While each day we still hear expressions of anger, detailed polls indicate support for many specific elements of the plan.  With time, we hope, those whose invective is fueled by fear and confusion will give way to a “wait-and-see” majority.  Some, of course, will continue the political debate, as is their right.  The Left will attack the perceived demon of private insurance.  The Right will attack its own bogeyman, government.  The challenge to the health care crowd is not to silence the political debate, but rather to focus on the real expectations of that wait-and-see camp. 

 

That will clearly be hard work, beginning with the law’s expansion of insurance coverage.  In states with historically low public benefit levels, Medicaid expansions will represent a culture change not unlike that of the civil rights movement.  Even here in New York, with higher eligibility standards, almost a million people eligible for public insurance are not enrolled.  The insurance exchanges that will be crafted will have to reflect our myriad regional insurance markets and coordinate the various forms of coverage available.  But at least New York understands the roadmap.

 

A second, uncharted dimension of health reform deals with limiting cost growth and improving quality, despite unrelenting financial, political, and institutional pressures.  To the wait-and-see majority, most of whom already have coverage, the real test will be whether health reform can “bend the cost curve” while maintaining or improving the quality of services—the “value, not volume” mantra.

 

Third, there is an emerging vision of “high-performance health care,” encompassing strengthened primary care; improved coordination of services; a shift from payments for individual services to bundled, even capitated, payments; linkage of all encounters through electronic records; and better engagement of patients in maintaining their health and understanding their care—in a nutshell, changing how we deliver care and changing how we pay for it.

 

Three themes also frame any strategy for the future.  First, this is urgent business.  Cost pressures are real and unrelenting.  When temporary federal Medicaid support ends in 2011, state budget crises will intensify.  Businesses face annual premium growth, still in a soft economy.  Public support for reform remains uncertain.  Far from being lulled by stated reform opportunities and future targets, planning for change needs to begin now. 

 

Second, while high performance can be achieved in individual parts of the system, the components have to connect in new and different ways, and performance must be defined across them.  Primary care can be improved but it needs seamless connection, when necessary, to specialty care.  Inappropriate emergency room care can be deflected but not when hospitals view the ER as a portal for admissions.  Reducing readmissions requires coordination between hospitals and nursing homes or home care, and the involvement of patients and their families.  Financial transactions have to support intended outcomes.

 

Third, we need to define a new locus of activity, somewhere between statewide planning and local neighborhood concerns.  Payers, providers, patient representatives, and government officials must work out new arrangements at a regional level, whether that’s defined, variously, as one county or several, New York City, or even an individual borough.

 

The tasks are daunting, but there’s real opportunity.  Literally dozens of strategic conversations are taking place among providers.  State and federal financial support for health information technology expansion has created new capacity for coordination, and doctors and hospitals are in the discussion as well. 

 

A senior business executive once said to me, “Stop telling me about the problem.  Show me some solutions.”  For the wait-and-see majority change will not come easily.  But health reform provides an opportunity for a fundamental shift in how we provide and pay for care—a strong start on the road to solutions.

 

This commentary in the "A Word with Jim" series was originally published in Blueprint.