Making Health Reform Work Blog Moving to New Site

Dear readers of the Making Health Reform Work blog:

Our blog is moving to a new home, effective immediately. Readers can now find all previous posts at http://www.businessofgovernment.org/blogs/making-health-care-reform-work, with new posts coming to the site this coming week.

Please join us at the new site as we continue to explore the challenges and opportunities that will come with the implementation of the new health reform law.

Regards,

Don Kettl, Dean, School of Public Policy at the University of Maryland

Jack Meyer, professor, schools of Public Policy and Public Health at the University of Maryland

A discussion with NGA Executive Director Dr. Ray Scheppach

Dr. Ray Scheppach, the executive director of the National Governors Association, discussed the challenges and opportunities of the health reform law with Prof. Jack Meyer of the schools of Public Policy and Public Health at the University of Maryland.  Here is what Dr. Scheppach had to say about Medicaid expansion, the health exchanges and the fiscal challenges confronting the states:

JM: What are the major challenges involved in implementing the new national health reform legislation?

Dr. Scheppach: A key challenge is to provide states with enough funding to meet expanded Medicaid enrollment and the likelihood of higher reimbursement rates to health plans and health care providers. There will be a big push to enroll people already eligible but not participating in Medicaid, and current estimates of this increase may be too low. Newly eligible people (all poor and near-poor adults will be eligible in 2014) will benefit from Medicaid coverage but states may not have enough long-term federal support to meet these needs.

JM: What is the most important positive development that could emerge from health reform?

Dr. Scheppach: If we can figure out how to build the state-level insurance exchanges the right way, states will have a strong new tool to drive favorable changes in the health care delivery system and lower spending in the long term. Between Medicaid and the insurance exchanges, collectively, states are likely to be purchasing on behalf of more than 100 million Americans. This will provide leverage to bring the hospitals, physicians, and health plans to the table and adopt those new approaches to delivery and payment that lead to better health outcomes and lower costs. States can build better managed care systems and provide higher payments to provider systems that implement electronic health records.

JM: The new legislation calls for the federal government to pick up all of the costs of expanding eligibility for Medicaid in the early years, with states making a modest contribution in later years. Can states adjust to this timetable?

Dr. Scheppach: Several factors will make it difficult for states. First, we have a jobless recovery at this time. Second, the increased funding for provider payments only affects some providers (e.g. primary care physicians) and that increase is only temporary. Finding enough physicians to meet the expanded demand for care will be a real challenge. Third, many states have pulled funding from trust funds or increased borrowing, and this money will have to be paid back. Fourth, many states have too few staff who have the knowledge to carry out all of these new functions, and we will have a minimum of 24 new Governors next year.  Finally, it is very difficult for states to raise taxes. States will not be back to 2008 revenues levels until about 2012 or 2013, just before the expansion kicks in. So, I am concerned about states’ ability to shoulder more responsibility, even in later years.

JM: What are we going to do about long-term care? That is only addressed to a small degree in this legislation.

Dr. Scheppach:  Health reform will not be complete until we address long-term care. We need to integrate Medicaid and Medicare and use pooled funding to better manage the care of high-needs older Americans and people with disabilities.

The bottom line is that we need to control long-term Medicaid spending in order to avoid continuously reducing the amount of resources available for other needs, such as education and infrastructure.

Background:

Dr. Scheppach was appointed executive director of the National Governors Association in 1983. He oversees the day-to-day operations of the association and works closely with NGA’s chair and vice chair and their staffs to help identify priorities for the nation’s governors. Before coming to NGA, Dr. Scheppach worked for seven years at the Congressional Budget Office – the last two as deputy director.

Jack Meyer is a Professor in the Schools of Public Policy and Public Health at the University of Maryland and a Principal in the Washington, DC office of Health Management Associates.

Just what is an “exchange”?

By Donald F. Kettl

        We all know that health “exchanges” are the big innovation of the health insurance reform act. We know they’re supposed to drive down costs, provide citizens with more choice, and ensure that everyone has access to coverage.

            But just what are they? That’s a deceptively difficult question to answer. We don’t have much experience. There are just two health exchanges in operation, staked at opposite ends of the spectrum.

• Massachusetts, where it’s known as the “Connector” https://www.mahealthconnector.org/portal/site/connector/menuitem.a6bd9ea72595da2ea87b5f57c6398041/?fiShown=default) . The Connector is a slick website that offers different packages for different consumers—families, young adults, employees, and employers. Click on the photo that best describes you, and the site walks you through the options for getting health insurance. This exchange guarantees that insurers meet basic government-defined coverage standards. Buyers can pick the plan they like.

 

• Utah, where the Utah Health Exchange is a market-based e-shopping center for health insurance plans (http://www.exchange.utah.gov/).  This exchange provides extensive information about the companies offering coverage in the state but doesn’t provide any state guarantees of minimum standards.

 

The big question: what will the federal government require state exchanges to do? These two examples make clear that, left to their own devices, the states will create very different kinds of exchanges. The fundamental dilemma for the federal government is what standards to set for each exchange, and how much flexibility it ought to leave state officials. This is destined to be a huge battleground. If you think the Tea Party debate is intense—wait until you see what’s coming here.

Former Senate Majority Leader Tom Daschle talks about health reform (Part II)

Former Senate Majority Leader Tom Daschle visited the University of Maryland on April 26 to participate in the Stamp Distinguished Speaker Series. He spoke to students about how the new health care reform law passed earlier this year will affect them. Before his talk, Daschle graciously sat down with Stephen Majors — a graduate student in the School of Public Policy assisting with the “Implementing Health Care Reform” blog — for a “Q and A” on health care reform. Here is Part II of the conversation:  

SM: The (insurance) exchanges — a key component to expand coverage to the uninsured – have to be formed by 2014. How are they going to find the balance between the federal government and the states in terms of how they work? Is that something you’ve been advising on?

Sen. Daschle: That’s a very good question. There was a fairly significant debate between advocates for a federal exchange and advocates for state exchanges. The compromise was to allow states the opportunity to do this, but within a federal framework. So you’ve got a federal architecture and state administration. They are going to be incented to do a number of things. They will get $9.80 for every $10 spent on new Medicaid funding. In other words, they are going to get almost all of it paid for by the federal government for the first 10 years, and then it drops down to 10 percent.

They are also going to be in a position to set the criteria for the insurance companies that participate in the exchange, so long as they have at least one silver and one gold plan. The plans are based on their actuarial value, and by actuarial value I mean how much does the plan actually pay? They’re going to start at 60 percent as the floor. That’s the bronze. The silver is 70, the gold is 80 and the platinum is 90. They have to have a minimum of 60 and they have to offer at least one 70 and one 80. So that’s a federal requirement.

SM: There’s been a lot of talk about how this legislation didn’t do all it could or should have in terms of addressing the cost problem. Both politically and policy wise, when do you think is the right time to take that next step?

Sen. Daschle: There’s good and bad news. The bad is that we didn’t go far enough. But I think we went as far as the political landscape would allow. The good news is that we have a number of tools now to begin bending the cost curve. And I think if we use them right and use them effectively over the course of the next 10 years, I believe we can accomplish a great deal with regard to cost containment. CBO has said we could save $141 billion in the first 10 (years) and $1.2 trillion in the second ten (years). And I think we can even do better than that.

SM: What would your former colleague, the late Sen. Ted Kennedy (one of the strongest advocates for health reform), think about this law that just got passed?

Sen. Daschle: Ted Kennedy was an incredible pragmatist. He always knew that you had to settle for what you could get and keep building after that. And that’s exactly what he would look at here. All of his life he either was working to put something new in place or build on something we’ve already done. So he would say, “Let’s keep building.”

SM: There was a whole lot of rhetoric and debate back when Medicare got passed and people thought it was big government coming in to steal the show. Now, you talk about taking away Medicare, and people are up in arms and they’ve come to expect it and depend on it. Do you see folks 30-40 years from now looking back at this, and this becoming the same kind of established piece of the landscape?

Sen. Daschle: I don’t think there’s any question. The same thing happened with Social Security. Alf Landon was the Republican candidate for president in 1936. One of the main planks in his platform was the repeal of Social Security, which had just passed the year before. He lost and you never heard anyone call for repeal again. I think the same thing will happen with health reform. It’s legislation that will be here for a long, long time to come, in large measure because it helps just about every American in ways large and small.

SM: Is there anything about this health care law that would be important to the audience of this blog, that hasn’t gotten covered much in the mainstream media, or anything that we didn’t talk about today that you think is particularly important?

Sen. Daschle:  I think that it’s probably going to affect your generation more than just about any other for a lot of reasons. You’re going to be the first generation affected by a lot of the legislation in much more of a meaningful way than I am. You’re going to be required to buy health insurance for the first time; fortunately there are significant subsidies available to those who are going to have trouble financially doing that. But that’s a big issue.

Beyond that, I think you hopefully are going to benefit far more from wellness and prevention than we’ve ever seen before. One of the big problems with your generation and those who are younger is that obesity is becoming a huge problem, almost pandemic levels now. Almost one in three people in your generation are considered obese today. And that’s going to lead to diabetes  and a whole range of other chronic illness that we’re going to have to address. This legislation is designed to deal with that. It’s going to be, with the risk pool and the opportunity to participate in these exchanges, really the first opportunity you are going to have, regardless of circumstance, to buy health insurance. We’ve never had that before in our country.

The final thing is there’s really going to be an effort to try to entice people to consider primary care medical school as a profession. We want to see more people go into medical school as primary care doctors and nurses. This bill will incent that.

SM: What is your role in health reform going forward?

Sen. Daschle: I haven’t really decided. One possibility is to work in a semi-official or semi-public way with the White House and Health and Human Services. No decisions have been made in that regard. I’ve been writing a book on health policy that is out in October. I’ll be on a book tour and do public speaking on health.

Background: Sen. Daschle currently works for the global law firm DLA Piper and serves as a Distinguished Fellow at the Center for American Progress. In 2007, Daschle and three other former majority leaders created the Bipartisan Policy Center, an organization that seeks to find workable solutions to the most challenging public policy problems.

NOTE: This is Part II of our interview with Sen. Daschle. Please check out the previous post for Part I of the discussion.

Former Senate Majority Leader Tom Daschle talks about health care implementation (Part I)

Former Senate Majority Leader Tom Daschle visited the University of Maryland on April 26 to participate in the Stamp Distinguished Speaker Series. He spoke to students about how the new health care reform law passed earlier this year will affect them. Before his talk, Daschle graciously sat down with Stephen Majors — a graduate student in the School of Public Policy assisting with the “Implementing Health Care Reform” blog — for a “Q and A” on health care reform. Here is Part I of the conversation:  

SM: How much are you involved, informally, with the administration in terms of talking to them about your expertise in health reform at this point?

Sen. Daschle: Many of them are former staff, and they’re still friends. And I have a great deal of interest in it. It’s not something that I would say is frequent. It’s more occasional. Some of the staff I talk to more than others. Occasionally I talk to the president. But I would say it’s an infrequent matter, especially now that the legislation has been passed. They talk to me about different things we might be able to do to augment the implementation. So we’re exploring ways in which some of us can be of help but we haven’t made any decisions yet.

                                                

SM: Some of the recent poll numbers, depending on how much stock you put in those, show that a good portion of the public is leery of this health reform. Maybe you’ve talked about this with the president or the administration, but how are they going to continue to sell this and make people realize this was the right thing to do?

Sen. Daschle:  Well, I think they (people) are understandably leery. They’ve been fed a great deal of information. A lot of it is wrong, a lot of it is emotionally driven. I think, as a result, they’re trying to sort this out and they’re looking for the best information they can find to do that.

I’m really encouraged over the course of the last month that as more information seeps out and as people better understand what we’re talking about, the numbers seem to be going in the right direction. More and more people are becoming more comfortable with it because they understand it better than they ever have before. This is the most health literate we probably have ever been because the American people have been subjected to a tremendous amount of information about health care now for the last two years.

SM: Are there any specific plans that you are aware of to continue to educate the public about health reform?

 Sen. Daschle: There are different strategies and plans being considered. I don’t think any of them are in their final stages, yet. I would say that in the not too distant future, you’re going to see a real effort. The president has especially emphasized to his staff how critical it is that we not think we’ve now done all we need to do and move on. I’ve shared with him, and I think most people believe this, that we have still have a big, big job to do. If you look at this in football terms, I think we’re on about the 30-yard-line with about 70 yards of implementation left to cover.

Over the course of the next year, you are going to see a very aggressive effort in and outside of government to educate and to organize the American people in a way that will enhance the degree of support for the legislation that was passed. Earlier today I was with a former colleague of mine who also was majority leader, (former Tennessee Republican Sen.) Bill Frist. He made it very clear — he was fairly emphatic — that health care reform is not going to be repealed. It’s really now a matter of implementing the legislation in an appropriate way. 

                                                                 

SM: It’s my understanding that the high risk pool (to cover those with pre-existing conditions until insurance exchanges are set up in 2014) is supposed to be up and running by June 21^st, and there’s $5 billion appropriated for that. Do you have any concerns of whether that is going to be enough?

 Sen. Daschle: I think it’s hard to say. $5 billion is a lot of money. It’s used as a transition to the exchanges that will take place and be constructed in every state. I think it’s an appropriate amount of money. $5 billion to cover those who have preexisting conditions today so they can sign up seems to be a pretty good investment. I’m confident that we’ll be in a position to do that by June and to provide many people who have never been able to buy insurance before with the opportunity to do so.

SM: Based on your talks with some of the administration officials, do they view the high risk pool as kind of the first big hurdle in implementation because this is the thing that is supposed to really help people in the near term? Is there a recognition that, politically, this is an important milestone?

Sen. Daschle: I think it is. And that’s a good way to look at it. It is a milestone. Each one of these milestones is very important. But I think the first ones are going to be especially important because we have to demonstrate that we can do this and that we can stay on schedule and that it can be a somewhat flawless and smooth transition to this new marketplace we’re building. So this will be the first milestone of import and it’s one everybody is going to be watching.

Background: Sen. Daschle currently works for the global law firm DLA Piper and serves as a Distinguished Fellow at the Center for American Progress. In 2007, Daschle and three other former majority leaders created the Bipartisan Policy Center, an organization that seeks to find workable solutions to the most challenging public policy problems.

COMING TOMORROW: Sen. Daschle shares his thoughts on the insurance exchanges, what the law will mean for young people, his plans for the near future, what the late Sen. Ted Kennedy would say about the health reform law, and more.

 

National Health Reform: New Public Health Programs and Grant Opportunities

Many new federal grants to state and local governments are frequently overlooked in the debate over health reform, as are the various private sector research and health services organizations. These grants provide the tools to drive improvements in access to health care delivery and improved public health. Here are a few of these new initiatives:

• A Prevention and Public Health Fund for prevention, wellness, and public health activities: $7 billion for fiscal years 2010 through 2015 and $2 billion for each subsequent year.
• New funding for community health centers in the amount of $11 billion to be delivered over five years, beginning in 2011. Some of this funding may be used to support school-based health centers, and to bolster the National Health Service Corps, which makes loans to medical students and students in other health professions who agree to practice for a period in under-served areas.
• Community transformation grants, available on a competitive basis to state and local governments and community-based organizations, for implementation, evaluation and dissemination of evidence-based community health activities. These grants are from a pot of new funding that begins with $500 million in 2010 and reaches $2 billion a year in 2015.
• A one percent increase in the federal matching rate for states under Medicaid if their program covers certain evidence-based preventive services with no cost-sharing, including immunizations and smoking cessation products.
• An additional $100 million for the 2011-2016 period for states that develop an evidence-based program for diabetes prevention, controlling cholesterol and blood pressure, weight control, and various chronic conditions related to those problems.
• New grants totaling $100 million from the Agency for Healthcare Research and Quality to states to set up Primary Care Extension Program Hubs, on a state or regional basis. Primary care physicians will receive education about preventive medicine, health promotion, chronic disease management, and mental health and substance abuse services.

This is just a sample from the large menu of new program initiatives and grant opportunities. State and local governments will be challenged to obtain these grant funds and make the programs effective. University-based Schools of Public Health and Public Policy, among others, can form partnerships with state and local governments to assist in program design and evaluation.

Implementing High-Risk Pools: An Early Test of Leadership

By Jack Meyer and Elliot Wicks

The trademark phrase of George Allen, the former coach of the Washington Redskins, was “The future is   now!” For those charged with implementing health reform, this phrase is suddenly ringing true.

One of the first, and most important, challenges facing government policymakers is to be ready on June 21^st to open the doors of a new federally sponsored “high-risk pool.” This risk pool would provide health coverage for people with pre-existing conditions who have been without health insurance for at least six months. Without this provision, the new law would provide no relief for such vulnerable people until 2014.

Section 1101 of the Patient Protection and Affordable Care Act, the main health reform law, directs the US Department of Health and Human Services (HHS) to set up the high-risk pool either directly or through contracts with states or private, non-profit entities. Those who enroll will be able to make the transition into statewide insurance exchanges in 2014, at which time the high-risk pools will not be needed because the changes in insurance rules that go into effect at that time will prohibit insurers from denying coverage or charging higher premiums to those with pre-existing conditions.

Premiums for the pool will be no higher than for a normal-risk population and the oldest enrollees may be charged no more than four times as much as the youngest ones.  Government subsidies will make up the difference between what these high-risk people will incur in medical claims and the amount they pay in premiums. Out-of-pocket costs for enrollees will be capped in line with the limits allowed under Health Savings Accounts (HSAs) ($5,950 for individuals and $11,900 for families in 2010). The law does not specify what services are to be covered, so presumably HHS will define the details of the benefit package.

What are the major challenges facing the federal government and the states to make this coverage available to all who qualify by June 21^st of this year, as called for in the law, and to assure that promises are kept throughout this three and a half-year transition period?

The first challenge is to start on time and be ready to serve the eligible population, in just a little over two months! Meeting this deadline seems especially important because otherwise the administration will be open to the charge that they can’t properly implement even the simplest of the many changes the law requires. The quickest and easiest way to meet the deadline would be for the feds to establish a single national pool open to eligible people in all states. But the administration has apparently chosen a different path, designed to build on existing state high-risk pools. HHS Secretary Kathleen Sebelius sent letters to all the states on April 2. The Secretary notes that states may:

• Operate a new high-risk pool alongside a current state high-risk pool;
• Establish a new high-risk pool if they do not already have one;
• Build upon other existing coverage programs designed to cover high-risk individuals;
• Contract with a current “HIPAA carrier of last resort” or other insurance carrier;
• Do nothing, in which case HHS would carry out a coverage program in that state.

States must provide HHS with an indication of their preference by April 30. Next, if they decide to form a new pool or continue with an existing one—35 states already have some type of high-risk pool—they will have to align their eligibility, covered benefits, and premium-rating rules with those identified in the legislation or specified by HHS.

The feds, for their part, must be ready to accept consumers without a state option into the national pool by June 21^st. Presumably, HHS will contract with one or more private health plans to help administer the new national plan, in particular to process and pay claims, much as Medicare uses “fiscal intermediaries” such as Blue Cross and Blue Shield plans. Some of the mundane but important tasks will involve being ready to enroll people and send them an insurance card, assuring that the funds are ready to pay for claims that may be submitted very soon after people enroll—this is a high-needs population that may well have some “pent up demand” for health care—and assuring that adequate numbers of physicians, hospitals, labs, and other health care providers are willing to provide services for the new federal plan. Ideally, to contain costs the program would contract with networks of providers under conditions that ensure some level of efficiency and good care management. But given the extremely short timelines, it is hard to see how HHS has time to negotiate such contracts, at least in the first year; so the alternative would appear to be to pay on a fee-for-service basis.

Congress appropriated $5 billion to cover the cost of this program. Will it be enough? States must meet a “maintenance of effort” requirement if they choose to run their own pools (but not if they send their eligible people to the federal pool). So the federal money will presumably be spent to pay the entire gap between incurred claims and premiums collected for those who have not been served before, and to “top up” the coverage of people now enrolled in state high-risk pools.

A quick look at some numbers suggests that the funding may not be fully adequate. A recent report from the Kaiser Family Foundation shows that the 35 states with high-risk pools spent $900 million on coverage for only 200,000 high-risk pool enrollees nationwide in 2008. These enrollees represented only 2% of the total number of people who bought coverage on their own in 2008 through what is called the individual market. The Kaiser report shows that 25% of individual insurance applicants receive adverse underwriting responses from insurers—denials of coverage, premium surcharges, or benefit restrictions.

So it would seem that the need for high-risk pools may far exceed the current enrollment.  Bottom line: the $5 billion in funding, which works out to about $1.4 billion a year, may not be enough to meet the needs of those who sign up. The law permits HHS to cap enrollment or make other adjustments if the money appears to be running out, but to do so would surely be interpreted by the public as reneging on the promise the law makes to protect people with pre-existing conditions.

The new high-risk pool arrangements pose an early test of the credibility of health reform. A smooth start and effective implementation could get health reform off on the right foot. In contrast, a bureaucratic entanglement leading to major confusion and delays in enrollment and service could cast a pall over the reform plans.  This is an important test of leadership, and the future is now.

No “government takeover”

            If there’s any phrase that’s echoed through the health reform debate, it’s “government takeover of medicine.” Conservative wordsmith Frank Luntz has brilliantly characterized the issue. The big nasties are “politicians,” “bureaucrats,” and “Washington,” he explains.   Win the war of words and win the battle.

            The language battle is far from over, but one thing is clear: The health insurance reform bill that Obama signed isn’t (and, frankly never was going to be) government takeover of medicine. Consider three different vignettes that tell the tale.

            First, the government’s big medical programs are Medicare (for seniors) and Medicaid (for the poor). Together they account for 20% of all federal spending. But the agency that administers them, the Centers for Medicare and Medicaid Services, accounts for less than 0.2% of all federal employees—just a bit more than 4,000 employees. The health care bill didn’t create a monster new bureaucracy and there aren’t any plans to grow CMS into a Frankenstein-sized agency.  This might be the single most remarkable and revealing statistic in the entire federal government—CMS leverages one-fifth of the entire budget with a mere 4,400 employees.

            Second, once they sign up for the program, most individuals receiving Medicare and Medicaid never see a government employee. That’s because they receive their care from private doctors and nurses and hospitals—providers that they choose and that the government (the feds and the states) pay for. This isn’t going to change under health reform. People will still be able to pick their health care providers. They will just have insurance (whether they like it or not) to pay for the care.

            Third, part of the cost of health reform will come from $500 billion in savings from Medicare. The federal government has to squeeze the program to pay the bill, but this isn’t a takeover. It requires the feds to find ways of extracting savings from the private providers and managed health plans (see point two) who actually do the program’s work. And it’s more complicated than that. The feds don’t actually work with the providers but leverage the program through a web of intermediaries—all in the private sector—who collect the bills from providers and collect the money from the government. (Billionaire Ross Perot made his money figuring out how to do this better than anyone.) The feds have been trying for years to wring savings from the program but continue to struggle—to the point that Medicare is a charter member of the U.S. Government Accountability Office’s “high-risk list” of programs susceptible to fraud, waste, and abuse.

            Despite the clever language, we’re really not talking about government takeover of medicine. We’re talking about government finding a way to leverage one of every six dollars in the American economy. It’s long been a shared public-private-nonprofit system, and it will continue that way. The trick is how the government’s leverage is going to work—the rules it will write to shape a system that is—and will remain—in private hands. The coming reality is a whole lot more interesting than the rhetoric.

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Implementing Health Reform: Some Daunting Challenges

Now that national health reform has been enacted, it is time to move from partisan posturing to practical matters.  Specifically, we need to start asking: How are we going to make this work? Though battles are still raging over some provisions in the final bill (e.g. the Constitutionality of individual mandates) people are beginning to turn their attention to the details of implementing the new law.

Here are just a few quick examples of the emerging challenges. Health reform would make some 16 million people newly eligible for Medicaid and the children’s health program (SCHIP) when it is fully implemented. How will we assure that the great majority of them actually enroll, and more important, how will we effectively meet the complex medical and social needs of a population that includes many adults with multiple chronic conditions, people with both mental health and substance abuse problems, and a significant number of homeless people?

Further, all of the states will be required by the new law to set up insurance exchanges. How will they prepare to enroll millions of people, receive subsidies from the federal government, match them with individuals’ premium contributions (income determinations must be done to establish those contributions), and send the total premium to the health plan selected by the individual? Are the states adequately prepared to review the bids of myriad health insurance plans, and determine how efficient and cost-effective those plans are?

Health reform will place tough new burdens on the Centers for Medicare and Medicaid Services (CMS)—intensifying the pressures on a woefully understaffed agency that is just now getting a new director after a hiatus lasting over a year. Medicare would be charged with setting up demonstrations to reward newly formed organizations of physicians and hospitals for meeting targets related to quality improvement and cost control; figuring out how to “bundle payments” to pay for an entire episode of care, rather than the costly use of piecemeal payments for each service rendered; and establishing a new Center for Medicare and Medicaid Innovation to promote a wide range of changes in health care payment and delivery.

Finally, where will we find enough doctors, nurses, and other key workers to meet the needs of an aging population, with expanded demand for care from the newly insured? How can we actually “wire up” the health care system so that we can trade the clipboard for the keyboard?

We invite good ideas and commentary on the considerable challenges of health care implementation. Even as the politics of health care reform promise to spill over into the upcoming November elections, how do we make sure that those tasked with implementing the reforms and with delivering health care more effectively are able to accomplish what the new legislation demands of them?

I welcome your comments and look forward to a lively conversation.

You can also follow me on Twitter here: http://twitter.com/jmeyer5014

Welcome to Kettl’s Health Care Implementation Blog!

With this post, I want to welcome you to a new blog on health reform. Everyone has a stake in the issue; one of the few things that all humans share is breathing and an intense desire to continue doing so. One of the other things they share is a connection to government—the need for some mechanism to bring some order to basic human chaos. And of course, many people make their living as part of the health care industry.  Put these elements together and fireworks are inevitable.

The conversation on this blog will be different from most of what you’ve seen. After a truly epic debate, a new strategy for health insurance is now the law of the land. If the battle over passing it was huge, the challenge of making it work will be even larger. Health care, as pundits of every stripe have bleated, represents 1/6 of the U.S. economy—and a part of the economy in which every American has a living, breathing interest. The massive health reform bill’s 2700 pages contain lots of bold promises and a whole lot of unanswered questions.

This blog will be different because it will focus on the central puzzle: Just how is this going to work? What steps have to be taken to fulfill the act’s mega-promises? Just as important, how is the government going to balance the competing forces: for government leadership versus individual control; for broad coverage versus cost savings; for the best way of preserving our quality of life versus bankrupting the country? We’re not talking only about making health care reform work. We’re also talking about developing important new tools for government and redesigning the way it works.

We’re excited about this effort, a partnership between the University of Maryland School of Public Policy and the IBM Center for the Business of Government, because it offers a unique voice on these big implementation issues.  We see this blog as part of a conversation that complements other blogs that address issues relating to health care and the new reforms: Kevin, MD,  Health Care Renewal, Doctor Anonymous, HeathCare Economist , and Gary Schwitzer’s HealthNewsReview Blog to name a few.  And we’re always looking for insightful commentary from readers, so feel free to leave comments that we can address in future posts.

We’re operating with two driving ideas. The battle over the passage of health reform really was just the prelude for even bigger implementation battles to come. And how the implementation battles are fought and won will, more than anything else, define what health reform really means.

I’ve come to this after decades of work in government’s underbelly—the puzzle of how government affects citizens and how to make that interaction work best so that we’re all better off. This quest has taken me from local urban development policies to the Federal Reserve, from government reform efforts in New Zealand to “reinventing government” in the United States. Making health reform work is the next great frontier, and we all have a vested interest in understanding that complicated machine so we retool it in a way that works for us all.

Joining me in this effort is Jack Meyer, Professor of the Practice in the Maryland School of Public Policy and the School of Public Health and a Principal at Health Management Associates, a Washington research organization. Jack brings not only a long career of experience in health issues to our conversation. He’s one of the few people who have actually read ALL of the bills that led up to 2010’s reform package. From time to time, we’ll be joined by other experts in this conversation.

We welcome you along what is sure to be a wild and tumultuous journey toward making health reform work. The term of art is “implementation,” but that doesn’t begin to capture the many aspects of this issue that are sure to arise as the government transforms the act’s promise to its performance.

Please join us in this conversation.