The single most important next step in health care policy is to make reform a consumer-friendly experience. Many Americans remain skeptical about the benefits of reform. For them, the proof of the pudding may be in the eating.

Americans’ direct experiences with reform will shape public opinion as much, if not more, as the arguments between members of Congress. Every good experience will multiply by word of mouth and through the media. The reverse will also be true.

HHS Secretary Sibelius set a consumer-friendly tone last night by launching a weekly, public webchat about how reform will affect Americans’ daily lives. SBA Administrator Kathleen Mills was also on hand to address questions submitted online about small businesses. For future web chats, viewers will have a chance to vote on which questions will be discussed.

In that same vein, the administration must pay special attention to the places in reform where consumers and government interact directly. Here are three of the most critical checkpoints:

1. Proving you have insurance. With the IRS in charge of enforcing the new requirement to have coverage, the challenge to make reform consumer friendly will be particularly acute. The new law requires insurers and employers to report lists of the people they cover. But fraud and enforcement concerns are sure to mean demands for more solid proof from individual taxpayers. Americans might, for example, have to file tax returns with copies of their insurance policies attached.

One way to streamline this process is to extend the system doctors now use to verify a patient’s insurance coverage for billing purposes. Taxpayers would either authorize the IRS to access a verification system or enter their insurance information on a tax form with no additional paperwork.

2. Buying insurance and getting subsidies. Will shopping for coverage and establishing eligibility for subsidies be easy and painless, like buying from Amazon, or dealing with frustrating and endless lines at a DMV to renew a license? To ensure the former, small businesses should be allowed to auto-enroll their employees. Auto-enrollment is required for larger companies. Small business owners should have the same opportunity — and be encouraged to supply insurance for their workers through the exchange. Another potential fix is “auto-eligibility” for subsidies — using existing data on income and wages to calculate a worker’s benefit.

3. Getting coverage for a pre-existing condition. In June, the administration must provide nationwide access to a high-risk pool for people who have been turned away by private insurance companies because of health problems. Sixteen states lack a pool completely, while other states have closed off their pools. Moreover, some governors and attorneys general appear to be more interested in suing over the legislation than implementing it. The President must remind Republican governors that the high-risk pool is a bipartisan idea and was a major plank in Sen. John McCain’s 2008 presidential campaign. He will need to build cooperation with governors to ensure success on the ground in each state.

Implementation of reform comes at crucial time in our nation’s political history. Opinion polls show barely one in five Americans believe the federal government does the right thing all or most of the time. Done right, implementing health reform will disprove doubters and lay the groundwork for solving other critical public problems.

Lacking a public option, the major check on insurance company price increases and abuses in the new health reform law is managed competition and regulation. That check is already being put to the test by the insurance companies.

In six months, the new law says children can no longer be denied care for pre-existing conditions. But the insurance companies immediately said they'd found a loophole:

Insurers agree that if they provide insurance for a child, they must cover pre-existing conditions. But, they say, the law does not require them to write insurance for the child and it does not guarantee the “availability of coverage” for all until 2014.

William G. Schiffbauer, a lawyer whose clients include employers and insurance companies, said: “The fine print differs from the larger political message. If a company sells insurance, it will have to cover pre-existing conditions for children covered by the policy. But it does not have to sell to somebody with a pre-existing condition. And the insurer could increase premiums to cover the additional cost.”

Secretary Sebelius immediately fired back with a letter to Karen Ignagni, head of AHIP, the insurance industry's main lobbying arm. The letter made clear the administration's intention to issue regulations to enforce both the spirit and letter of the new law, including covering children with pre-existing conditions and providing both access to plans and benefits. And today, it seems the insurance industry relented:

In a letter to Health and Human Services Secretary Kathleen Sebelius, the industry's top lobbyist said insurers will accept new regulations to dispel uncertainty over a much-publicized guarantee that children with medical problems can get coverage starting this year.

…

"Health plans recognize the significant hardship that a family faces when they are unable to obtain coverage for a child with a pre-existing condition," Karen Ignagni, president of America's Health Insurance Plans, said in a letter to Sebelius. Ignagni said that the industry will "fully comply" with the regulations, expected within weeks.

It remains to be seen exactly how this particular battle will play out. While insurance companies say they'll comply with regulations to issue policies and provide benefits to children with pre-existing conditions, there is no talk about the cost of such policies. Still, for families currently unable to get coverage for their sick children at any price, even this modest change in practices will be a relief, though the bigger changes - including the subsidies to make insurance not only accessible but affordable - don't go into effect until 2014.

This is the first of what will be many battles with the insurance companies over regulation. The administration and the new regulatory structures put into place by health reform won the first skirmish. But there's no doubt that insurance companies will throw many obstacles in our way as we move towards guaranteed health care for all. We'll have to keep fighting them and their army of lawyers and lobbyists as health reform is implemented and improved upon in the years to come.

It's still true that if the insurance companies win, we lose.

After more than a year of debate, Congress and the President have enacted sweeping health reform legislation that will finally bring affordable health insurance coverage to millions of previously uninsured Americans, improve the availability and security of coverage for those who already have it, and begin to control the escalating cost of health care in this country. With enactment of reform legislation, the U.S. now joins all other major industrialized nations with a system for ensuring access to essential health care. This is truly a historic accomplishment.

While several coverage expansion provisions (such as coverage of young adults under parents’ policies) are set to take effect in 2010, the numbers of uninsured are likely to continue at a high and rising level until additional coverage expansions kick in in 2014. The nation's economy is still in a serious contraction, with numerous states facing imposing budget deficits and millions of Americans suffering through protracted periods of unemployment. Extension of the enhanced federal matching rate (FMAP) to state Medicaid programs and continuation of COBRA premium subsidies for unemployed workers are two strategies for maintaining Medicaid and employer coverage during this exceptionally difficult time. Without immediate action, federal COBRA subsidies for unemployed individuals and families will cease at the end of March and the enhanced FMAP for states will end in December.

The expansive jobs bills passed by both chambers of Congress and currently awaiting conference include extensions of both the enhanced FMAP and COBRA programs through June 2011. A separate extension of COBRA subsidies and other unemployment benefits intended to bridge the gap before enactment of the jobs bill remains pending. At this time, it appears exceedingly likely that passage of either piece of legislation will not be accomplished in time to prevent a gap in subsidies for millions of Americans. Similarly, several senators and representatives have proposed standalone legislation to extend the enhanced FMAP, but those efforts have stalled pending the outcome of the jobs bill.

The passage of historic health reform legislation is a victory for all Americans. However, we must remain vigilant about ensuring that vulnerable groups have access to affordable coverage during this period of economic hardship. Extension of the increased federal matching rate to state Medicaid programs and continuation of federal COBRA subsidies to unemployed workers and their families are both vital steps during these difficult times.

What’s next? Someone is going to have to clean up what probably is the single worst health reform package found anywhere in the world in modern times. Let’s hope the next Congress moves with all deliberate speed to correct these intolerable disasters:

1.A requirement that just about everyone must buy a health insurance plan whose costs will be growing at twice the rate of growth of his income.

2.A wildly erratic system of subsidies that is completely inconsistent with the needs of an efficient labor market.

3.A health insurance exchange in which health plans will try to attract the healthy and avoid the sick; and after enrollment, will overprovide to the healthy and underprovide to the sick.

Health care reform is now the law of the land, and Congress and the Administration need to treat it that way. For the Administration, that means proceeding with implementation as rapidly as possible. The danger in implementation is in thinking too small. Every successful corporate turnaround has involved new structures operating in a new environment. After all, the old structure is the one that led to the trouble. Health care reform will only succeed if it follows the corporate model.

Health reform is ultimately accountable to the promises the President has made. Thus, the operational center has to be in the White House. A team of officials needs to be responsible for implementation and accountable for progress.

The most wrenching change must occur in the Department of Health and Human Services. The Secretary needs to bring in an implementation team responsible for carrying out reform: creating and operating health insurance exchanges; reforming Medicare payment systems; eliminating administrative excess; monitoring malpractice reform; and the like. Given how burdened the existing agencies in HHS already are, this cannot be done by simply assigning more tasks to existing people. Rather, it requires a new team to see the big picture, direct the efforts of existing personnel, and ensure the various parts fit together. This is a full-time job for a group of people, not a part-time task for one or two already-burdened individuals.

The most important task for Congress is to respect the promises it just made. The theme of health care reform was that enlightened leadership of federal health programs could improve quality and lower costs throughout the health system. Congress has endorsed that principle, and now it needs to give the Administration the flexibility to carry out reform, even when interest groups begin to complain. Congress will also need to fix the SGR, at least in the short-term.

Undoubtedly, there will also be a need for future legislation, though it will hopefully be much less controversial. Even those who opposed reform have an interest in making it work.

The task is difficult but not impossible. The military is currently held in high esteem, but during the Vietnam War it was not. Hard work and success led to an increase in confidence in military leaders. The Obama Administration has the opportunity to do the same thing for health care. The federal government is not seen as a visionary leader or successful reformer of health care. With enough vision and capacity, it might.

Corrected at 1:57 p.m. on March 29.

The immediate post passage environment has been dominated by the kind of political rancor that characterized the lead up to passage of the legislation itself and is reminiscent of the town hall meeting wars of August. The health reform legislation will provide much needed help to Americans struggling with their health care bills and represents a framework to build on for the future. But the legislation did not have bipartisan support and the process wasn’t pretty; health reform passed like kidney stones.

The current highly politicized environment around health reform is likely to continue through the midterm elections. Republicans will focus on their now familiar criticisms of the legislation and calls for repeal and Democrats on the benefits and peace of mind the law will deliver to the American people which are popular with the public. There will be a big challenge for the media, especially the echo chamber of cable news, to not focus so much on the politics and the controversies so that the news organizations themselves and their coverage become part of the political process itself and create a negative environment surrounding implementation of the law. Providing balanced coverage of the electoral politics and policy substance – with an emphasis on explaining what the law means to people – will be a challenge for a media increasingly drawn to controversy.

Beyond the political cacophony surrounding the midterms the real challenge that will make or break health reform is implementation. While the major elements of the law such as the coverage subsidies, Medicaid expansion, new insurance exchanges, and major insurance reforms do not kick in until 2014, a sizeable list of early deliverables take effect very soon. These include establishing a temporary high risk pool, extending dependent coverage to age twenty six, providing tax credits for small businesses, ending insurance company rescissions, and beginning to fill the donut hole with a $250 rebate. These early benefits provided by the law are tangible and understandable to the public and implementing them effectively and smoothly and without delay will be important to the early verdict reached by people regarding health reform.

But the biggest implementation challenge of all will play out in the states which, among other major responsibilities, will need to create exchanges, enforce new insurance reforms, and preside over historic Medicaid expansions that will bring coverage to low income adults who do not have children. As a former head of a state agency with responsibility for much of this territory, I can assure you these will be far more than technical and administrative challenges, requiring legislative battles in every state and in many states pitting governors against legislatures and state agencies against one another before things are sorted out. All of this will take some time to sort through to be ready for full implementation in 2014. As CMS’s terrific Cindy Mann put it at a meeting last week discussing HHS’s plans for implementation: “2014 begins today”. States will need to begin gearing up to expand their responsibilities at the same time as they are cutting back due to the recession, with states facing $375 billion in budget shortfalls in 2010 and 2011. State innovation and customization to local circumstances can be a strength of our system, but states will need help to handle the implementation challenges ahead.

Right now the focus is on the post-passage, pre-midterm political storm surrounding health reform. While that “story” occupies attention the real story and ultimate barometer of success will be implementation, and the most important part of that story will begin to unfold in the states very soon.

CORRECTION: The original version of this post incorrectly referred to the tax credits for small businesses.

While this is another important step forward, there’s more to be done to ensure access to physician care for America’s patients. We will remain actively engaged to ensure that before Congress adjourns there are additional important changes to our health system that couldn’t be addressed in the reconciliation process, including repeal of the Medicare physician payment formula that threatens access to care for seniors and military families. AARP and the Military Officers Association of America (MOAA) have joined with AMA to urge Congress to repeal the Medicare physician payment formula. We will hold Congress’ feet to the fire to be sure that access to care for seniors and military families is a priority when members return to Washington after recess.

Congress must also move immediately to correct problems with the Independent Payment Advisory Board. We will be relentless in our pursuit of permanent repeal of the Medicare physician payment formula, corrections to IPAB, medical liability reform and other important actions that we outlined in a letter to Congress.