This is the first of a three-part blog series by strategic policy director, Michael Miller.
With Democrats recently installed as the majority in the House of Representatives, a favorite story line of health care reporters has become the presumed fault line between different parts of the caucus. These stories often depict two camps: supporters of building on the foundation the Affordable Care Act (ACA) created versus supporters of replacing the ACA (along with employer-sponsored insurance, Medicare and Medicaid) with a single-payer system—often referred to as “Medicare for all” (although this term lacks a precise meaning and can be attached to many different policy proposals). With the campaign for the Democratic nomination for president in 2020 underway, this story line is only to grow. But is it accurate? If so, is it possible to bridge the divide? What are the implications likely for health care advocacy? How can health care advocates navigate this debate and keep moving forward?
I will try to offer some answers by looking at three questions, in turn, across three blogs over the next few weeks. This first blog will lay out how Community Catalyst thinks about the goals of reform and how we evaluate policy proposals. In part two, I will discuss the barriers to achieving those goals. In part three, I will lay out, at least in broad brush strokes, how we see the path forward.
The goals of health care reform
Comparing policy proposals should not be our first step in charting a path forward. Instead, we should spend a little time clarifying what we are trying to achieve. Clarifying our goals gives us an opportunity to identify areas of agreement over ends that may transcend disagreements about means. It also helps us identify not only what proposals do but also what they may be leaving out. We believe that at a high level there are five goals of health care reform. There are also two “meta goals” that go beyond health care as a topic.
At a high level, Community Catalyst embraces five key goals for health reform:
- Comprehensive affordable coverage for all
- Access to quality care
- Improve health status
- Cost containment
- Consumer protection and engagement
Of these five goals, we believe three—improving coverage, quality and population health/health status—are particularly important to advance health equity broadly and help eliminate structural racism, in particular.
Of course, underneath these broad topic headers are innumerable policy choices—scope of benefits, structure of cost-sharing if any, financing, quality measurement, use of financial incentives, regulatory structure, respective roles for federal and state government and the public and private sectors, and more—that have to be specified in legislative proposals. But with zero chance of enacting comprehensive health reform through a divided Congress until 2021 at the very soonest, there is still plenty of time to work through those issues. It is not my intention to address these questions in detail in the following blogs. The focus of this series is strategy more than it is policy.
The “meta goals”
Debates about health policy are always about more than the subject matter. Every debate about social welfare policy of any kind is also a debate about whether and how government can act to improve people’s lives. The proposition that government is a tool to address the shortcomings of a market economy were embedded in the New Deal and the Great Society has been under sustained attack for more than 40 years. In addition, every policy debate either advances or undermines the notion that when we act together, we can change policy to address our common problems. It is critically important to note that these two meta goals can only be advanced when we actually win policy changes that help people (or defeat proposals that hurt people).
A framework for thinking about health reform
Combining the policy goals and meta goals together leads Community Catalyst to embrace the following guideline for evaluating reform proposals: the best health policy proposal(s) are the ones that move us as far forward as possible toward our goals and can pass into law (and be implemented and sustained).
Two key things follow from this framework—the first is that while coverage, and cost containment are important, they are not the only things that are important. We need to combine our advocacy for affordable coverage with work to improve quality and health status, and we have to be particularly mindful to address the needs of populations that are currently poorly served or discriminated against.
The second important consequence of this framework is that it puts a premium on what can actually pass. Proposals that are strong on paper but can’t be passed or implemented fail to further our policy goals. They also fail to serve as object lessons for how collective action can shape government policy and how government policy can make a difference in people’s lives.
The bottom line is that if we are serious about achieving our goals, we also have to take seriously the barriers to those goals and develop strategies to overcome those barriers. Of course, “what can pass” is not set in stone. It changes as political circumstances change.
Sometimes the best that can be done is to avoid moving backward. Sometimes the stars align to permit big leaps forward, and sometimes only incremental progress is possible. While our goals remain unchanged, our immediate policy priorities need to reflect our political environment.
Stay tuned. The second blog in this series will take a close look at the barriers we face in trying to advance a health reform agenda; the third will sketch out a path for moving forward in the context of either continued federal gridlock or, at best, a narrow majority in support of reform at the federal level.