Chipping Away at Change
By Lynn A. Blewett, PhD
Failure to pass a comprehensive health care reform bill that includes an individual mandate, public program option, and extension of premium subsidies would not mean that we cannot continue to make progress toward health care reform. I believe a bill will pass and that we will continue to make progress by chipping away at some of these issues through smaller, incremental steps over time. This may be frustrating to reform advocates, but I would suggest that this is how we in America have generally tackled unwieldy legislative tasks such as this one.
Although Congress said no to the Health Security Act of 1993—the 10,000-word bill that featured regional purchasing plans, community rating, and universal coverage—it did say yes to incremental reform shortly thereafter, starting with passage of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). In addition to its extensive privacy provisions, HIPAA set significant precedent for federal regulation of employer-based ERISA health insurance plans, which are currently not required to adhere to state health plan requirements. (ERISA refers to the Employment Retirement Income Security Act, which designates employer-based self-insured health coverage as an employment benefit and not insurance. Typical insurance plans are regulated at the state level, but ERISA plans are not subject to state regulation.) HIPAA limited the use of pre-existing condition exclusions; prohibited group health plans from denying coverage or charging extra for coverage based on a family member’s past or present poor health; provided guarantees for certain small employers and individuals who lose job-related health coverage to purchase health insurance; and guaranteed, in most cases, that employers or individuals who purchase health insurance can renew coverage regardless of health condition.1
Congress also passed several related laws that included benefit mandates such as a 48-hour hospital stay starting at the time of delivery of a child (again applied to ERISA plans as well as state-regulated plans); mental health parity, which prevents large-group health plans from placing annual or lifetime dollar limits on mental health benefits that are less than the annual or lifetime dollar limits on medical and surgical benefits; and protections for patients who choose to have breast reconstruction in connection with a mastectomy. The following year, Congress passed the State Children’s Health Insurance Plan (SCHIP), which now provides subsidized comprehensive health insurance coverage to more than 9 million low-income children.
The official term for this type of legislating is “incrementalism,” and it may be the only way to reform our highly politicized and moneyed health care system. If Congress says no to a public plan, it may later pass stricter limits on private insurance premium increases or limitations on deductibles and copayments. Congress may say no now to an employer mandate but later may pass provisions that allow states to develop requirements for minimum benefit sets for employer-based insurance (extending the state reach to self-insured plans). Congress may say no now to universal coverage but give states the authority and funding to develop pilot programs that would achieve universal coverage and/or health system reform that would be extended to ERISA plans and Medicare, which are currently outside a state’s regulatory reach. For students of public policy, the concept of incrementalism was first described in Charles Lindblom’s classic 1959 article “The Science of ‘Muddling Through.’”2 Lindblom suggested an explanation of how political decisions were made that countered the prevailing notion of rationality and the use of science and technology to fix political problems. He suggested that decision making is not a rational process. Decisions do get made eventually, although perhaps not as neatly and quickly as we would like. For people pushing for transformative health care reform, I suggest that any bill that passes at the outset will set the stage for continued reform in subsequent years through small-but-significant steps. We just need to keep chipping away.
Lynn Blewett is an associate professor of heath policy management in the University of Minnesota’s School of Public Health.
References
1. Centers for Medicare and Medicaid Services. Health Insurance Reform for Consumers. Available at: www.cms.hhs.gov/HealthInsReformforConsume/01_Overview.asp#TopOfPage. Accessed August 31, 2009.
2. Lindblom, C. The science of muddling through. Pub Admin Review. 1959;19:79-88.