America's voters have spoken: They want change. It's now up to Washington to deliver.

This election showed that American workers are struggling with the rising cost of everything -- from food to fuel to housing to health care. They know that skyrocketing health costs are shrinking their paychecks, and if they lose their jobs they lose their health care. Two-thirds of voters said they were worried about health care costs -- and among them, 60% voted for Barack Obama, according to CNN exit polling.

The country has shown it is ready for real health care reform. Why wait? Already, the movement for better health care has brought together workers and business owners who agree that costs have to be brought under control. Already, too many Americans fear they are just one health care crisis from financial ruin. For this and many reasons, voters all across the country sent a clear mandate to lift up ordinary families rather than ignore them, to make the American Dream affordable again. They went to the polls in history-making numbers, and elected a president to make history, too.

Watching for Health On Election Night

Like most of you, I watched in anticipation of election results Tuesday night. The first results we were fed were not about actual winners and losers, but exit poll results to describe voters' mood and concerns, including how health ranked among important issues facing the country. I don't mean to knock the exit polls. They are very useful for explaining why people voted as they did and, in fact, two senior members of our polling team assist a major network in helping to analyze them. But when it comes to understanding how much the public really cares about health this year, and more importantly, what the prospects for action on health reform are after the election, my best advice is don't pay too much attention to the issue rankings in the exit polls this time, and be sure to look at another, perhaps more telling, question asked that received far less media coverage on Tuesday night.

Health ranked third along with terrorism (9%), just behind Iraq (10%) among issues voters say were the most important, but health, along with every other issue, trailed the first place issue, the economy, by more than 50 points. The economy is the dominant concern right now. Given a list of issues to pick from that includes the economy, wouldn't you pick it number one? Of those voters that ranked health care as the most important issue, nearly three-fourths voted for Senator Obama. Nothing new there, people who rank health care highly as an issue have historically tended to vote for Democrats. Now, we know from our own polling that concerns about paying for health care and health insurance are a key part of what the public means when they check the box labeled the "economy" in polls. However, when health is asked as a separate issue, as it is in most polls and was in the exit polls, it is predestined for a distant second- or third-place ranking in the current economic environment. What is really happening is that people’s concerns about health can be registered in two places in the polls: as a separate issue, or as a part of the public's economic and pocketbook concerns, but it has not been reported that way. The exit poll results don't tell us much about which economic problems the public is worried about most, where health fits on that list, what health concern the public has uppermost in their mind (affordability), and what the polls mean for the prospects for action. In fact, in our latest tracking poll, our final one before the November 4 election and the 11th we've done during this long campaign, we found that nearly twice as many voters say that in the face of economic challenges "it is more important than ever to take on health reform" (62%) than say "we cannot take on health reform right now" (34%).

Based on the issue rankings in the exit polls, some may characterize the economy as the only meaningful issue right now, failing to recognize that the term itself is a catchall that does not tell us much about the specifics of people’s concerns. It is an umbrella with several component parts, including (in the order of priority in which the public ranked their actual economic problems in our last tracking poll) gas prices, job issues, losses in the markets, paying for health care and health insurance, paying for food, credit card debt, and paying the rent or the mortgage. In fact, the public is not actually focused on the economy per se in the sense that economists would be, but on very real, everyday pocketbook problems.

However, another exit poll question, that received far less attention, provides a clear indication of the public’s concern about paying for health care. Two-thirds of voters Tuesday told exit pollsters that they were worried about being able to afford the health care services they need. These voters chose Obama (60%) over McCain (38%).

The big questions now are: Will the new president make health reform an early and top priority before the next election cycle looms and the clock runs out on the ability to do anything big? Will congressional leadership do the same or focus exclusively on immediate health issues they have to deal with such as an SCHIP reauthorization and restoring Medicare physician payment cuts? Will the Senate and the House have the same priorities in health or different ones, and in the Senate, where an emphasis on health reform is more likely, will they coalesce around one plan or splinter? If there is a debate about major health reform legislation, it will quickly engage the public, and public opinion will matter hugely again at that point. But for now, it's what leaders in Washington do that will matter most, and nothing in Tuesday night’s exit polls changes that picture.

Collapse

On the left wing of the Democratic Party ( which is, after all, Barack Obama’s base) there are only two health reform ideas: (1) spend more money and (2) impose top-down regulations which, directly or indirectly, tell doctors how to practice medicine. Unfortunately for Obama, there is no extra money and command and control doesn’t work any better in health care than anywhere else in the economy.

So, as I said below, if health care is to be reformed, Obama must be willing to redistribute in a big way the existing subsidies. That should not be all that hard since (if the rhetoric is to be believed) redistribution is the primary goal of the Obama presidency anyway.

Also, Obama must be willing to repeal existing laws, regulations and other perversities so as to liberate patients and doctors so they can do what human beings naturally do in every other market: control cost, increase quality, and improve access.

To that end, I suggest this blueprint: http://cdhc.ncpa.org/commentaries/applying-the-do-no-harm-principle-to-health-policy

This was also helpful to Mitt Romney and John McCain. Readers may comment at my blog: http://www.john-goodman-blog.com/

Collapse

I actually think it may be a mistake to delay the healthcare reform discusssion and action--taking too much time will allow the proposals to be nibbled to death by ducks. It is dangerous to delay because it will be too far down the line to get bipartisan support--that activity will wear thin as we get closer and closer to the next elections where the party in power loses seats. If we can get consensus on quality, structural and financing and coverage reforms we can phase it in...

Now that the elections are over and the results are in, our leadership must return to the job of running America. The next President and Congress will inherit some of the biggest economic challenges in history. The ballooning federal deficit and severely constrained state budgets means that Washington will have to find ways to trim the federal budget and stem the tide of red ink.

Add to this the glaring need for reform of our health care system. We have a non-system that leaves 46 million people without coverage, and relies on reimbursement policies with incentives that promote neither efficiencies nor better care. That’s why the issue becomes less about whether or not we can afford to reform health care; instead, the question is, can we afford not to?

The truth is both parties have ideas necessary for successful health care reform. Neither Congress nor the President can solve our health care challenges alone. And as it appears that neither party will have 60 seats in the U.S. Senate, bipartisanship will be more important than ever. Our country needs a balanced, realistic conversation between all parties in order to improve America’s health and health care.

On his way to his historic election, President-elect Obama offered a plan that would substantially alter the health “system” and there’s no doubt that his administration will have to tackle the many challenges facing health care. President-elect Obama showed pragmatism on the campaign trail and that’s good, because the most likely, successful path to health care reform will be a phased approach. Because even as urgent as health care reform is, you don’t easily or lightly alter major parts of a $2.1 trillion sector of the economy.

Finding and implementing solutions to our health care challenges is a big job, and we believe that doing it in a thoughtful and coordinated manner and getting it right the first time is more important than getting it done first.

Collapse

President-Elect Obama and Senator McCain set perfect tones for the governance we need in their gracious speeches last night. Both emphasized healing and working together. These are two concepts that presidential candidates understand uniquely, having seen and navigated the profound diversity of people and views that comprise our nation. Their call for cooperation and bipartisanship will prove vitally necessary in the quest for health reform – real health reform, not lowest common denominator milquetoast.

Part of the need for bipartisanship is simple math. Whatever the final makeup of the Senate (and we may not know for a while), we know that neither the Democrats nor the pro-reform camp will reach the magic, filibuster-proof 60 vote threshold. Furthermore, there is no guarantee that Democrats will unite unanimously in favor of any legislation, especially legislation as complex as health reform. Therefore, especially given the leadership displayed by both McCain and Obama last night, we view the potential composition of the Senate as an opportunity far more than a challenge.

We have an opportunity to build a health reform package that can cover all Americans, kick-start the delivery system toward efficiency and sustainability, and earn the trust of the American people through a bipartisan legislative process. A Democrat-only strategy, as some Obama supporters may be tempted to pursue, risks driving the stakeholders we need (the ones who will make reforms smart and implementable and therefore sustainable) to a monolithic Republican camp of opponents. In other words, if the initial proposals have nothing in them for Republican champions to rally around, we could lose those Republicans who are interested in real reform. Some of these Republicans have already made their preferences and commitment public and some have even supported comprehensive legislation. Yet, if we do not engender the cooperation of willing Republican negotiators, we will provide a safe haven for stakeholders and advocacy organizations opposed to reform.

A far better strategy would be to take the spirit of Obama’s eloquence last night literally. We do not need a “Blue” health plan or a “Red” health plan, but rather a plan for the United States of America. Congressional Democrats and the White House will need to listen seriously to those who voted against Obama, as the president-elect promised. They need to build into the plan enough market forces and budget constraints that can make reasonable Republicans – not those trapped in ideology – as comfortable with the plan as conservative Democrats. That will enable the American people to feel comfortable and supportive of the final legislation as well, rather than succumbing to fear of change that helped sink previous reforms. Enemies of reform will spend millions trying to scare the people, and bipartisan tableaux will be crucial to counteracting that old but wickedly effective tactic.

This will appropriately take some time; not forever, but surely most of the first session of the next Congress. It is perfectly reasonable for the Obama Administration to lead with economic and energy initiatives before we settle on the details of a coverage expansion and delivery system reform proposal that can pass and be signed by the President. Unlike the 1993-94 experience, the next White House is not likely to draft a 1,300 page bill and send it down Pennsylvania Avenue for perusal. As we all recall, that didn’t work out very well. What we may not recall so clearly, however, is that President Clinton also had large Democratic majorities in Congress (258 in the House and 57 in the Senate) similar to what President Obama will have come January 2009. I expect that this time the new President will make his priorities clear in a variety of ways, but that the committees will drive the legislative process from hearings to the Senate floor to a conference committee.

Leadership will be more important than some policy details. Political leaders, health system stakeholders, employers, labor, consumers, the media and civil society all have vital roles to play in this important opportunity. A few policy details are essential: for Rs there must be private insurance markets and a central role for individual choice, and for Ds we must make health insurance and quality care affordable for everyone, and we must provide enough good information to make individual choice meaningful. The rest, as they say, is commentary. That commentary, however, will be scrutinized quite intensely, as it should be. I could not be happier or more optimistic about the upcoming debate.

Collapse

National Journal Congressional Correspondent Rich Cohen got it directly from Rep. Henry Waxman, D-Calif., today!

Waxman intends to challenge Rep. John Dingell, D-Mich., for the chairmanship of the House Energy and Commerce Committee, which has significant jurisdiction over health care. NJ's CongressDaily will have a full report in its 3:00 edition.

Dingell has long advocated single payer health care, and has been expected to take a leading role on health care reform next year.

What would Waxman bring to the health care reform process, in contrast to Dingell? Is there really a difference?

The election of Barack Obama and the composition of the new 111th Congress create real opportunities for health reform. But a strategy must be developed at the outset, as there are a number of courses of action open to the new Obama Administration.

One option, as noted, would be to postpone legislative action on health reform while tackling other immediate priorities including energy, the economy, and Iraq. The president could defer action on health reform while setting out a process for getting wide input and forging consensus--such as a Congressional working group or Commission charged with soliciting views, seeking input from the public, experts, and health care stakeholders, and developing recommendations for the Administration. Meanwhile, the Administration could focus on a number of administrative changes that are possible through Executive Order, rule-making, and administrative actions. For example, it could make use of the rule-making authority to support state efforts to maintain and improve Medicaid/ State Children’s Health Insurance Program (SCHIP) coverage. The advantage of this strategy is that it permits time to sort through difficult issues and find areas of consensus, while addressing other urgent policy priorities. But it also gives the opposition time to build.

Another course of action would be to seek legislative enactment of a few measures that would garner bipartisan support, and show quick action on part of the health reform agenda. This could include, for example, reauthorization and adequate funding for the SCHIP and investing to accelerate the adoption of information technology and creation of a health information exchange.

If the Administration believes that there is not sufficient consensus to enact health reform at the federal level, the new president might seek funding to permit five to ten states to move forward and test alternative approaches. The advantage would be the opportunity to learn from testing new approaches on a broad scale, and learning from such action.

An alternative that would retain a strong role for the federal government in shaping health reform would be to set forth a long-range vision accompanied by a request for legislative action on some initial reforms. This could include reauthorization of SCHIP and enactment of measures like health information technology and creation of a comparative effectiveness institute. It could also authorize planning and implementation of administrative structures that would be required in the health reform proposal adopted by president-elect Obama during the campaign such as a national health insurance exchange or a health board to oversee rapid experimentation and diffusion of payment innovations in Medicare.
Another possibility is to include building blocks for reform in a single legislative package that authorizes the flexible roll out of reforms over a six-to-eight year period. A first phase could include reforms that improve the effectiveness and efficiency of health care, such as the implementation of health information technology and the establishment of a center for comparative effectiveness to improve decision-making. This phase could also expand the State Children's Health Insurance Program to cover low-income children and low-income adults, perhaps phased gradually by income level. Consideration could also be given to phasing out the two-year waiting period for coverage of the disabled under Medicare.

This has the advantage of ensuring savings from health reform are dedicated to coverage expansions, that sufficient planning is given to implementation of more complex provisions, and that politically popular as well as difficult reforms are considered in their totality and early-on when a new Administration and Congress have the requisite political capital. Such a sequenced approach to health reform could put the U.S. on a firm path to a high performance health system, yielding better access to care, improved quality, and greater efficiency.

Finally, president-elect Obama could move swiftly to enact comprehensive health reform in a single legislative package while he has the political capital garnered in a major election victory. If leaders in Congress, such as Senator Kennedy, have a legislative package ready to go, it could be introduced immediately and folded into a major omnibus budget reconciliation act. It would be a bold stroke--one appropriate to the seriousness of our current difficulties and the even more challenging fiscal problems ahead as the baby boom generation reaches retirement.

Windows of opportunity for real health reform do not stay open for long. While the challenge is daunting and the stakes are high, the need for action is also acute.

Collapse

While picking up seats, Democrats did not win the 60 seats in the Senate that they were looking for. A 60-seat super-majority would have made health care reform a much easier task for Democrats next year.

Without 60, how will Democrats have to proceed on health care next year? On which issues will they have to work cooperatively with Republicans?

Moreover, Obama has been saying for weeks that he will seek energy legislation before turning to health care. At the same time, reform advocates have stressed the need to do health care early, while their political capital is strong, and before Washington begins to get cautious because of the next congressional election in 2010.

What problems does this pose for health care reform?

It would indeed be wise for all those committed to major health reform to be cautious as they contemplate how to advance their agenda after the election.

One lesson congressional Democrats should bear in mind is that ignoring the need for bipartisanship after a triumphant election is likely to doom reform. After Bill Clinton was talked into snubbing Republicans in 1993 his seemingly invincible health reform steamroller ground to a halt. There are plenty of areas for bipartisanship next year. Despite the brickbats of the election to and fro, there is actually deep bipartisan support for restructuring the tax treatment of health care to widen coverage – with over $200 billion in tax subsidies available, as John Goodman reminds us. There are also several bipartisan bills already introduced, drawing together strong liberals and conservatives, that would give legislative waivers to states to use existing and any new money far more creatively and flexibly to expand coverage at little or no extra cost.

Both these bipartisan approaches make a lot of sense when we face huge deficits and difficult economic times. The election won’t change that situation or the merits of working across the aisle.

Whoever wins the White House is also going to have to remember that Americans are very nervous about change, even good change, in health care – and they can react strongly against someone who hides big change in their proposals (again, ask Bill Clinton). If he wins, Senator Obama will have to proceed carefully as he lays out what his national benefits design and public plan actually means for Americans who think right now that nothing will change for them. Senator McCain has already had a taste of the difficulties of defending quite sound parts of his plan against the charge that people’s coverage could alter.

So while the election might increase the momentum for congressional action, and seem to endorse structural reform of health care, this is no time for hubris and overconfidence.

Collapse

Here is what the election will not change: there is no new money available for health reform. That means that any funding for reform must come from money that is already in the system. That, by the way, is not a bad thing. We don't need to spend more money on health care overall.

Sen. Coburn's overhaul of the health care system, for example, is totally funded by rearranging existing susidies. Sen McCain's plan was originally designed to be revenue neutral as well.

There is roughly $250 billion in tax subsidies and about $30 billion or so that pays for uncompensated care (DISPRO) plus all of the money that currently goes for Medicaid and SCHIP.

If the next president isn't smart enough to use all of these funds for much better purposes, he should abdicate and let someone else have the job.

Dangerous waters ahead!

That sign should be on every member of Congress and every member of the new administration’s desk. If I were the new President, I would tell everyone to take a collective deep breath of humility. Just having control of the White House and the Presidency is not enough to change the healthcare reform debate. Used skillfully and thoughtfully with a majority in the House and Senate, healthcare reform could be an integral part of the first 100 days agenda.

In the Clinton administration, increasing funding for the EITC quickly made a difference in lifting people out of poverty. The new Urban Institute analyses of welfare reform makes it clear that EITC was the most powerful tool to lift people out of poverty.

A strategic president can take whatever levers he controls – i.e. waivers to the States to expand coverage to working people, ramping up fraud investigations, IT expansion and integration--to move quickly while asking Congress to pass the expansion of SCHIP.

The danger for both parties is to not see healthcare reform as a key economic pocket book issue. Reformers must find a way to get on the first hundred days’ agenda and writing a bill with both parties in Congress.

The country will be in a different political world in 2009. Either John McCain or Barack Obama will be working alongside a historically larger Democratic majority in the House and Senate. Thus, the success of bringing solutions to health care fully sits on the shoulders of how the Democratic leadership chooses to govern.

If Speaker Pelosi and Majority Leader Reid believe that the country has now embraced the ideas of the hard left, then we can expect more confrontation and gridlock. However, if they realize that the country wants positive, tri-partisan progress (a red-white-and-blue approach), then there will be ample opportunity to actually solve the problems we face in reforming health care.

We will learn early on which path the Democratic leadership will take. In March, SCHIP will be reauthorized. The choices will be either a radical, heavy-handed bill like the two that were vetoed last year or a collaborative solution like the one we saw in 1997 when creating SCHIP.

At the Center for Health Transformation, we lead by example. Just in the past week, we’ve collaborated on two op eds with leading Democratic senators. With Sheldon Whitehouse of Rhode Island we wrote in the Washington Times, “Health reform means much more than just expanding insurance coverage. To be sure, every American deserves health insurance, but they also deserve cost-effective, high-quality care. Right now, simply having health coverage is no guarantee of quality care. That is why any legislative efforts in 2009 must put the health back in health reform.” We will work together on a broad array of shared priorities, including health information technology and physician reimbursement reform.

With Senator John Kerry of Massachusetts we wrote a New York Times opinion editorial with Billy Beane, the general manager of the Oakland Athletics, exploring how innovative baseball executives are using data-driven models to inform their decision-making. That same philosophy of data-driven health care that surfaces best practices based on evidence is badly needed in health.

There is broad, tri-partisan consensus on accelerating evidence-based care, and we must work together to implement real change. The Democratic leadership will find good partners if they are willing to look for them, and I urge the new president to do the same or suffer the consequences in 2012.

Collapse