1. Health care IS a core economic issue. Rather than seeing the major economic problems as reasons not to address health care, there are good reasons to see this are a reason TO address health care — and this is being reinforced by leading economists such as Henry Paulsen, Ben Bernanke and incoming economist heavy weights in the new administration such as Peter Orszag (who will take over the Office of Management and Budget) and Tim Geithner (incoming Treasury Secretary).

2. President-elect Obama said so - and keeps on saying so. Candidates do want to follow through on their commitments and health care was the number one area that Obama ran on. He spent over $100 million promoting what he would do to reform health care and voters listened. A Pew poll reports that 77% of voters stated that health care was a “decisive concern” in their choice of who to vote for. And, Obama has not stopped talking about it.

3. More than Congressional interest — we have thoughtful Congressional leadership. Six weeks BEFORE the inauguration of a new President, the Chair of the Senate Finance Committee, Max Baucus presented a wide ranging proposal that was the product of years of thoughtful engagement by the Senator — that engagement has been wide and deep. Senator Baucus recently sponsored a series of hearings on health care. Beyond Senator Baucus there is engaged interest by other key leaders, such as Senators Kennedy, Clinton and Enzi. President-elect Obama’s appointment of Tom Daschle as BOTH Secretary of HHS and Director of the White House Office of Health Reform tells Senators and Congressmen that they’ll have willing and savvy partners in this administration. In contrast, fifteen years ago, the then Chair of the Senate Finance Committee wanted nothing to do with health care and the “hand-off” from the White House to Congress was badly fumbled.

4. Reform interest is bipartisan. For health reform to pass - there must be a dozen Republican Senators on board. Baucus has modeled bipartisanship in his close working relationship with the ranking minority member of the Senate Finance Committee, Senator Grassley. Other examples of bipartisanship can be found in the Wyden-Bennett proposal that is important as much for the fact that it has garnered 14 co-sponsors - equally split among Republicans and Democrats - as for the content of the bill; and by Orrin Hatch’s long history working with Senator Kennedy, including his co-sponsoring the original Children’s Health bill. While there is a new Democratic majority, many of these democrats are from “moderate” states - much of the action will be in the center.

5. Rather than “dueling” proposals — reform proposals are largely aligned and all embrace the need to address both quality and cost. Instead of many dueling proposals, there is broad agreement on both the problems and some of the prescriptions for change. As described in Baucus’ proposal, coverage is a primary problem - but it is driven by underlying cost problems and the failure to deliver consistently high quality care (i.e., our drumbeat for “value” has caught on). The solutions involve both coverage expansion and changing underlying drivers through measurement, payment reform, supporting effective chronic care and prevention, and supporting health care infrastructure like IT (again — these should all sound familiar as our drumbeat that is getting picked up). Many of these consensus value-promoting actions can be traced to work such as that of PBGH medical director Arnie Milstein’s leadership as a member of MedPAC and years of work with administration officials, staff and others to provide concrete examples of both the value shortfalls and the path to creating a high performing health care system.

6. Proposals have low “fright factor” for existing insureds and build on existing systems versus starting from scratch. Virtually all of the proposals build on the existing employer-based and public programs, rather than seek to do a whole-hog restructuring. One of the proven messages in this election (and proven by Harry and Louise fifteen years ago), is that the worst path to reform is to make those relatively satisfied with what they’ve got feel insecure. Senator Baucus’ proposals — like virtually all of the others in play — don’t raise the specter of taking away what works; they build on what is out there.

7. Coverage expansion is framed as BOTH about the “right thing to do” and addressing cost. It is truly an embarrassment and moral indictment that we have almost 50 million uninsured, but the proposals recognize that addressing the uninsured is not just a moral challenge but a financial imperative. The uninsured AND under-funded public programs result in the cost-shift to employers that are helping making care unaffordable. In addition, employers are shouldering the costs of hiring new workers who have not benefited from the preventive programs and support that will enable them to be as productive as possible. PBGH has documented and disseminated the huge impact of cost-shift from the uninsured and under-funded public programs.

8. Bigger is often more doable than smaller. With more elements “in play” it is often easier to make the deals that must be made. The reform effort in California got very close to the “finish line” because many elements were part of the reform - for example hospitals were ready to give in some areas, because they got in others. There will be winners and losers in reform, but with multiple pieces in play it can dilute the laser focused opposition that can come if there is only one issue on the table.

9. Special interests recognize the need for reform. Many of those for whom health care is their livelihood - whether they are doctors, hospitals, health plans or drug and device manufacturers - recognize that we are on the path to a train wreck. They would rather be part of a dialogue and a rational path for reform that allows them to plan and shape the solution. PBGH and its members have been meeting with leaders from the medical community, hospitals and others - to help them understand the urgency and the need to have solutions that are truly patient centered.

Whether this prediction holds true depends on many factors, including the extent to which business is at the table and helps get reform across the finish line. Key to the drumbeat for reform has been both some large employers and organizations such as the Business Roundtable, the Chamber of Commerce and the National Federation of Independent Business. Business can be the “tie-breaker,” but is better positioned to play that role today because of work over the past five years to identify and build common ground with major consumer and labor organizations. PBGH’s founding and operation of the Consumer-Purchaser Disclosure Project nationally, and close working partnerships with labor and consumer groups in California, are important examples of efforts that have not only amplified the voice of the entire “buy-side” of health care, they have lead to greater sharing of problem identification and prescriptions for change among employers, consumer groups and labor.

I welcome your thoughts and reflections.

Let’s keep our eyes on the prize – transforming an inefficient and ineffectual health care enterprise into a dynamic, responsive, and effective one.  Tom Daschle’s insights really did make him well-suited to the leadership role.  We should do well to keep these at the forefront in forging ahead to address health care’s shortfalls.

First, Daschle understood the nature of the interlocking drivers that maintain our system as-is.  His book, Critical, underscores that there are many forces that shape our health care and these same forces  — aka “special interests” — reinforce and perpetuate each other.  There’s not one glaring culprit to point the finger at.

Second, it Daschle rightly noted that it is more important to address the leadership and governance problems than to tinker with the individual cogs of the vast machine.  Every one of those cogs – how we pay primary care doctors, how NIH spends its money, how we invest public dollars into health IT, whether to let Medicare negotiate drug prices, and literally thousands of others – will involve a constant balancing of private and public interests and lots of technical analysis.  Daschle said the key is to take the most important policymaking processes out of the political swamp where the loudest and richest stakeholder groups, often acting in their short-term interest, can sometimes overwhelm the long-term public interest.  To do that, he advocated creation of an independent Federal Health Board.

Third, the most powerful drivers of “value” in a reformed health care system are exactly the levers most subject to political and business pressures – and least easily resolved through a public interest lens if left strictly to market forces.  In the simplest terms, if the market were the right forum to adjudicate our cost, quality, and safety challenges, it would have done so by now.  Instead, Daschle argued that a Federal Health Board could “promote ‘high-value’ medical care by recommending coverage of those drugs and procedures backed by solid evidence.  It would exert influence by ranking services and therapies by their health and cost impacts.” (p. 172)  The Health Board would “help create the right incentives by paying providers based on health outcomes, rather than on services delivered,” (p. 175) by “making the health care system more transparent” with cost and quality information provided to the public, and by guiding our national health IT investments. (p. 177-9)  All of these goals are spot on…employers and others need to be at the table to make sure the a Federal Health Board (or, Senator Baucus’ Independent Health Coverage Council) drives value and fosters market innovation.

Those of us who are committed to improving the quality and affordability of our health care system will need to keep talking about the elements that Tom Daschle argued for – comparative effectiveness that addresses costs, accountable investments in IT, payment for outcomes rather than services and new mechanisms of policy-setting that put the public interest above those of the many system stakeholders.  We will have to ask whoever comes next not to miss this once-in-a-generation opportunity to introduce discipline and science into our health policy process.  We want to let loose the talents and compassion of many thousands of health care professionals to advance our national commitment to safe, effective, available, and affordable health care.  But to do that, we will need to employ a small but carefully targeted bit of public policy that sets the public interest ground rules for a more open and competitive health care marketplace.

This is an article by Atul Gawande from the recent New Yorker in which he makes the case for major reform building on existing structures. He not only provides good examples of how other countries have evolved their health care systems, he provides a good framing and analysis of what needs to happen here in the US. In particular – two excerpts capture his message (and capture well PBGH’s effort to foster transformational change building on what we have):

“[A]ccepting the path-dependent nature of our health care system – recognizing that we had better build on what we’ve got – doesn’t mean that we have to curtail our ambitions. The overarching goal of health-care reform is to establish a system that has three basic attributes. It should leave no one uncovered – medical debt must disappear as a cause of personal bankruptcy in America. It should no longer be an economic catastrophe for employers. And it should hold doctors, nurses, hospitals, drug and device companies, and insurers collectively responsible for making care better, safer and less costly”.

And…

“It will not be utopia.  People will still face co-payments and premiums.  There may still be agonizing disputes over coverage for non-standard treatments.  Whatever the system’s contours, we will still find it exasperating, even disappointing.  We’re not going to get perfection.  Be we can have transformation – which is to say, a health-care system that works”.