I decided at the last minute to "live blog" the HCFA conference. I wanted to send some of the conference out to outreach and enrollment workers who are in their offices enrolling as I write. John McDonough & Nancy Turnbull, two of the smartest, savviest policy makers, graciously agreed to my blogging them. Here are my impressions.
Nancy: Did the advocates make a mistake agreeing to the individual mandate? Have we contributed to a national dialogue that isn't really that great?
John: The individual mandate was never advanced by ACT!! or HCFA. It was advanced by BCBS Foundation as a one possible option. We found it academically interesting, but didn't know how you could practically do it. Mitt picked it up, but he didn't have much impact so we didn't worry. Then, Federal Waiver came thru with a condition of the individual mandate. Then we knew we'd have to accept something in the spirit of the individual mandate. Then the speaker put forth a plan with a robust employer mandate with an individual mandate. This individual mandate met the conditions that advocates had given. We remain in a strikingly experimental place.
John: What are the key lessons about health care reform we've learned in MA that other states/the feds should look to?
Nancy: Get as much federal money as you possibly can. We would not be doing this without having brought in significant federal money. The decision to defer many of the hard decisions to the implementation phase was a good one. Benefit packages, affordability, etc. made thru the legislative process would not have worked as well. Doing it during implementation made consumers more a part of the conversation. Coverage first was the right strategy. Do you expand coverage first, or control costs? We're gonna go for coverage and hope we can control costs. Over the next few years we'll see if that was a good strategy. We also are blessed to have such a great advocacy community.
Nancy: My question goes to cost. The next challenge. Providers have been an important part of the coalition. How in this new era of cost containment does this change things. When insurance companies and providers are involved in our coalitions and fund some of our work, can we do what we need to do to control costs?
John: Well, I hope so. It is politically very difficult to expand health coverage without provider/insurer support. It absolutely creates periods of discomfort, it is a challenge to negotiate relationships so the differences don't derail the effort. Our political conclusion is that it is better to have them with us, and are an essential part of the conversation. Right now we are facing paying for CommCare and HCR. Right now there is a dialogue about who else should pay beyond tax payers, consumers, and the Commonwealth. In that conversation it is unlikely that the ACT!! coalition will come in as a united voice.
John: Quality question. Some people, like Paul Levy, say to fix the cost problems, we could fix quality. I wonder even if we were able to fix all of the quality problems would it fix the cost problem?
Nancy: The work that is being done in quality improvement is vital work. Focusing on quality alone is at the best naive, and the worst, copping out. Lots of what we need to fix would increase use. Not all quality improvement is cost reducing. Quality improvements won't necessarily result in cost savings. That is not at all to say we shouldn't pursue quality improvements. But we need to look at the other things we need to do to control cost. It will be infinitely more difficult than our conversation about access.
Comments on audience Q&A: Rules of the road for financial agreements laid out in 1991 are not serving us now. There is no transparency, but decisions made under that agreement affect us all. Nancy suggests looking at the German system, where they have achieved remarkable improvements in care for those with chronic illnesses. We should look at more collaboration and less competition among health plans.
John: People think Nancy may not really know how to write a haiku. What is your own personal process?
Nancy: Usually I begin around 4 am. It involves cursing and frequent references to the internet to confirm the right number of syllables.
Nancy: What's John actually gonna do after he leaves HCFA? Too hard for John to answer alone, so I'm going to ask all of you. I've put together a slide show of options...
I hope she'll post it for me to link to.
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