Vidhya Alakeson on US health reform

As with his presidential campaign, Barack Obama’s approach to health reform will leave little to chance. His strategy for enacting the first major coverage expansion in more than 40 years is starting to take shape. He is building public support for reform early in the hope that it will be enough to counter the opponents of healthcare reform when they eventually flex their muscles.

In his speech on election night, Obama talked about maintaining in office the grassroots involvement that was the hallmark of his campaign, and health reform is his first experiment in doing so. Just as people gathered in each other’s houses during the campaign to talk about their hopes for an Obama administration, Obama called on them to do the same on healthcare during December, using the online infrastructure developed for the campaign to organize themselves locally. Secretary-designate Tom Daschle has even promised to drop in on a few living room discussions. We don’t yet know how many such discussions have taken place and they are unlikely to be enough to counter the lobbying power of the pharmaceutical and healthcare industries, but this experiment will surely be copied by other politicians.
The second component of Obama’s strategy seems to be to defer most of the tricky decisions about coverage and payment to some sort of federal health board, an idea floated by Daschle in his 2008 book on health reform. Getting both sides of the aisle and both houses of Congress to agree on a bill that establishes a federal health board similar to the Federal Reserve will be an arduous, but possible, task. By contrast, trying to get agreement on the individual components of reform will be impossible and will doom the entire reform effort.
In his book, Daschle describes the federal health board as having two broad functions. First, it will establish a framework that will shape private sector competition in healthcare, including setting minimum standards for coverage by private health plans that want to compete for the uninsured. This part of the health board’s role will be modeled on the Commonwealth Connector that was established in Massachusetts as part of the state’s universal coverage initiative in 2006. The board’s second role will be to develop evidence-based standards for quality and coverage based on clinical and cost effectiveness. There has been a lively discussion among the health policy community in the US over the last couple of years about the need for a publicly funded center to drive evidence-based medicine. In Daschle’s vision of healthcare reform, the federal health board will be the body to do this.
There is much excitement around the idea of a federal health board because of its purported ability to depoliticize health care in the US. But the UK government’s recent decision to raise the cost effectiveness ceiling for cancer drugs approved by the National Institute of Health and Clinical Excellence shows how difficult it is to take the politics out of health care. In time, members of the federal health board will be lobbied as hard as members of Congress as they decide on the details of health reform. But there is one aspect of healthcare politics as it is currently played that will be significantly improved by the creation of a federal health board. Members of the board will not be elected; they will be appointed. As a result, organizations that lobby the board will not be able to withhold or increase campaign contributions to get decisions to go their way, as they currently can for elected members of Congress. In this respect, the creation of a federal health board will be an important piece of campaign finance reform as well as a central plank of healthcare reform.

Vidhya Alakeson is a former Harkness fellow.