The New Health Dialogue

Credit: Justin Sailor

We’ve reported several times on the gap between rhetoric and the health reform trenches in the state – ie. that even in very red states where governors or the attorneys general are contesting the constitutionality of the individual mandate, insurance and Medicaid and health officials have rolled up their sleeves and dug into at least the early stages of implementation. Given the tenor of the campaigns that led to Republican gains in governorships, state legislatures and in a few cases state insurance commissioner offices, we expect to see health reform roll out unevenly in the states. But as Noam Levey and Bruce Japsen (respectively of the LA Times and the Chicago Tribune) pointed out, it isn’t likely to grind to a halt.  Remember that if a state doesn’t run its own exchange, the federal government will. The rules for exactly what the exchanges must look like haven’t been finalized, but they are expected to give states some design leeway. We never expected the insurance market in Utah, for instance, to look too much like Oregon or Vermont a decade from now. Those state-to-state differences may be even sharper because of the current political climate, as states decide how to shape their exchange, and what kind of regulations to impose on plans outside the exchange.

And given Florida Gov.-elect Rick Scott’s history, we don't expect the Sunshine state to become the poster-child state for efficient and enthusiastic state health reform implementation. Scott you will remember led Columbia/HCA hospitals in the 1990s. He was ousted amid a scandal that eventually led the company to pay a record $1.7 billion in fines. Scott was never charged personally. NPR's Scott Hensley goes down memory lane with Scott, and at Healthbeat Maggie Mahar, who has interviewed him and watched his career for years, has written about him repeatedly including this recent post (which contains links to her earlier posts). 

In terms of whether the election was really about health reform – we’ll leave the pundits to fight that one out. We liked Chris Cillizza’s piece today; he gives a few different ways to look at it. Of course, the longer and louder foes of reform shout about having a mandate from the voters, the more it becomes a tad self-fulfilling, and people begin to think that it was in fact the underlying message of the 2010 election.  So don't expect Fox to change the subject. There’s no doubt that some voters went Republican to register objection to health care. But I tend to think of it as a sort of subsidiary objection. Voters who backed Republicans because they were mightily ticked off about health reform were already mighty ticked off about the economy, unemployment, the deficit, the government. If the economy were booming and unemployment fading, it’s hard to imagine this much controversy and anger about health reform (outside the hard-core base). There would still be a conservative anti-health care vote but it wouldn’t have been as large or decisive.