusion of a funeral benefit in the proposed social insurance would be, as Rubinow puts it, “a grave tactical error because of its implied threat to the gigantic structure of industrial life insurance…”? Or, that there would be an unexpected attack from “Christian Scientists and all other medical cults… who saw a sinister effort of conventional medicine to suppress religious and medical freedom.”

Rubinow explains how, in the face of the attacks from the different interest groups, Americans began to reflect more on their individual rather than communal priorities with the “young and healthy and unmarried” not wanting to take on the burden of those who were “older and the sickly.” The interest group politics of the early 1900s and the anti-health reform lobbying it spawned led the population at large to fear the loss of the status quo — even if the status quo wasn’t so great. As Rubinow says, the proposal was condemned in part because “it would interfere with the natural right of the poor workman to select his own medical adviser, the right they now exercise to a large extent by waiting in line many hours for admission to a free clinic.”

Rubinow drew many lessons from the failed effort to achieve social insurance by the Progressives in 1916. His catalog of what went wrong is eerily prescient of what went wrong in later eras — including what has happened so far in our own. Just substitute some of the details of the time and the names of current interest groups and the same basic issues are evident. I particularly like this part of Rubinow’s conclusions: “Concerted opposition is very much more stubborn than concerted advocacy of the measure, and not only stubborn, but blind…. Occasionally farsighted individuals see [the benefit of the measure]. The organized group seldom does.”

Sound familiar?

References

The Polls: Health Insurance
Author(s): Hazel Erskine
Source: The Public Opinion Quarterly, Vol. 39, No. 1 (Spring, 1975), pp. 128–143, page 130
Publisher(s): Oxford University Press on behalf of the American Association for Public Opinion Research
Stable URL: http://www.jstor.org/stable/2748079 (subscription required to view the full text)

Conflict of Public and Private Interests in the Field of Social Insurance
Author(s): I. M. Rubinow
Source: Annals of the American Academy of Political and Social Science, Vol. 154, The Insecurity of Industry (Mar., 1931), pp. 108-116
Publisher(s): Sage Publications, Inc. in association with the American Academy of Political and Social Science
Stable URL: http://www.jstor.org/stable/1017919 (subscription required to view the full text)

Jerome Groopman published a provocative and thoughtful essay In the February 11, 2010 New York Review of Books  about the way one determines “quality health care.” Groopman’s focus is on clinical guidelines and just how prescriptive they can be. He makes a fundamental distinction between guidelines that can be applied in a standardized way (e.g., how to clean a catheter to reduce the likelihood of infection) and guidelines that may need to be varied based on a variety of patient characteristics( e.g., diabetes sugar control). He is concerned that much of what has been discussed at the federal level in the context of health care reform misses this distinction and could well be applied by payers rigidly. For example, there are proposals being considered that would provide incentives to physicians and hospitals based on how rigorously guidelines are followed, independent of individual patient characteristics. His message is terribly important and often overlooked.

In our rush to embrace knowledge and science, we may over attribute “perfect knowledge” to those who analyze data and publish guidelines for care. As Groopman points out, if one looks back over time, guidelines have often changed when it comes to the best approaches to take for certain treatments. Science with regard to the human body is not immutable and results of research on outcomes of various clinical practices can be misinterpreted or misunderstood. Patients have often been confused by these changes, as recently witnessed with regard to guidelines on mammograms, pap smears, PSA tests and the like. Many of these guideline changes are in fact more nuanced than they seem when reported by the press. And all include recommendations to consider patient history and other factors in determining the right course for any particular patient. Indeed, guidelines are often a review of the extant data, intended to be useful to patients and clinicians in personal care decisions, not prescriptive “how to” manuals. That distinction is too easily forgotten by policy makers.

Does this mean we cannot use guidelines to make medical care decisions, interpret data, recommend best practices and evaluate quality of care? No – guidelines are useful and important components of quality improvement and evaluation. What is important, however, is to not over-value those guidelines and over-legislate their implementation. Medicine, like much in life, still needs judgment and understanding of the applicability of the general to the individual. It is essential for clinical decision-makers to be able to bring an understanding of the strength of the science and a depth of understanding of the research to implementation. Too little reliance on what we know in science certainly leads to potentially bad outcomes for patient care, but so can too much. Policy makers beware: in the search for strategies to reduce health care spending, Groopman has something very important to say.

The last time a major effort at health care reform was tried, it died an ignoble death. Bill and Hillary Clinton were certain that they had read the political signals correctly and that health care reform was a winning issue for them. Bill Clinton framed health care as an essential economic issue after he was elected and before he became President. He included health care as a major issue at the economic summit he held in December, 1992. Bill Clinton got it then. Remember? “It’s the economy, stupid!”

At the time, business leaders who attended the summit were quoted as saying that they were “wowed” by his command of the issues and commitment to fixing the economy. In a news conference after the summit, the President-elect listed the ideas where he believed there was consensus. “Repairing the nation’s health care system” was high on that list.

Well, he was wrong. There wasn’t a consensus about “repairing the nation’s health care system.” Much has been written about why health reform failed in 1994 — that’s not my focus right now. Rather, I think it is important to understand this issue: Consensus on the need for reform.

In the early 1990s, much was said about rising health care costs. At that time, health care cost trends were in double digits and employers were increasingly talking about the economic burden of health care premiums. Consumers, too, were talking about their fears of losing health coverage. The press reported about people staying in jobs to avoid becoming ineligible for coverage due to pre-existing conditions. “Job lock” was the term given to employees’ fear of changing jobs. It was easy to read the signals in those days as a mandate for fundamental change in the health care system.

What became increasingly clear as the health reform debate went forward, however, was that the desire for change was a mile wide and an inch deep. Consumers and employers began to be concerned as the dimensions of “reform” began to take shape. Opponents were easily able to characterize the health care proposals as taking away health care security — not giving it. In the end, the proposals failed because the public (consumers and employers alike) decided that they were more afraid of the changes being proposed than they were of the “status quo.”

When the Clinton proposals failed, most thought that the health care system in place at the time would pretty much stay as it was. But, in fact, that’s not what happened. Employers were serious that they wanted change in health care — they just couldn’t coalesce around a single vision of what that change would entail. So, after the failure of health reform at the federal level, almost overnight, employers changed the health benefit plans they offered quite dramatically. The country moved almost wholesale into managed care.

For a time, that strategy seemed to be working. Health care trends moderated and analysts were claiming victory for reform. The only problem was that consumers hated the “reforms” they got. Almost as quickly as benefit plans were changed, the “managed care backlash” started. Laws were passed to limit what health plans could do and employers retrenched in face of employee complaints. And the “status quo” of the early 1990s? Long gone.

Are there lessons from the Clinton years for today’s foray into health care reform? As someone might say, “you betcha.” While the public might be fearful of the current proposals for health reform, it shouldn’t be fooled into thinking that the failure of these sets of proposals means that the status quo will stay in place. One thing is certain: change in health care will come one way or another.

There is much speculation — and advice — about what to do about health reform given the change in Congress since the Massachusetts’ Senate race. Some policy makers and pundits are advising that it would be better to take small bites out of health reform — rather than trying to continue down a path focused on change to the entire system. There are significant problems with such an approach when it comes to insurance reform (see for example, this New York Times Economix blog post).There are, however, some considerable gains in health care that could be made in this way and that should not be overlooked.

Mental health care is a good case in point. On January 29, 2010, the Department of Health and Human Services (HHS) promulgated the rules for the Mental Health Parity and Addiction Equity Act of 2008. This Act, which was appended to the 2008 TARP and signed into law by President Bush, has the potential to help many millions of Americans. HHS estimates that 11 percent of the population suffers from serious psychological disorders and nine percent suffer from addiction disorders. Some researchers put these numbers closer to one fourth of the population, not counting family members who also suffer as a result of these diseases.

Advocates have been working towards mental health parity for many years. Many thought equity was achieved when the Pete Domenici Act went into effect in 1996 only to be disappointed to discover how many loopholes were left by that Act. Efforts to close those loopholes started in earnest right after that Act was passed. Though it took more than 10 years to achieve full parity, that goal was achieved — with bi-partisan support — with the passage of the Pete Domenici and Paul Wellstone Act in 2008.

The 2008 Act reformed insurance coverage (for those with health insurance). The comprehensive health reform bills passed in late 2009 by the Senate and the House would have helped further mental health research and care. A little known component of both the Senate and the House health reform bills, the ENHANCED Act (S. 1857 and H.R. 4024), would have provided substantial funding for a national network of depression centers. The funding would have gone to academic institutions or non-profit research entities to expand services and research into treatments for depression, bipolar disorder and the like. Funding for an element of the health reform bill like this — discrete and building on the current system — is something that could be passed as piece unto itself. Given the history of mental health legislation (and the fact that mental disorders are equally likely to strike Democrats and Republicans), such legislation is more likely to garner bi-partisan support than other more sweeping elements of the health reform bills.

Is reform like this good enough? Well, it doesn’t provide a fundamental change to the system. As such, it won’t provide significant help to the millions who have no coverage at all. And, it won’t address the underlying cost issues that drove the discussion and the desire for system-wide health reform. But, it could help many millions in this country, and, in fact, the world. While I still believe we need — and hope we get — comprehensive health insurance reforms, maybe we could at least move forward on something as important as this while we wait.

Well, every politician for the past 100 years has known that health care reform is the “third rail” of politics. And, if they didn’t know before Massachusetts, they know it now. So, why did health reform fail this time? Is it for the same reasons it has in the past or is there something unique about this moment or this president’s strategy for health reform that seemed to get so off track? While the history of health care is fascinating and the commonality of failure can make it seem that there is a hex over health reform that has infected everyone who tries, each failure of the major efforts at reform actually has its own unique set of causes. What is common about all of them is that the public cares a lot about health care — it is truly a personal issue. What is also common is that the public generally is more comfortable with systems that are known — even if largely disliked – than with approaches that are unknown or unclear. That is, the public generally has a fear of change. Opponents have always had an easier time engendering fear among Americans about what is proposed than proponents have had in helping people see the advantages of proposed changes.

Beyond these commonalities, what was it about this current health reform proposal that led to such a negative view in a state like Massachusetts? Is it because the policies that have been proposed by either the House or Senate are so radical that they are inconsistent with American values? Is it because there really isn’t support for changing how we finance health care in this country? I don’t think either of these are the case.

Indeed, one of the great ironies of the vote in Massachusetts was that the bills in Congress are, in large measure, patterned after the health care reforms that were enacted in Massachusetts in 2006. Those reforms were bi-partisan and are still strongly supported by the citizens of Massachusetts. And they are by no measure considered a radical departure from the structure of health care that exists in the rest of the country. The current bills in the House and Senate are similar and were also designed to build on the current system not replace it (to counter a criticism of earlier national reform efforts).

So, if it is not that the proposed bills are so radical or even so different from what is already in place in Massachusetts, what was it that set off the voters such that many of them told pollsters that their vote was all about stopping national health reform? I believe the issue at its core was not the substance of the legislation, but rather the process of legislating.

Health care accounts for one sixth of the U.S. economy. As such, virtually every interest group has a stake in what happens and all want to be at the table. The process of legislating anything requires dialog and compromise. And, legislating something as complicated and sweeping as health reform means that dialog and compromise will involve a lot of moving parts.

So is that bad? Not necessarily, but for something this big, it is ugly, visible, and takes time. And through this process, provisions that are not very savory often find their way into the bill (exhibit A: the special deal for Nebraska on Medicaid payments).

Also, the bills in Congress are trying to change — all at once — many elements of the health care insurance, financing, and delivery system. Because there are so many components in play, the legislation is complicated and the change hard to communicate in simple terms. That means that media coverage is often focused on the process rather than content of reform — and certainly, the process and its ugly side is a lot easier to understand than many of the detailed changes in tax structure, subsidies, independent quality review commissions and the like.

This process has always been the way Congress gets things done. But, we live in an era of 24/7 news coverage, instant analysis and approaches to filibusters that have helped increase the partisanship in Congress. Indeed, if the Medicare negotiations were occurring today, I think it unlikely that that bill would have passed either, despite President Johnson’s prodigious legislative skill.

So, where does all this leave us? Can the current effort at health reform go forward as is? If not, what is the message about the political reality of tackling anything this big — now or in the future? While these proposals got awfully close to the finish line — so close that nearly everyone in health care had already started talking about implementation issues “when” health reform is done rather than “if” health reform is done — I am guessing these proposals will have to be scaled back greatly to reflect political realities. I do think something will pass — and it will be something meaningful: the Democrats and the President have made this issue too central to their agenda for nothing to move forward. But, given today’s world, whatever is ultimately passed will need to be more easily understood and be smaller in scope than what many had hoped.

I know that a lot of advocates and those who worked so hard on these bills are in deep despair about the prospects for this reform legislation. But, maybe it is better to recognize the reality of today’s environment and take it as a lesson for the future on how to deal with important issues. After all, Winston’s Churchill’s view of democracy is as important today as when he said it in 1947: “Many forms of government have been tried, and will be tried in this world of sin and woe. No one pretends that democracy is perfect or all-wise. Indeed, it has been said that democracy is the worst form of government except all those other forms that have been tried from time to time.”