As we prepare for the 30th Anniversary AcademyHealth Annual Research Meeting (ARM), we’ve asked leaders in the field to share some of their memories of the event and/or perspectives on how the field has changed since our first meeting in 1983. Below is a submission from Dr. Sherry Glied, Professor of Health Policy and Management, Mailman School of Public Health, Columbia University and former Assistant Secretary for Planning and Evaluation at the U.S. Department of Health and Human Services.
Early in President Obama’s first term, it became evident that achieving bipartisan support for comprehensive health reform legislation was unlikely. Then, on June 20, 2009, Al Franken was sworn in as Senator from Minnesota, giving the Democrats a filibuster-proof majority of 60 votes in the Senate, a supermajority that lasted only until January 19, 2010, when Scott Brown was elected in Massachusetts -- a total of 213 days. In that period, just over 30 weeks, Congressional committees developed legislation, the Congressional Budget Office (CBO) scored proposals, and both Houses passed laws. Both the House and Senate bills were very wide-ranging in scope, encompassing everything from reform of the insurance market, to new subsidies, to extensive delivery system reforms, to public health and workforce policies, and much more.
The torturous path that led to final passage of the Law meant that the Department of Health and Human Services had already missed several statutory deadlines (codified in the December Senate bill that was never amended) even before the Presidential signing ceremony. With the Law finally in hand, the Executive branch immediately began work on implementation. By the end of July, new regulations had been promulgated establishing an early retiree reinsurance program, a web portal, and a pre-existing condition insurance program, and defining the rules governing dependent coverage, grandfathered plans, lifetime and annual limits, consumer protections, preventive services, and claims and appeals.
A lot of bytes have been flashed over the pros and cons of the law, the legislative maneuvering, the strategy and tactics – but with that timeline in mind, it’s also reasonable to ask “How could so much be achieved in so little time?” To be fair, Medicare passed a little quicker (President Johnson signed it just 204 days after proposing it to Congress), but Medicare was much simpler – it built on the Social Security infrastructure and made no effort at all at reforming the delivery system, containing costs, or addressing public health -- and Medicare passed long before the CBO, whose cost estimates had since been one of the major roadblocks to reform, was invented.
Much of the credit for the rapid passage of the Act, and the equally speedy rollout of implementing regulations, goes to the community of health services researchers. After the demise of the Clinton health reform plan, many saw health reform as impossible and politically toxic. Yet research continued, and the knowledge base on issues like how the non-group market worked, how people responded to new coverage opportunities, how delivery system reform connected to cost containment and quality improvement, and how much mental health parity might cost advanced considerably after 1993. In effect, researchers ensured that future health reform efforts would be ready with numbers and ideas when they were needed.
Health reform is a challenging issue for the political process. The beneficiaries are diffuse and often invisible. The opposition is large, diverse, and well-funded. The issues are invariably arcane. The accumulation of data and studies over the 1990s and 2000s helped to overcome the opacity and lack of public salience of the problems motivating health reform. Research helped to persuade policymakers and opinion leaders both that something needed to be done and that politically viable options were within reach.
Once interest in reform was re-ignited, the health services research literature took on even greater importance. As the CBO began to develop its health reform model, in the fall of 2007, it turned to that literature to ground its parameter estimates. When staffers on the five different Congressional committees involved in writing legislation sought ideas and advice, they turned to that literature and to its authors. When HHS began to draft regulations, the health services research literature was our almanac. As political reporters began to cover the legislative tactics around passage of legislation, they could turn to a set of credible and established experts to fill them in on policy details.
The political process is a frustrating ordeal for health services researchers. Our work is misinterpreted, ignored, or taken out of context. Legislation is invariably messy, self-contradictory, and full of inappropriate compromises, gumming up our tidy models. Any good health policy researcher should be able to suggest at least one significant improvement to the Affordable Care Act (although we are likely to disagree among ourselves about it!). Nonetheless, the process of passage and implementation of the Affordable Care Act suggests that the political process and the health services research enterprise can and do complement one another. As reform implementation continues, the work of health services researchers, assessing and evaluating alternative options and monitoring processes and outcomes, are likely to remain critical to achieving the goals of the Affordable Care Act.
--Sherry Glied, Ph.D.
Registration for the 2013 AcademyHealth Annual Research Meeting is now open. The ARM is the premier forum for health services research, where more than 2,400 attendees gather to discuss health policy implications, sharpen research methods, and network with colleagues from around the world. The ARM program is designed for health services researchers, providers, key decision makers, clinicians, graduate students, and research analysts.
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