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Inside National Health Reform

Inside National Health Reform

Copyright Date: 2011
Edition: 1
Pages: 360
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  • Book Info
    Inside National Health Reform
    Book Description:

    This indispensable guide to the Affordable Care Act, our new national health care law, lends an insider's deep understanding of policy to a lively and absorbing account of the extraordinary-and extraordinarily ambitious-legislative effort to reform the nation's health care system. Dr. John E. McDonough, DPH, a health policy expert who served as an advisor to the late Senator Edward Kennedy, provides a vivid picture of the intense effort required to bring this legislation into law. McDonough clearly explains the ACA's inner workings, revealing the rich landscape of the issues, policies, and controversies embedded in the law yet unknown to most Americans. In his account of these historic events, McDonough takes us through the process from the 2008 presidential campaign to the moment in 2010 when President Obama signed the bill into law. At a time when the nation is taking a second look at the ACA,Inside National Health Reformprovides the essential information for Americans to make informed judgments about this landmark law.

    eISBN: 978-0-520-94961-4
    Subjects: Health Sciences

Table of Contents

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  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-viii)
  3. List of Tables
    (pp. ix-x)
  4. Foreword
    (pp. xi-xii)

    The Milbank Memorial Fund is an endowed operating foundation that works to improve health by helping decision makers in the public and private sectors acquire and use the best available evidence to inform policy for health care and population health. The Fund has engaged in nonpartisan analysis, study, research, and communication since its inception in 1905.

    Inside National Health Reformby John E. McDonough is the twenty-second book of the series of California/Milbank Books on Health and the Public. The publishing partnership between the Fund and the University of California Press encourages the synthesis and communication of findings from research...

  5. Preface
    (pp. xiii-xiv)
  6. Acknowledgments
    (pp. xv-xvi)
  7. List of Abbreviations
    (pp. xvii-xviii)
  8. Introduction—A Meeting in Minnesota
    (pp. 1-14)

    I joined about forty persons in a nondescript conference room somewhere near Saint Paul, Minnesota, in late April 2008. Most were veterans of the 1993–94 national health reform campaign conducted during the first two years of President Bill Clinton’s administration; a smattering of folks such as me, who would be involved in the next round, were also in attendance. That effort began with fanfare and high hopes in January 1993 when the president named first lady Hillary Rodham Clinton to lead a five-hundred-person task force to develop comprehensive health reform legislation. It ended in utter failure in the fall...


    • [PART I. Introduction]
      (pp. 15-18)

      About thirty years ago, former U.S. surgeon general Julius Richmond and the health researcher Milton Kotelchuck wanted to answer a question: How does public health knowledge get translated into public health policy, action, legislation, and law? More broadly, how does knowledge get translated into public policy? The answer, they concluded, involves three ingredients: the knowledge base, social strategy, and political will.¹ Theknowledge baseis the science-based evidence necessary to make judgments and decisions. Thesocial strategyis a plan of action by which knowledge can be translated into policy.Political willis society’s desire and commitment to develop and...

    • 1. The Knowledge Base—Why National Health Reform?
      (pp. 19-34)

      In national politics South Dakota is a reliable red state, a backer of Republican candidates in every presidential election since 1968—even rejecting its homegrown Democratic candidate, George S. McGovern, in 1972. Reflecting this orientation, of the fifty-one Democratic U.S. senators in the 110th Congress (2007–08), South Dakota senator Tim Johnson was ranked the thirty-ninth most liberal.¹ The state’s “red” designation does not diminish the hurt that many residents experience from having inadequate or no health insurance. As the national health reform campaign heated up in the spring of 2009, Senator Johnson himself the victim of a congenital brain...

    • 2. Social Strategy—Massachusetts Avenue
      (pp. 35-49)

      In October 2008, one month before the presidential election, the staff of the U.S. Senate Committee on Health, Education, Labor and Pensions (HELP) was already preparing for a legislative effort to enact national health reform in the new Congress set to convene in January 2009. The committee chair, Senator Edward M. Kennedy (D-MA), had directed us to bring together key system “stakeholders” to see whether they could find consensus on a path to reform.

      We assembled about twenty and gave them the moniker “the Workhorse Group,” intending to work them hard to reach consensus. They sat around tables in the...

    • 3. Political Will I—Prelude to a Health Reform Campaign
      (pp. 50-62)

      The scene: a Democratic presidential primary debate in Las Vegas, Nevada, on November 15, 2007, less than two months before the pivotal Iowa caucuses. After a shaky showing in the prior debate, Senator Hillary Rodham Clinton was urged by aides to challenge Senator Barack Obama on inadequacies in his health reform proposal, which was projected to cover fewer uninsured Americans than her plan because of the lack of an individual mandate to purchase health insurance. Here is the key exchange moderated by CNN’s Wolf Blitzer:

      SENATOR CLINTON: Well, I hear what Senator Obama is saying, and he talks a lot...

    • 4. Political Will II—A Health Reform Campaign
      (pp. 63-100)

      Knowledge and strategy would not have led to the Affordable Care Act’s passage without the third ingredient, political will—the commitment by political leaders to do what is needed to achieve success. In Washington DC, political will was on display in abundance throughout the process in the White House, the Senate, and the House, for and against passage. It mattered early, it mattered during the process, and in the end, it was indispensable.

      In the U.S. Senate, at the start, two figures dominated and used their positions to place health care front and center early, Senator Max Baucus, a moderate...

    • Illustrations
      (pp. None)

    • [PART II. Introduction]
      (pp. 101-106)

      Just as a book has chapters, a play has acts and scenes, and a baseball game has innings, so too does a federal law have titles, each with its own purpose, shape, identity, history, assumptions—data-based and otherwise—and curiosities. Some fit comfortably into the whole act or statute, and some stick out at an odd angle. Some may look pretty darn appealing during markup or floor consideration and then take on a ghastly appearance once implementation time rolls around. One senior House staffer likened the Affordable Care Act (ACA) to a garden packed with a wide array of plants....

    • 5. Title I—The Three-Legged Stool
      (pp. 107-139)

      Like many other parents of children with chronic and disabling illnesses, Brenda Neubauer is a tenacious advocate for her son, Jake. When she realized that health insurance coverage for Jake would hit a lifetime cap by the time he was sixteen, she contacted her U.S. senator, Byron Dorgan (D-ND), for help. Dorgan was surprised to learn that insurance companies would limit coverage for individuals who had paid premiums in good faith. In 2008, along with Senator Olympia Snowe (R-ME), he filed legislation to prevent any health insurer from imposing lifetime limits less than $5 million and increasing over several years...

    • 6. Title II—Medicaid, CHIP, and the Governors
      (pp. 140-154)

      In four weeks of Senate debate on the PPACA through December 2009, it is easy to find statements by Republican senators disparaging the Medicaid program. Far more difficult is finding statements from Democratic senators either supporting or defending the program that provided health insurance protection—including the Children’s Health Insurance Program (CHIP)—to an estimated 60.4 million Americans in 2010, now the nation’s largest health insurance program (by contrast, Medicare had an estimated 46.8 million enrollees in 2010).¹ If the ACA is implemented as written, that number is projected to grow by 21.8 million to 82.2 million by 2019.² Through...

    • 7. Title III—Medical Care, Medicare, and the Cost Curve
      (pp. 155-181)

      May 11, 2009—Leaders of six key health organizations representing the insurance industry, hospitals, physicians, medical-device makers, pharmaceutical makers, and health care workers stood with President Barack Obama at a White House press briefing to announce their commitment to help to achieve $2 trillion in health care system savings over a ten-year period, a large portion of which would help pay the bill for health care reform. The president lauded the leaders:

      Over the next 10 years—from 2010 to 2019—they are pledging to cut the rate of growth of national health care spending by 1.5 percentage points each...

    • 8. Title IV—Money, Mammograms, and Menus
      (pp. 182-196)

      “Prevention is better than cure,” is a widely accepted truism among the public, and among public officeholders, especially in matters relating to health and medical care. It is better to prevent or detect a cancer early than to treat it late. When money is added to the equation, things change. While prevention may be better, it is not always cheaper, and often it is more expensive, depending on the preventive measure, to whom it is applied, the rate at which the condition strikes, and other variables. Evidence for this has been known for decades, documented by Louise Russell in her...

    • 9. Title V—Who Will Provide the Care?
      (pp. 197-205)

      Of the ACA’s ten titles, Title V stands out in a peculiar way. It was the only title that generated no public conflict and no attacks in the legislative process leading to enactment. The need to address health care workforce issues is viewed by both parties as urgent regardless of health reform. Two key factors motivated policy makers to act: an aging and growing population with expanding rates of chronic illness combined with an aging and dispirited health care workforce. A frequent criticism of the 2006 Massachusetts health reform law was the law’s failure to address health care workforce shortages,...

    • 10. Title VI—The Stew
      (pp. 206-228)

      Most public policy experts believe that smaller bills and smaller measures can win approval more easily than larger bills and larger programs. This hypothesis fits reality much of the time, and sometimes it does not. The ACA was one of those other times. Embedded in the health reform law are many smaller initiatives that had been clamoring for attention for years, in some cases a decade or longer. No one denied the legitimacy of these issues; they just could not generate sufficient attention or controversy to get high enough in the queue, and so always got left behind.

      An example...

    • 11. Title VII—Biosimilar Biological Products
      (pp. 229-237)

      The scene was Senator Edward Kennedy’s Capitol Hill hideaway, steps away from the Senate chamber on a late afternoon in June 2009. Of the thirteen Democratic members of the Senate Health, Education, Labor and Pensions (HELP) Committee, Kennedy was the only one not seated around the chain of tables pulled together for a high-stakes meeting on a contentious health reform issue—how to structure legislation to permit the manufacture and sale of generic-like biopharmaceutical drugs.

      The key decision was how many years to permit makers of original biopharmaceutical products to avoid competition from new “biosimilars” beyond the life of their...

    • 12. Title VIII—CLASS Act
      (pp. 238-249)

      Many Democrats and progressives were disheartened to see the absence of a so-called public-plan option in Title I of the final health reform law. While it is true there is no public-plan option to be offered through the health insurance exchanges, there is a “public-plan option” in the ACA. It is in Title VIII and is known as CLASS, which stands for Community Living Assistance Services and Supports. It’s public—it will be run by the Department of Health and Human Services (DHHS). It’s a plan—it will provide specific benefits to enrollees who will pay premiums. And it’s an...

    • 13. Title IX—Paying for the ACA (or about Half of It)
      (pp. 250-268)

      When it came to paying for the ACA, the first question was, how much of it needs to be paid for? There was no agreement up front. Many health reform supporters saw that Republican congressional leaders made no effort to pay for the Medicare Part D program, the wars in Afghanistan and Iraq, or the 2001–3 Bush tax cuts. Some of the price tag could and should be paid for, but not all. Why was health insurance coverage for all Americans less important than those other priorities? Some stakeholders involved in the HELP Committee’s negotiation process wrote a joint...

    • 14. Title X-Plus—The Manager’s Amendment and the Health Care Education and Reconciliation Act
      (pp. 269-286)

      In a “normal” federal legislative process, Title X would never have been advanced as a stand-alone title, and the Reconciliation Act would never have been advanced as a stand-alone bill. Instead, the numerous large and small changes they make—Title X amends provisions in Titles I through IX, and the subsequent Health Care and Education Reconciliation Act (HCERA) amends provisions in Titles I through X—would have been blended into the underlying legislation, and a single, coherent, comprehensive substitute PPACA would have been approved on the floor of the Senate in the case of Title X and by both the...

  11. Conclusion
    (pp. 287-308)

    There was a better national health reform law to be written than the Affordable Care Act. There were better approaches to save money and to restrain the rising costs of health care, better ways to cover uninsured Americans, better methods to improve the quality of medical care and to put the nation on a healthier path, and smarter ways to pay for the whole effort. It is fair to say that the ACA is no American’s idea of the best possible reform. And yet—because Americans do not agree at all on what the best possible reform would be—the...

  12. Notes
    (pp. 309-328)
  13. Health Reform Timeline
    (pp. 329-330)
  14. Index
    (pp. 331-339)
  15. Back Matter
    (pp. 340-340)