Changes in Health Policy
There is an old saying that the only thing that is constant is change. Like most adages, there is a lot of wisdom in this statement. But it provides little comfort for those who are dealing with the stresses of change. In the weeks ahead we will be exploring the concept of change – in organizations, in our professional lives, in society, and in policy and politics. Change will be the focus of a Virtual Conference hosted by the Military Families Learning Network entitled ‘Learning Through Change,’ and will be held from September 26-29, 2017. In addition, in this and my next blog, I will be discussing how change is a product of historical influences and present compromises. Understanding how change is influenced by the past and by the present can help us better encourage and manage change.
In this blog, I am going to briefly talk about change in the context of politics and policy from a historical perspective. As a political scientist, I have spent much of my career examining how public policies, like Medicaid and the more recent Affordable Care Act, have been developed and implemented.
Many of us are familiar with Lin-Manuel Miranda’s highly-praised hit Broadway musical, Hamilton. For many, it’s a must see – and it certainly is on my list, but I probably will have to wait for the movie to come out. As the wonderful book that the play is based on, Ron Chernow’s Hamilton (Penguin 2004), clearly shows, Alexander Hamilton was often frustrated because he could not achieve his goals of creating a more centralized government in the new United States. He ran into the fundamental reality that new laws and policies must build on existing legal and institutional foundations.
In short, change is shaped by history. For example, Hamilton and the other framers of the Constitution had to take into account that states like New York and Virginia, as well as 11 others, were already well established. They could not be replaced with an entirely new system of government. As a result of constitutional decisions made some 230 years ago, we live in a federal system where not all policies mesh clearly between the states and Washington, D.C., or among the states themselves.
We have explored how our federal system can create challenges for military families moving across state lines in past MFLN Military Caregiving webinars on Medicaid. This is also key to understanding current controversies surrounding the ACA and its future – some of which we have explored in previous blogs such as ‘A Little Medicaid Summer Reading’ and ‘The Affordable Care Act – What You Need to Know.’
Much of the turbulence surrounding the Affordable Care Act (ACA) reflects how change is contingent on the past and moves uncertainly into the present and future. If we set politics aside, which is admittedly hard to do in today’s partisan environment, we can see that the law has been both hobbled and enabled by existing arrangements in the states, at the federal level, and in the marketplace.
As radical as some have made it out to be, the ACA was developed in the context of, and depends on, existing public and private structures. Think of the ACA as a software upgrade where existing law, policy and health systems are the operating platform. We both a sense of comfort and frustration, we regularly encounter software upgrades with our favorite and most needed programs. Changes are necessary, but it would be impractical to completely replace existing systems. It is easy to apply this analogy to the policy arena. Believe it or not, the major provisions of the ACA build on statutory platforms that were first established in the 1930s and 1940s (the Social Security Act and the Public Health Service Act respectively). Existing government agencies at both the state and federal level were tasked with implementing most of the ACA. The ACA relies on the private sector to provide insurance in the new “exchanges” which have been the subject of so much debate and controversy. Healthcare providers and systems operate much as they have done before. But like all software upgrades (especially big ones) there are bugs, problems, and unanticipated consequences.
If he were alive today, Alexander Hamilton would no doubt be highly interested, perhaps a little chagrined, and no doubt impressed by the lasting legacy of the Constitution’s framers. For example, when originally passed, the ACA all but mandated that the states expand Medicaid to new low-income populations. This was challenged by many states in the courts, with the argument being made that this did not respect state power and responsibilities in the federal system. In making its decision, the Supreme Court reached back to the time of Hamilton and ruled that the states should have more flexibility in deciding whether or not to expand Medicaid coverage. As a result, many states have expanded Medicaid – but a good number have not. Again, the past shapes change.
Join me next week as we look at another force that shapes change….compromise.
This MFLN-Military Caregiving concentration blog post was published on August 4, 2017.