Political Polarization Creates Tribal Politics

The current political situation is a complicated picture that greatly impacts the future of health reform in this country.

The Forlorn Hope of Bipartisanship
Last December’s lame duck session surprised the public because we saw an unexpected true collaborative, bipartisan effort, and real problems got addressed. “Don’t ask-don’t tell” was repealed, Congress passed a food safety bill and a bill for benefits for 911 rescue workers, and tax cuts for the wealthy were extended. Then, the Tucson tragedy brought the Congress together in mourning and muted the vitriolic rhetoric. Next came the State of the Union address, which, along with the bipartisan seating plan, was almost universally well-received. Since then, the parties have not come together on any number of serious health policy problems facing our country. There has not been a glint of even the most rudimentary gesture of faux or real bipartisanship.

The AcademyHealth annual National Health Policy Conference earlier this year, which brought together leaders in policy, industry, and health services research, left attendees with a range of conflicting visions for the future of health reform. In part, the meeting was inspiring in that attendees were updated about emerging and meaningful health system transformation. Don Berwick, administrator of the Centers for Medicare & Medicaid Services (CMS), announced that CMS will be launching the largest patient safety initiative ever seen. He is committed to changing the experience that patients have in our current healthcare culture. The Department of Health and Human Services (DHHS) is working to “liberate” healthcare data in order to make it fully accessible and user-friendly. The DHHS is modeling this initiative on the weather data released from the National Oceanic and Atmospheric Administration, which makes all weather-related data entirely public, integrated, and meaningful.

The political front provides a more discouraging assessment of what may come. A panel of Congressional staffers revealed that each party is operating in an entirely different stratosphere with diametrically opposing goals. The Republican staffers reported that their health reform efforts are now aimed at putting the entire reform effort on the chopping block, fundingwise. “Repeal and replace” has shifted to hoisting a sledge hammer to cut $60 billion dollars from the budget. The Democrats reported that they want to work with the Republicans on areas that both parties seek to improve. The Democrats want to increase taxes and make investments in programs that boost the economy. Noted congressional scholar Thomas Mann reminded us to be hopeful. It was his opinion that we have not seen this kind of fierce partisanship since the Civil War…and we survived that!

The Good News
We heard from Oregon about that state’s ambitious and creative health exchanges, which are designed to “amaze and delight” users. (Health exchanges are state-based marketplaces for health insurance that are mandated by the Patient Protection and Affordable Care Act and the healthcare-related provisions in the Health Care and Eduction Reconciliation Act of 2010, which are collectively known as the ACA. The marketplaces are required to make the purchase and pricing of insurance transparent, seamless, and integrated, making it possible for users to assess what they are purchasing.) Many people see the health exchanges as the public face of reform and consider them to be the foundation of the ACA. While states have a huge degree of autonomy in setting up health exchanges, some envision a highly active purchasing role, using their large market share to negotiate/leverage better prices, while others will simply set up a clearinghouse of information on available insurance plans.

Emerging Obstacles to Health Reform
On the political side, a number of new obstacles have emerged that will require a fierce commitment to bringing evidence into the continued debate on health reform as it is played out in the budget process. The Institute of Medicine reported that approximately 50% of all health care delivered lacks any evidence base whatsoever, an estimate that demands more investment in building the evidence base in order to bend the cost curve. There are a number of obstacles to health reform, including asymmetrical polarization, timing, the courts, the states, and the economy.

Asymmetrical Polarization
Since the 87 freshman Republicans won their seats in the US House of Representatives based on an agenda to greatly reduce government spending, there is an intense pressure to thwart any efforts to improve the ACA. The very first act of the new House was to vote to repeal the ACA; representatives are now expected to block appropriations (ie, funding) for many ACA programs. This “repeal and replace” posture creates tribal politics, cuts off any efforts at bipartisanship, and indisputably limits the ability of Congress to address serious problems in our health financing and delivery systems.

Politically, the right has lost its center and shifted to the far right, a position based on a fierce commitment to remove or reduce the government’s role in all aspects of society. Since the repeal of the ACA failed, actions appealing to the far-right Republican base will focus on defunding ACA health programs. As the budget process unfolds this spring and summer, we can expect this ideological “digging-in” to sharpen and the fight to be ugly. It is as if each side is approaching the dialogue from another dimension—not even coming together on the obvious areas both parties have agreed on, such as malpractice reform, a binding Medicare advisory body to Congress, and ways to negotiate the insurance mandate without an actual mandate. Political ideology trumps serious debate/problem solving in this highly lopsided political polizeration and shift to the right. The state of the “permanent campaign” makes it nearly impossible for policymakers to engage in any serious long-term problem solving. The nature of health reform is hugely complex and cannot be addressed in sound bites. The shift of the Democrats to the center has also created polarization, with no space—or even a shared planet— to address serious efforts to bend the cost curve.

Timing
Just as many of the provisions of the ACA are set to be implemented, the Republicans took over the House, thwarting efforts to fully implement reform. The public has not had the opportunity to fully experience the legislation since it is scheduled to be rolled out over the next decade, thereby placing the ACA in a tenuous position. Even the wildly popular elimination of preexisting conditions is not understood by the public.  For example, many people do not realize that banning policies on preexisting conditions directly hinges on expanding the insurance pool, ie, the individual mandate. Everyone needs to realize that we cannot eliminate preexisting conditions without expanding the insurance pool. These two important concepts must go hand-in-glove; however, the removal of preexisting conditions is very popular, while mandating that we purchase insurance creates enormous conflicts.

The Courts
The 28 states that are challenging the constitutionality of the individual mandate are moving through reform at various rates of speed. Some states are pursuing reform at full throttle, while others are postponing reform efforts until a court decision is made. It is expected that this decision will be expedited to the US Supreme Court. It is hoped that this issue will not become another highly politicized “Gore vs Bush” decision since that form of decision making greatly undermines the court. The legal limbo that the individual mandate creates is yet another barrier to states investing wholeheartedly in creating meaningful health exchange, ie, insurance marketplaces.

The States
With the exception of Alaska, every state in the nation has applied for a $1 million dollar planning grant to set up health exchanges. The ACA has approached reform with the intention that states would have a great deal of flexibility in creating these health exchanges, with only a few requirements. Each health exchange is expected to look different, and the states have enormous power in implementing the reform provisions. The states will be responsible for collecting all the required information and, with public input, creating the health-exchange governance and appeals processes. This will require engaging consumers and providers and creating a robust database that informs policymakers on best practices. The bill requires DHHS to set up a health exchange in those states not willing to develop their own. Moreover, some exchanges may be regional, resulting in a complication for advanced-practice registered nurses (APRNs) who work under different state practice acts. Suffice it to say that the successful implementation of the ACA hinges in large part on the states.

The Economy
Economic indicators that measure the success of the economy will play a huge role in whether or not the ACA gets fully implemented. If signs of recovery are not forthcoming over the next 3 years, it may be a major challenge to keep the full ACA alive. Even more ominous is the unemployment rate; if it does not drop to 8%, we will see more skepticism and less willingness to invest in healthcare transformation.

Actions for APRNs
These barriers are expected to create uncertainty and chaos as the fights and court battles play out over this summer. Regardless of their political opinions, APRNs need to provide a unifying message about patient care that bridges the profound differences and speaks to the center. We must reposition health care as a bipartisan issue and remind policymakers that our current delivery system is not sustainable. The ACA builds on our notion of capitalism and that free markets and the private sector must be central to our system. The role of government is where the tension lies, and it is expected to intensify in the weeks and months ahead. A major challenge for APRNs, regardless of their political beliefs, is to avoid ideology and use an evidence base to reframe the center. In our quest to bring a stronger evidencebase into our health system, we, more than any provider group, can bring intellectualism into the forefront and speak with authority. We have the public’s trust—more than any other health profession—and we must be firm in advocating for them. Partisan anger and inflated rhetoric must be elevated to a meaningful dialogue if we are to make any headway on our troubled health system.