Op-Ed in Raleigh, News and Observer

I have an op-ed in the Sunday Raleigh (N.C.) News and Observer offering a bipartisan way forward on health reform that I think makes sense regardless of what the Supreme Court says about the Affordable Care Act. If you are a reader of this blog, it will be familiar fare.

If you are coming here from the op-ed, here are some related posts:

• Laying out general compromise with a bit more detail
• The ACA actually allows high deductible plans
• Comparing my catastrophic ideas with those of Martin Feldstein
• Post with overview of all the health policy suggestions from my book
• My book Balancing the Budget is a Progressive Priority frames health reform as central to ever having a balanced budget; a necessary, but not a sufficient condition to getting there. The other thing that must occur is a tax increase given any plausible level of federal spending. Many other things are covered in the book, but without health reform and a tax increase over the long run, we will never have a balanced budget.

High deductible plans in the ACA

Yesterday I speculated about what form a health reform deal between Progressives and Conservatives might look take (Universal catastrophic coverage implemented via Medicare).

Like many of the complaints about the ACA, the idea that everyone is forced to purchase the same plan is untrue–it does not mandate a one size fits all policy. Below are actuarial estimates produced by 3 insurance companies commissioned by Kaiser Family Foundation of what various insurance options to be sold in ACA exchanges would look like.

The Actuarial value column shows the percentage of total costs to be borne by a person (there are a series of assumptions made to produce these estimates, that are meant to be illustrative) covered by the mandated benefit package; Plan A, 60% corresponds with the so-called Bronze level package that represents the minimum coverage that persons would have to purchase in 2014 to generally comply with the ACA. You can see that there are other levels of coverage stated in actuarial value terms, 70%, up to 94% that people could choose. Obviously, a higher actuarial value means higher premiums and less out of pocket exposure during the period of insurance, and under the ACA the premium subsidy amount provided to individuals and families varies by income.

Also of note are the different ways to attain the same actuarial value and corresponding out of pocket maximum. Sticking with the Bronze plan (row A) in the Table, Actuarial Research Corporation designed a plan with a deductible of $6,350 and no coinsurance, while Aon Hewitt achieved the same actuarial value with a deductible of $4,350 and coinsurance of 20%. It is true that all of the plans cover the same benefit package.

Several points/questions:

• The ACA allows catastrophic plans (the max out of pocket allowed in 2014 will be $5950 for individuals, $11,900 for families). I suggested larger deductibles/maximums, but personally I would trade a higher catastrophic deductible/out of pocket max for universal coverage.
• It is unclear to me how the price charged for care while someone is in their deductible will be set? Presumably that will be an aspect of the plan offered on an exchange in the ACA, but this is an important question, especially for catastrophic plans, and I realize that I am unsure. Under my suggestion, Medicare payment rates could be used.
• There are different mixes of premiums, deductibles, and coinsurance through which to achieve the same actuarial value. Adding the premium side to this adds more complexity and choices, but you can generally achieve the same premium-side actuarial outcome by a set deductible/out of pocket maximum and income based premium subsidy, or you could modify the deductible/out of pocket maximum by income, probably implemented via a maximum amount of income that could be spent on health care.
• You have to set a benefit package in some way if you claim to be interested in people making informed choices. Under my suggestion, everything covered by CMS would count toward spending through the catastrophic deductible, and would be covered by Medicare once the maximum out of pocket amount was reached.

What would a health reform deal look like?

A central claim of my book Balancing the Budget is a Progressive Priority is that slowing the rate of health care cost inflation is a necessary, but not a sufficient condition to our ever achieving a sustainable budget down the road (it will also take a tax increase). Further, it will be virtually impossible to take the very hard steps to address health care cost inflation without both political parties coming up with a set of health care reform strategies that we will actually try, and which make both sides responsible for seeing to the hard work this will take. Health reform is far more difficult than Social Security reform (in a technical sense), for example, because mailing checks is much easier than purchasing health care. We will never be done with health reform and there will be many mid course corrections.

Even though we don’t know what all the steps will be, we desperately need to take some initial ones, and we will soon know what the Supreme Court will say about the ACA. This will be a landmark decision that will have profound political and policy consequences, but in one sense, regardless of what the Supremes say, the next step is to identify a bipartisan way forward on health reform (stop laughing; we have to do it).

Central to my book is a set of health reform policies that I claim represent the type of deal that would emerge if the two sides actually negotiated with one another. For such a deal to emerge, it would take both sides being clear about what their primary interest was in health policy. For Progressives, universal coverage has always been the holy grail and dream deferred, not just of health policy, but really of all social policy. As I noted in this debate with Jim Capretta, I don’t thinkConservatives have an interest that is so clear and heartfelt as universal coverage is for Progressives, but if I had to take a stab, I would claim that it is their belief that people don’t have enough “skin in the game.” As an aside, this makes little sense to me and when I look at empirical data on cost sharing with my more conservative friends, we see different things. In a similar way, when I say that I think the lack of a predictable, universal health insurance coverage scheme is an existential mark against our nation, they don’t get my degree of feeling.

Accepting such differences is an important step, because reaching a deal will mean abiding with one other to reach a compromise.

The essence of the deal I suggest in the book is this:

• Universal catastrophic coverage implemented through Medicare, with gap insurance available to persons wanting it (no mandate!) via state based exchanges (with subsidy for low income persons)
• With a massive deductible (I suggest $10,000/persons; $15,000/family to maintain a key role for private insurance; far larger out of pocket exposure than Bronze level cover in the ACA)

There are many legitimate ‘yeah buts’ that both sides will have, and I am not even getting into the other parts of the health policy deal I propose, and that are detailed in the book, in this post. However, a compromise health reform deal will have to capture the ‘big idea’ for both sides. I think step one of such a deal looks something like this if we ever manage to do it. And if we don’t, we will never again have a sustainable budget.

GAO suggests new Medicaid formula

The GAO has proposed a Medicaid matching formula that would better target federal resources to states during economic downturns when Medicaid enrollment typically increases. When the Employment to Working Age Population (EPOP) ratio dropped in 26 states, an increase in the federal cost share (Federal Medical Assistance Percentage, FMAP) of the Medicaid program would be triggered automatically, and would remain in place until the EPOP returned to pre-recession levels. The EPOP measure would not be influenced by persons “giving up” and leaving the labor force, so provides a more precise measure of economic hardship in a state that is likely to trigger Medicaid enrollment increases than would unemployment.

If this policy had been in place during the recent recession, increases in federal aid for Medicaid to states would have begun in January, 2008 and ended in September, 2011 and would have increased federal costs by $36 Billion. Under the Recovery act, the dates of increase were October, 2008 to June, 2011, but GAO notes the amounts are not directly comparable because they were not only designed to respond to recession-driven cost increases.

GAO suggests that moving to this formula would provide a more predictable amount of federal support for Medicaid during economic downturns. HHS is generally positive about this change per comments it provided on the GAO report, but suggested that more work is needed to identify the appropriate number of states experiencing a downturn based on the EPOP measure that must be observed before increased FMAP share is granted (many options). However, GAO points out that the 26 state threshold is closely correlated historically with the official beginning of recessions, and is easily measured, allowing for an automatic and quick response.

Medicaid is a counter-cyclical program that means costs for states rise just as tax receipts generally fall. This proposal would shift more of this extra recession-driven burden to the federal government, which is better able to deficit finance during economic downturns than are states. The proposed policy makes sense so long as we are roughly maintaining Medicaid in its current safety net role. Moving toward block granting of Medicaid is really the polar opposite approach; fixing the per capita Medicaid costs of the federal government no matter what, with more of the burden being shifted to states.

Fairly stark policy options.

Blahous on CLASS, reform

I respect Charles Blahous a great deal as an analyst, and I like him and think that he is a nice guy. In fact, I brought you a series of interviews with him last May on the Medicare and Social Security Annual Trustee reports. However, I find his latest at e21 on the CLASS Act and health reform generally to be frustrating, because it focuses on deconstructing (CLASS and the ACA) without offering something better.

I agree with him that CLASS as passed wouldn’t work, but it is just as clear that there are policy options that could make it work and address LTC. Imagine the impact a post by him (Medicare and Social Security Trustee) offering solutions might have–saying something like “CLASS was flawed but how we deal with LTC is also flawed, and the the current default is for Medicaid to be on the hook for massive nursing home expenditures. Here is how we could move to implement a voluntary LTC insurance program. This is good for the country.”

However, I respect the idea that an adversarial political system creates better policy through the competition of ideas. Yet, in health reform, conservatives seem to be far clearer about what they are against as compared to what they are for (I mean this generally, and am not singling Blahous out here). When I hear Republicans say “lets repeal Obamacare and we will then pass common sense reforms” I can only think why didn’t you do anything from 2002-06 when you controlled both branches of Congress and the White House?*

I can respect the adversarial argument, and have spilled about 50,000 words saying the key to a long range sustainable budget is a compromise on health reform. However, it takes two sides to compromise. The House of Representatives owes it to the country to move ahead and begin marking up bills like the Patients’ Choice Act, and Rep. Ryan’s Medicare reforms in the committees with jurisdiction such as Commerce and Ways and Means to show us what they would do. They need to commit to the details so that the CBO can weigh in and we can look at both the fiscal impact and effect on the uninsured of their ideas under the same bright lights to which the ACA has rightly been exposed. And then we can decide what to do.

*Many of my conservative friends will say they did worse than nothing, they deficit financed the Medicare Part D drug benefit during this period.

Patients’ Choice Act Needs to Meet the CBO

As I noted Thursday, Rep. Paul Ryan‘s speech last week embracing the Patients’ Choice Act (PCA), completed the “replace” part of his call to “repeal and replace” the Affordable Care Act.  While the details of Rep. Ryan’s plan differ for the various parts of the system, the overriding idea is moving toward a defined contribution from the federal government, instead of a commitment to providing a given level of insurance coverage, shifting costs to either individuals or states. The outline of Rep. Ryan’s overall “replace” plan is:

• Medicare (45 Million persons in 2011). No great changes for those now covered by Medicare, or who will be so covered in the next 10 years. However, for those who become eligible for Medicare more than 10 years from now, they would receive a voucher with which to purchase private health insurance. Eventually, Medicare as a government insurance plan would go away with the death of the last beneficiary, replaced by this system of private coverage.
• Medicaid (60 Million persons in 2011). Block grant the program to states, fixing the cost to the federal government and shifting the balance to the states.

These two policies were adopted  in broad form (235-189) when the House of Representatives passed its Budget Resolution on April 15, 2011, and have been much discussed; I am not going to get into them (Austin has written a lot on the Medicare proposal). I am going to instead focus on the last part of Rep. Ryan’s replacement strategy, the Patients’ Choice Act, that would directly impact around two-thirds of the U.S. population almost immediately if passed:

• Privately insured (160 Million persons in 2011) and uninsured (50 Million persons in 2011). The Patients’ Choice Act represents Rep. Ryan’s vision for how health insurance would be remade for persons who are not elderly and not poor enough to qualify for Medicaid. In short, the tax preference of employer paid insurance would be repealed, all persons/families would get the same tax credit with which to purchase private health insurance, either inside or outside of state-based exchanges. The premium levels are far below average premiums today, meaning they would finance only catastrophic levels of coverage. There are many details that need to be considered. I outlined some of them last week.

I am going to drill down on these details by going through several of the key Titles of the PCA over the next couple of weeks. However, the punch line for this analysis is clear regardless of what I think:

• the House Republicans need to mark up the PCA in committee (Commerce and Ways and Means for sure, perhaps Budget), pass the bill out of the relevant committees, and see what the CBO has to say about them.

Politically, it is an advantage to “have a plan” but not commit to the nitty gritty details. The PCA has been around for a while, having been introduced into the 111th Congress on May 20, 2009 but has never been scored by CBO since it did not see the light of day in the last Congress because the Democrats controlled the House of Representatives. However, the Republicans have controlled it for the past 9 months, and there is nothing standing in their way of filling in the blanks, passing the  PCA out of committee(s) and seeing what the CBO has to say. To paraphrase what a Little League umpire once told me, the PCA is nothing until CBO tells us what it is. Only then can the country understand the replace part of repeal and replace.

Should Medicaid be Federalized?

My friend and colleague Peter Ubel thinks so, and he makes some good arguments. I think that he is partly correct. I believe we should consider federalizing the long term care portion of Medicaid, but would favor transitioning acute care Medicaid beneficiaries into private health insurance purchased in exchanges, with full premium support. My view is informed by a mixture of policy concerns and political realities as I understand them.

There is nothing fatally flawed about the structure of Medicaid with respect to providing access to acute care for beneficiaries. The latest study that has everyone buzzing about Medicaid (more: Austin | Pollack |Gardner) showing reduced access to specialists for Medicaid beneficiaries (children) could easily be reversed. Just raise the payment levels and make Medicaid the BEST payer instead of the worst (lower than private insurance and Medicare). That would fix the problem of reduced access for beneficiaries overnight. Of course, that will not happen.

Medicaid serving as the best payer seems far fetched, a fact that shows how disconnected from reality much of the Medicaid debate has become. Because in the the nursing home sector, Medicaid is, if not the best payer in terms of highest rate, the most predictable and predominant payer of such care. The ‘Medicaid debate’ we tend to have is is incomplete and misleading, because most of the ‘debate’ focuses on acute care Medicaid, and doesn’t even acknowledge that the most expensive part of the program is long term care, mainly nursing home care. The figure below, from a presentation by Charles Milligan and Cynthia Woodcock at the recent AcademyHealth meeting on Medicaid drives this reality home:

Medicaid pays for 16.2% of total health expenditures in the U.S., but 40.6% of the national NH expenditures.  While Medicaid is considered a poor payer for acute care services (physician, hospital), it is viewed as a much better payer of nursing home care, as compared to other sources, primarily because there are fewer other sources. There is little private long term care insurance, and very few persons have enough savings to pay for even a few months in a nursing home, so Medicaid ends up paying a large chunk of the bill. If you are in the nursing home business, then unless you are a boutique provider, you are in the Medicaid business, as shown in another slide from Milligan and Woodcock (Note that Medicare only pays for up to 90 days in a skilled nursing facility if the stay is linked to an acute medical event). In total, Medicaid is the primary payer for two-thirds of persons living in a nursing home.

What should we do? To try and get a handle on what next for Medicaid, the first step is to realize that it is really three insurance programs (at least):

• Program 1: covers mainly pregnant women and children for acute services. There are around 45 Million such persons. The ACA would expand this portion of the the program greatly. This is the group that experienced barriers to access in the recent study, and this is where most of the debate is centered. Such beneficiaries are numerous, but are relatively inexpensive on a per capita basis.
• Program 2: covers long term care, most notably nursing home care for Medicare beneficiaries who are also poor and therefore covered by Medicaid. Such persons are know as Dual Eligibles, because they are covered by both Medicare and Medicaid). There are 9 Million duals, around two-thirds of them are eligible for Medicare because of age, the remainder due to permanent disability. This relatively small number of persons are extremely costly to both Medicare and Medicaid.
• Program 3: covers long term care and acute specialized services for persons younger than 65 who are disabled, but not eligible for Medicare; There are 5.9 Million such persons, who are more difficult to describe because of their variety of needs.

I suggest we move to transition Program 1, the largest group of Medicaid beneficiaries, into private insurance purchased in exchanges to be set up in the ACA. This will be more expensive than covering them in Medicaid, certainly initially. However, many conservatives seem to dislike Medicaid intensely because it is a government program, and many liberals are very worried about barriers to access for beneficiaries, which result from low payment rates and/or stigma associated with ‘poor people’s insurance’. Providers don’t like Medicaid because it doesn’t pay as much as private insurance or Medicare. If we are going to try exchanges and more persons buying their own insurance, lets try it. This approach would mainstream low income persons into the private insurance market, would expand (more than double) the potential of competition in the exchanges by adding more consumers to purchase insurance in these markets, and states could directly provide additional assistance navigating care that they decide low income persons needed. This approach assumes moving ahead with the general direction of the ACA.

I suggest we federalize the Medicaid cost of Program 2 noted above; this would primarily mean federalizing the nursing home costs of dual eligibles who are covered now by Medicare and Medicaid. There are numerous problems with the interaction between these two payers that cause problems for dual eligibles, that could best be addressed by having one payer responsible for their care. Two examples of policy reasons that could best be addressed by federalizing the Medicaid portion of dual eligibles.

• Bed hold payment. In some states, Medicaid pays for a bed to be ‘held’ for a beneficiary who goes to the hospital. In the case of dual eligibles, hospital care is paid for by Medicare. This creates an incentive for nursing homes to send patients to the hospital, thus shifting their care burden to the hospital and Medicare (and away from states), while still receiving bed hold payments and receiving the patient back after a hospitalization, often for reasons that could have been dealt with in the nursing home setting. Having one payer responsible for all the care of the now dual eligibles is that best way to sort this out.
• Reduced access to hospice benefits. Around 42% of non dual-eligible Medicare decedents received some hospice care prior to death. For dual eligibles (see pp.144-47), many of whom died in nursing homes, the figure is lower (36%), even though their need and potential to benefit from such services would be expected to be higher. The interaction of Medicare and Medicaid rules in some states impose a barrier to the receipt of hospice for dual eligibles. Medicare does not pay for room and board payments when someone receives hospice at a location that is not an inpatient hospice (most beneficiaries receive care at home, and Medicare doesn’t pay rent; if you are not in an inpatient hospice, you are expected to pay your own rent). In some states, if the Medicare hospice benefit is elected, then a patient may lose Medicaid’s payment for room and board, which is the majority of the charges for a stay in a nursing home. This would impose a tremendous cost on poor beneficiaries, that results in their not electing to use Medicare hospice benefits. These perverse rule interactions can reduce care options for very sick, elderly patients and could best be addressed if there was one payer responsible for the care of dual eligibles.

I am not sure what we should do for persons in Program 3, as they are a more complicated group to care for since they are younger than 65, but not eligible for Medicare. They suffer from a variety of physical, mental and intellectual disabilities, are among the most vulnerable members of society, and could need specialized services for years or decades. Medicaid could remain to care for such persons only, or other transitions may be more obvious to persons who know more about the needs of these populations than do I.

The bottom line is that Medicaid is really multiple programs, and this reality tends to be lost in most debates about the program. Most attention is focused on the more numerous (45 Million) low income persons covered for acute care services, missing the long term care aspect of Medicaid. I think we should move toward moving this large group of persons into purchasing private insurance in exchanges. The motivations for this suggestion are mostly political, as they could address key concerns of conservatives and liberals, and could aid in reaching some sort of consensus on how to move ahead in health reform by setting up insurance exchanges. Federalizing the Medicaid portion of the dual eligible’s care is more clearly indicated for a variety of policy and coordination of care issues; I gave only two brief examples, but there are more. I will blog on some of the other long term care realities that must be considered in any reform of the Medicaid program. And of course there will be difficulties and problems with any fix. However, these general directions seem the best course to take from my perspective.

Update: To clarify, three main points. First, the Medicaid debate needs to acknowledge the  ‘three’ programs which it typically doesn’t. Second, federalizing Medicaid for dual eligibles is the best way I see to address some of the inefficiencies that lead to poor quality and higher cost among dual eligibles. Third, transitioning Medicaid into premium support so that low income persons would buy private insurance in exchanges would be a huge change that would face many practical issues that I haven’t addressed; in that sense, what I put forward is an idea or direction in which to move, and not a plan.

 

 

 

Dutch health reform

Hans Maarse with a post on the changes in the Dutch health care system in the Hastings Center blog. A few snippets:

The reform is intended to bring about a system of regulated competition in health care. The aim is to introduce competition while upholding fundamental social values, in particular solidarity in health care financing and universal access to health care. Another aim is to enhance consumer choice. Everyone has the right to switch insurance providers by the end of the year.

Is the health insurance reform a success? The answer depends on the perspective taken.

An interesting read with a longer paper on the Dutch reforms also by Hans Maarse here.

My take on what this means for the U.S. is that it shows that if you have a broad political agreement, then you can (inevitably) muddle through on the policy. Some things work better than others, but almost nothing works exactly as planned. There may well be some technical/policy lessons to be learned for the U.S. as far as how to incorporate private insurance into coverage expansions with a goal of increasing competition and choice, but what we most need is a political agreement about how to move ahead. When (if) we ever get that, we can work on the policy.

 

Three questions on the road to sustainability

If we ever slow health care cost inflation to a sustainable pace, it will be because we learn how to ask 3 simple questions when thinking about a medical treatment:

• Does it improve quality of life for the patient?
• Does it extend the patient’s life?
• How much does it cost?

Asking the questions are of course much simpler than figuring out the answer, and far far simpler than deciding what to do with the answer.

The first step is not demonizing even the asking of the questions. This would represent a profound shift in our culture, and is needed. We need to grow up and learn how to talk about limits in medicine. Then we will have to learn how to give practical answers to these questions, and the answers will have to be knowable and usable at the bed side as doctors and nurses are caring for actual people–you, me, my parents, grand parents and kids. These are not just technical policy questions, but need to become cultural ones as well, asked by all of us, no matter what type of insurance we have.

Then we will have to decide what to do with the answers. None of this will be easy.

The good bad news is that there is a good deal of care that is non-productive, which I would define as care that does not improve quality of life or extend life. We should start there. I don’t know how much health care spending could be reduced by stopping care that didn’t improve quality of life or extend life, but this is the correct way to think about our attempts to slow health care cost inflation. We might have to get into the very hard business of deciding that some care that was productive but very expensive shouldn’t be done. But, we might not; we won’t know until we start asking these 3 questions. Matt Miller and Austin and Aaron have been talking about this today.

The Independent Payment Advisory Committee (IPAB) is a vehicle that could be used to begin to ask these questions. I have been amazed at the level of vitriol against IPAB given past Republican support of similar boards with far more proposed power than what IPAB has. However, if we are forgetting about the past, lets forget about it and reach a bipartisan way to ask these questions, using IPAB as the vehicle since it has the advantage of having been enacted into law.

One practical solution would be for the President to say he is going to name one of the Republican members of Congress who is a physician to be the chair of IPAB. I believe Tom Coburn is retiring in 2012, and he co-sponsored the Patients’ Choice Act that proposed IPAB-like boards. And he uttered the most profound statement of the entire Blair House health policy summit in February 2010 when he said that 30% of medical care is non productive (I don’t know if this figure is correct, but IPAB could start figuring it out). Senator Coburn could even say exactly how the boards he proposed in the PCA were good policy ideas, but the current structure of IPAB is not, and we could enact a bipartisan tweak of IPAB.

I am being totally serious. Anything that moves us in the direction of beginning to ask these questions, to begin to depoliticize the recognition of limits, and to get to the policy. I am not sure I can take another election based on ‘I am not as bad as the other guy’ while serious problems go unaddressed.

An Empirical Analysis of Congressional Gridlock, 1973-2002

by Craig Volden and Alan Wiseman appears in the April, 2011 issue of the Journal of Health Politics, Policy and Law. They ask two related questions:

• Is there evidence of legislative gridlock in Congress?
• Is it worse for health policy, as compared to other types of bills?

In addressing these questions, they lay out a variety of hypotheses that political scientists and others have advanced for why gridlock exists, why it might be worse in the health policy realm, and why gridlock may at times be overcome; none of this will be new to anyone reading this blog. The innovation and value-added from this paper is the empirical work they have done to provide an answer to these questions. In short, they show that most bills introduced do not become law, but that health policy bills are even less likely to become law than are bills that focus on other topics. There were 9,740 health policy related bills introduced into the U.S. House from 1973-2002 (8.2% of the over 119,000 total bills introduced), and they were always less likely to be become law than were bills focused on other areas. The authors take the low passage rate of bills introduced to be evidence of gridlock, and demonstrate clearly that the passage rate is lower for health policy, as compared to other types of bills (see Figure 1 below):

Table 1 shows that the rate of bill passage by topic area ranged from Social Welfare (1.33% pass rate; health policy was the second lowest at 1.58%) to the highest pass rate of 10.4% for bills addressing public lands issues over the period 1973-2002.

 

 

A sub-analysis of bills judged to be more substantive in nature/represent larger reforms by the researchers found a higher passage rate for all such bills, health policy or otherwise.  However, the more substantive health policy bills remained less likely to be passed as compared to bills addressing other topics across the entire period (Figure 2), though there were two Congresses (98th and 102nd) in which that was not true. Toward the end of the time series, it seems as though the rate of passage of the most substantive bills of all types is trending downward, which is evidence of more gridlock as they have defined it (bills not becoming law equals gridlock).

The most interesting aspect of this paper is the large effort they have undertaken to code all of the 119,040 bills introduced into the U.S. House of Representatives from 1973-2002 by type of bill and then further whether the bill was substantively important or more symbolic. The paper argues that many explanations of past health policy legislative failures or successes have relied upon idiosyncratic ‘one off’ explanations that do not take account of the long run of observational data that are available on this question. For example, after the demise of the Clinton Plan in the early 1990s, some offered as an explanation the fact that the proposal was developed primarily in the executive branch and then moved into Congress as the key explanation for its failure. Similarly, as the ACA hung in the balance in early 2010 and seemed like it would not pass, some were saying that President Obama had made a mistake by letting the proposal be first developed in the Congress and therefore had not put his stamp on the bill.  Opposite conclusions, using only 2 examples. Looking at a longer run of empirical data provides better information.

There are other details provided in the paper not highlighted in this post, such as the steady increase of the likelihood of a bill reaching the floor of the House from 1973-1984, and the subsequent decline, and there are detailed regression analyses that test specific hypotheses about what increases the likelihood of legislative success that I will cover in another post. However, the paper provides data that paint a general picture of more policy gridlock in the House of Representatives, both in health policy as well as more generally, with non passage of a bill taken as evidence of failure and therefore gridlock. Of course it is an assumption that non-passage of a bill is evidence of a problem; others might say it is evidence of a triumph.  And most persons would likely say that some bills are better passed, while others are better defeated. In any event, most bills are presumably viewed as good ideas by those who sponsor them, and most sponsors are disappointed with the outcome of the vast majority of bills they introduce. A follow up post will look at what predicts those bills that beat the odds, and what that might mean for the future of health policy legislation.