Governing Health (The Politics of Health Policy)
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Governing Health
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GOVERNING HEALTH
The Politics of Health Policy
FIFTH EDITION
William G. Weissert
and
Carol S. Weissert
Johns Hopkins University Press
Baltimore
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Names: Weissert, William G., author. | Weissert, Carol S., author.
Title: Governing health : the politics of health policy / William G. Weissert and Carol S. Weissert.
Description: Fifth edition. | Baltimore : Johns Hopkins University Press, 2019. | Includes
ibliographical references and index.
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Subjects: | MESH: Health Policy | Politics | United States
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Contents
Acknowledgments
Introduction
1. The Policy Process
2. Congress
3. The Presidency
4. Interest Groups
5. Bureaucracy
6. States and Health Care Reform
Conclusion
References
Index
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Acknowledgments
In the past, our children have been kind enough to accept responsibility fo
any e
ors or omissions. When they left the house, we blamed our dog
Bailey, but alas, he passed on to dog heaven a couple of years ago, and ou
new dog, Buddy, is just too sweet and perfect to be responsible for anything
ut boundless affection and great greetings. Thus we are left with each
other. Hence, all e
ors are the fault of each coauthor, who humbly accepts
the blame.
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Governing Health
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Introduction
It had been a long time coming when in 2010 the Obama administration and
a Democratic Congress passed by a single vote in the Senate and by
legislative sleight-of-hand in the House a historic reform of US health care,
the Affordable Care Act (ACA). The changes leveled the playing field in
health insurance by requiring all Americans to buy and all sellers to sell to
all comers, mandated that large and mid-sized employers provide insurance
or pay fees for government coverage, and ended preexisting condition
exclusions in health insurance policies as well as a plethora of othe
industry abuses that companies indulged in to protect themselves from
adverse selection, moral hazard, and an inevitable death spiral if they
enrolled too many sick patients. Access to care was expanded by the ACA
through these market reforms, through
oadened Medicaid coverage in
states that chose to accept a generous offer of federal support for expansion,
and through state or federal exchanges that sold comprehensive policies at
easonable premiums made affordable by subsidies based upon a sliding
scale of income.
But the Republicans hated the ACA (which they du
ed Obamacare) in
part because of the way the law was passed—namely, by avoiding the
necessity of a confirming Senate vote that would have fallen one vote short
of ending a fatal filibuster. (A liberal Democratic senator had died and been
eplaced by a Republican after the bill left the Senate, so there was no
chance of passing it there again if the House made too many changes.) But
conservatives also hated the law because, in their view, it inappropriately
expanded the role of the federal government into areas they believe are
etter left to the private market or state governments. Thus, when the
Republicans took over the House after the 2012 election, they began a
series of nearly 60 votes to repeal Obamacare. The votes won a majority in
each Republican House time after time, even though President Barack
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Obama was sure to veto the bill. But while Republicans knew they were
shooting legislative blanks, they also thought that the vote might garne
favor with supporters without causing much pain to some constituents.
Nonetheless, when President Donald J. Trump took office in 2017,
supported by Republican control of both houses, the repeal failed because
three Republican senators balked. Two could not support the damage it
would do to their constituents who were happy with their ACA coverage,
and one was offended by the closed-door drafting of the bill that led to the
epeal vote. Given the tiny majority the Republicans had in the Senate, the
epeal went down in defeat, just one vote short.
Still, President Trump vowed to keep his campaign promise to repeal
Obamacare, and he set about doing as much as he could with his executive
authority. Thus, Congress terminated the ACA mandate that all Americans
uy insurance, the president ended some subsidies that made many poo
Americans able to afford insurance, and granted states authority to offer less
comprehensive and shorter-term policies than called for by the ACA—all of
which also served his purpose of undermining public approval and
confidence in the ACA. In addition, by delaying announcement of whethe
insurance ca
iers will be paid back for subsidies they are required by the
law to grant to low-income people, he created uncertainty expected to drive
some insurers out of the market. Other orders restricted funds and time fo
open enrollment and outreach enrollment assistance to eligible people,
a
ed regional office staff from participating in open enrollment events,
invited governors to request waivers of ACA requirements, allowed
employers to opt out of contraception coverage if they have religious o
moral objections, and directed federal agencies to find additional ways to
permit sale of insurance that does not meet ACA standards.
To appreciate the full potential harm to the ACA of these efforts, it is
important to understand one simple reality of insurance: For a company to
avoid bankruptcy because too many sick people enroll, it must be careful
that people who are not sick also enroll. Those who enroll with a company
ecome its “risk pool.” If the risk pool gets too sick, the company must
aise its prices, with the effect that the least sick people now refuse to buy
insurance, even as the sickest can’t afford to go without it. Consequently,
the pool gets sicker as only those who are sick or very much fear getting
sick enroll at high prices. This is called the death spiral of insurance: As
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ising premiums drive out first the well and then the less sick, the pool
ecomes sicker and sicker and premiums go higher and higher.
The ACA protected insurers against a death spiral by requiring everyone
to buy comprehensive policies and by preventing insurers from setting
prices based upon medical need. The changes made by President Trump and
federal agencies at his direction has had the effect of eroding the strategies
designed by law to guarantee that the insurance risk pools include healthy
and younger people and are not dominated by sick and older people. The
esult has been an inevitable shrinking of the risk pool in many counties, a
sicker, more expensive group of buyers willing to buy insurance, flight
from those markets by insurance companies that fear that costs will exceed
premiums, and requests by remaining insurers for much higher premiums.
With access to insurance coverage beginning to na
ow and the number of
uninsured rising again from the historic lows reached following
implementation of the ACA, the pool has been becoming sicker as only the
sickest patients have been willing to pay the higher premiums.
If you are a supporter of health insurance for everyone, this is very bad.
If you believe that the federal government had no business usurping the
states’ role in health insurance regulation, then these steps that undermine
the ACA and may cause it to fail in many counties means less federal
ove
each. These divergent views generally reflect political alignment:
Most Democrats want the ACA preserved and improved; many Republicans
want it to shrink, one way or the other. President Trump wants it gone. That
is what he promised in his campaign.
If Democrats were to regain control of Congress, they might be able to
put some fixes back in place, provided President Trump did not veto them
—something he would likely do unless Congress offered deals on othe
administration priorities.
Yet come what may with the ACA, there are still significant problems
with American health care. Our costs continue to far outstrip those of
comparable nations, our drug prices are far higher than those of othe
countries, and our care intensity varies widely from hospital to hospital, city
to city, and state to state, with much of the care rendered proving ineffective
and probably wasteful.
But there are hopeful signs. Some incentives for improvement were
adopted in another new, less salient, law: the Medicare Access and CHIP
Reauthorization Act of 2015 (MACRA). In a rare instance of both
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ipartisan cooperation and acceptance by the physician community,
Congress passed a major reform of the way Medicare pays physicians and
other providers, hoping to move their payment incentives away from
volume and toward effective performance. The goal of the law is to ensure
that more providers follow best practice guidelines, rendering only care of
proven effectiveness for the patient’s condition, reporting diagnoses and
treatments to electronic health records systems, innovating while avoiding
unnecessary expense, and achieving markers of quality and cost-conscious
performance. Meeting standards means earning bonuses. Departure from
standards, excessive volume, high cost care, and other unreformed
ehaviors lead to fines. How tough the performance standards will be and
how hard the fines will bite will be greatly influenced by regulations to be
written by an executive agency, the Centers for Medicare and Medicaid
(CMS). Critics feared that force of the law would be blunted by the Trump
administration.
Such is the way of American policymaking in health care. What we pay
for health care, how much we rely upon market competition versus
egulation, how much we accept differences in the quality of health care,
how much excessive, unneeded, and potentially harmful care we tolerate
and pay for, and how some of us run into financial and other access ba
iers
when we try to get care are all aspects of health policy and are shaped by
many forces. These include the president, Congress, federal agencies,
physicians, drug companies, unions, hospitals, medical equipment makers,
insurance companies, managed care organizations, patient advocates and
other interest groups, state legislatures and state bureaucracies, and all of us
consumers of health care who demand that we have access to all the care
that is available, whether we need it or not. Republicans tend to favo
market solutions and fear bureaucratic interference in medical decision
making. They wo
y that an ove
earing federal government will create a
dependent class. Democrats criticize the market approach as unrealistic,
given the many restraints on competition, and wo
y that it will produce
a
iers to insurance and care, which will create a divided society consisting
of the nonpoor who are in good health and the poor who are in ill health.
Policies change between administrations of different partisan persuasion,
though frequently ideas from one administration are adopted by another.
Republican President George W. Bush won passage of Medicare
prescription drug coverage, an idea that had been pushed by his
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predecessor, Democrat Bill Clinton. President Obama’s ACA adopted
market exchanges to sell ACA policies, an idea long favored by
Republicans. Or did Republican Senator Marco Rubio (FL), who pushed
the state legislature to fund a small health exchange in his home state when
he was leader in the of Florida’s House of Representatives, get his idea
from the Republican-derided “health alliances” offered in President Bill
Clinton’s failed 1994 health insurance plan?
US health care policy reflects the complex cultural, political, economic,
social, historical, and institutional forces that shape it. This book explores
how government makes health policy, including the partisan political forces
that influence decisions. Most health care in the United States is delivered
y the private sector, but because public policy pays for and regulates so
much of this care, health policy is vitally important. Moreover, private
payers for health care tend to mimic the payment approaches of public
policy, so public policy’s reach extends even farther into the private portion
of health care policy—another reason that foes of large government oppose
the potential distortions that they fear will result from government
insurance. Because so much of health care is outsourced and becomes the
income stream of private-sector providers, claims processors, makers of
health care products, and others, private interest groups have a huge stake in
public policy and find it a good bargain to spend rather lavishly on lo
ying
and other strategies aimed at influencing public health care policy.
Most industrialized countries pay for most of their citizens’ health care
publicly. We place more faith in private payment and attendant market
competition to reduce prices and improve access and quality. In general, it
has not worked, in part because our delivery system restricts competition in
a number of ways: Some providers or insurers dominate their markets,
many drugs enjoy patent protection, which they are then able