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Pulling It Together: Implementation Is Forever

Now that historic health reform legislation is law, everyone is rightfully focused on implementation. There are two very different ways to look at implementation. One is the more legalistic worm’s eye view, which sees implementation largely as the process of putting into effect what was written in the law. In the worm’s eye view implementation proceeds in a linear fashion from legislation, to regulations specifying what the statute calls for in greater detail, to operations in the field.

The other perspective on implementation is the bird’s eye view. It sees implementation as adaptive and somewhat unpredictable; a function of real world developments, politics, the number of players and decision points and the time period involved in implementing a law. In the case of health reform, implementation would depend not only on what is written in the law, but also on how the political and economic landscape shifts, how governors and states respond to health reform, how the private sector responds, how health care institutions and health professionals filter the intent of the legislation on the front lines, what the media does, and most of all, what the public’s reaction to health reform is over the next several years.

Both perspectives are equally applicable to the health reform law. The statute and the real world will come together in unknowable proportions to shape what actually happens. There are many challenges ahead, but in this column I address two that I see as especially important: explaining the law to the American people and implementation in the states.


For over a year health reform has been the focus of an intense, emotional, and heavily politicized debate that has been as much about deeper issues and raw nerves in American politics as it has been about the substance of health reform itself.  The heavy political messaging will continue at least through the midterm elections and polls will continue to elicit reactions from the public about the law (mixed), the policymaking process (sharply negative) and the benefits the law provides (very positive).  But now that health reform is the law of the land all you have to do is turn on the car radio or the TV or talk to a taxi driver to see that the American people have flipped a switch in their heads. They will continue to have opinions about the law but what they are desperately trying to figure out now is what the law means for them.

I was getting a ride to a speech on health reform at Claremont McKenna College recently called The Athanaeum Lecture from a gentleman and his wife. They were both 58 years old. He was healthy, she had hypertension. They had no health insurance and they were making a real effort to understand the law. They knew that her hypertension would no longer exclude her from coverage. They very clearly understood that they would have to pay a penalty if they did not buy insurance by 2014. They had heard there would be subsidies provided under the law but were unclear how they would work. They knew why I was visiting the campus and wanted to talk about health reform. We discussed their employment plans, their likely income in 2014, who qualifies for tax credits under the law, the exchanges and the kinds of policies they would be able to get. By the time we arrived at our destination they had concluded that they could get substantial help buying a policy in the exchange in 2014 that would give them health coverage before their Medicare kicked in a few years later. They must have been reassured (or just smart), because after they dropped me off they attended a talk on campus by Sandra Day O’Connor, not my health reform talk.   Similar discussions are occurring across the country and almost everybody has a special circumstance or situation and they are hungry for answers to their own specific questions. Answering those questions in a way that is consumer friendly and responsive to people’s individual circumstances is a big challenge and will be critical to establishing a positive climate for implementation and to the success of the law.

The major benefits of the law — the coverage expansions, subsidies, and insurance market reforms — do not kick in until 2014. To compensate for that, the architects of the legislation built in a long list of early deliverables so the public would see tangible and understandable benefits right away — from allowing dependent children to stay on family policies until age 26, to beginning to eliminate the prescription drug donut hole for seniors. But, these early deliverables will likely help only a modest number of people and, of course, people’s premiums and out of pocket costs will continue to rise at a faster rate than their wages will. So, on the one hand, the law might not provide the kind of help people are expecting in the first few years. On the other hand, the sky will not immediately fall, as many people seem to believe it might. In fact most people will see little or no change to their health care arrangements.  If the benefits and timetable for the law are communicated effectively the expectations gap should be manageable, and over time the benefits the law provides will be highly-valued by the American people, but it will be crucial to develop mechanisms to answer people’s questions and link them to the benefits the law provides.


There are substantial implementation challenges to be met at HHS and some at other Federal agencies, but by far the biggest challenges will unfold in the states. Among the major responsibilities states have are: setting up the insurance exchanges for small business and individuals; enforcing the new insurance reforms; and overseeing the new Medicaid expansion that for the first time provides coverage to all low income people whether or not they have children, but brings with it new administrative challenges such as outreach and enrollment of new populations, integrating Medicaid with the new exchanges, and applying new income eligibility standards established under the law.  Every state legislature will need to act for states to move forward. States will need to implement all of this at the same time as they face an estimated $375 billion in budget deficits over the next two years and thirty seven governorships will be up for election. In short, states will need to gear up for health reform at a time when they are cutting back and do it in a fluid political environment in many states. There is new financial assistance in the law to help in establishing exchanges, but none for other tasks other than the normal federal-state split for administrative costs under Medicaid.  As a former head of a state umbrella agency with responsibility for a good deal of this territory, I can say from experience that states will need a lot of help and their performance will be variable. Some states will be real pacesetters, others will lag behind, and most will fall somewhere in the middle.

There is a huge job ahead to assist in the overall implementation challenge: to establish the facts about what the law does and does not do; to provide detailed information to the public about how different groups will be affected by the law and help people take advantage of the benefits it provides; to provide technical assistance to states; to help advocacy groups at the state and local level gear up to represent the interests of those who have the least information and influence themselves; and to track implementation and assess the impact of health reform on access, costs and care.  Different organizations will make different choices about the roles they play and the pieces of the implementation challenge they take on. At Kaiser we will focus on clearly establishing the facts about the new law; what people understand and do not understand about it and how they are reacting to it; and most of all on its impact on people, which is always the organizing theme for our work.  We will be launching a new website which we hope will be a go- to resource for analysis and information on health reform implementation.

In the end, however, it is the media that always is the public’s main source of information on health issues and that will be the case for health reform implementation as well. That is why we have long had such a strong commitment to health journalism at Kaiser and to being a resource on health policy for journalists and news organizations, and it is why we established Kaiser Health News, with its mission of producing in-depth coverage of health policy issues and providing its content for free to major news organizations and the public. The media’s big challenge will be to explain the law to people, and then to examine its impact and to cover the implementation of health reform beyond the Beltway as the story moves to the states and the marketplace. With shrinking budgets news organizations will be stretched thin to follow the story beyond Washington. Regional media can fill the void to some degree, but their budgets have been cut even more.  And with the mid-term elections looming, providing balanced coverage of the electoral politics and the policy substance – with an emphasis on explaining what the law means to people – will be a challenge for a media increasingly drawn to controversy. It is especially a challenge for cable news.  Media has a capacity to inform and to tell the story of how health reform is affecting people that goes beyond anything polling or health policy research can do, but it also can too easily become just an echo chamber for the political process itself.

Experience in every other developed nation teaches us that reforming health care is not like fixing a problem with your car. You don’t find the problem, identify a solution and then it is fixed.  After passing their form of comprehensive national health reform legislation, every other nation continued to make corrections and improvements and to struggle with the tension between ever more expensive medical care and limited resources. The new health reform law in the U.S. marks a milestone in health and domestic policy of enormous importance, both in the directions it sets and the policy objectives it achieves. All of the elements of the new law are scheduled to be in place by 2018.  But, like other nations we will always be reforming our health care system. In that broader sense, implementation is forever.