Bates, DW

Goldmann, D

Koller, CF

Pagel, C

UCL Discovery

AJPH EDITORIALSA Way Forward for Bipartisan HealthReform? Democrat and RepublicanState Legislator Priorities for theGoals of Health PolicyBoth the Affordable Care Act(ACA) and attempts to repeal andreplace it have been criticized fortheir highly partisan passage.Manyargue that only bipartisan reformcan be sustained over time re-gardless ofwhich party is in power.Bipartisan reforms require that atleast some speciﬁc, articulated,health policy goals fromeach partyare met.1,2 A new survey of statelegislators’ goals for US healthpolicy provides crucial insightsinto the challenges and opportu-nities for future bipartisan reform.Ascertaining state legislatorpriorities is important for tworeasons. First, with or without anACA repeal, Health and HumanServices Secretary Tom Price hascommitted the Trump adminis-tration to an expanded role forstates in determining health policy.As state ofﬁcials negotiate withfederal ofﬁcials and state legislatorsdebate health care statutes, arethere goals on which the politicalparties agree, and if so, whichgoals? Second, roughly 50% ofnational legislators ﬁrst served asstate legislators; state legislatorpositions can be considered closeproxies for those of Congress.3,4THE SURVEYWe worked with healthpolicy experts who hadexperience of one or more offederal or state policymaking,federal or state policy analysis,and health care delivery orga-nization. With their input, wecompiled a set of 13 healthpolicy goals covering domainssuch as costs, access, health, andquality. In late January 2017, weconvened a focus group of sixcurrent state legislators—threeDemocrats and three Re-publicans—to ﬁnalize the list.Following ﬁnal changes, all sixlegislators agreed that the 13goals were relevant potentialgoals of health policy and thatthe language was nonpartisan.The ﬁnal survey containedbasic demographic questions andasked legislators to rank the goalsin order of importance to them.The survey is provided in theAppendix (available as a supple-ment to the online version of thisarticle at http://www.ajph.org).Legislators could rank as manygoals as they wished and couldassign tied ranks to goals; weassigned the lowest rank to anyunranked goals.We mailed the survey to 2973legislators identiﬁed as membersof health or budget committeesin all state senates and assembliesin March 2017, with remindere-mails and a repeat secondmailing. The resulting 13% re-sponse rate (377 responses: 192Democrats, 182 Republicans, 3others) was good compared withthose of other surveys of statelegislators, and was encourag-ingly representative for geogra-phy, party afﬁliation, andlegislative chamber.HOW DO HEALTHCARE PRIORITIESDIFFER BY PARTY?There were no differences inpriorities for health policy goals onthe basis of geography or legislativechamber, but Republicans andDemocrats did have very differentpriorities for health care. Wemapped5 the Republican andDemocratic priorities to see whichgoals clustered together and howeachpartyprioritized thegoals.Wethen compared the Republicanand Democratic maps (Figure 1).We interpret the identiﬁedclusters6 as representing fourdistinct domains of health policygoals: “improving overallhealth,” “reducing costs,”“addressing health care delivery,”and “smaller government.” Al-though the clusters are similarbetween parties, their relativeimportance is different. Thehorizontal axis represents theoverall importance of the goals;for each party, the goals furthestto the right are most importantand the goals furthest to the leftare least important. Republicansprioritize reducing costs andsmaller government over allother goals, whereas Democratsprioritize improving health andequity and reducing costs.There is some disagreementamong Republican legislators onthe relative importance of thegoal “improve overall health”versus the goal “reduce govern-ment involvement.” AmongRepublicans, 29.7% gave a top-three ranking to “improve overallhealth” and a lower ranking(fourth or lower) to “reducegovernment involvement,”compared with 40.1% who didthe opposite. The apparent splitwithin the Republicans onthe importance of improvinghealth versus reducing govern-ment involvement probably re-ﬂects intraparty differencesbetween moderate and conser-vative points of view.ABOUT THE AUTHORSChristina Pagel is with the Clinical Operational Research Unit, University College,London, United Kingdom, and The Commonwealth Fund, 2016–2017 Harkness Fel-lowship Program in Health Care Policy and Practice, New York, NY. David W. Bates iswith the Division of General Internal Medicine, Brigham and Women’s Hospital, Boston,MA. Don Goldmann is with the Institute for Healthcare Improvement, Cambridge, MA.Christopher F. Koller is with the Milbank Memorial Fund, New York, NY.Correspondence should be sent to Christina Pagel, Clinical Operational Research Unit,University College London, 4 Taviton Street, London, WC1H 0BT, UK (e-mail: c.pagel@ucl.ac.uk). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link.This editorial was accepted July 12, 2017.doi: 10.2105/AJPH.2017.304023October 2017, Vol 107, No. 10 AJPH Pagel et al. Editorial e1192 DemocratsSmaller governmentPrivate insurance marketReduce government involvementReducing costsReduce costs for payersReduce individual costsImproving healthOverall healthIncrease accessabReduce disparitiesTreatment innovationQuality & safetyProvider workforceEmpower patientsElderly servicesMaternal & child healthAddressing health care deliveryLEASTIMPORTANTLEASTIMPORTANTImproving health182 RepublicansReducing costsAddressing health care deliveryQuality & safetyProvider workforceElderly servicesReduce dispartiesMaternal & child health Private insurance marketTreatment innovationEmpower patientsOverall healthIncrease accessReduce individual costsReduce costs for payersSmaller governmentReduce governmentinvolvementMOSTIMPORTANTMOSTIMPORTANTNote. The horizontal axis represents the overall importance of the goals; for each party, the goals furthest to the right are most important and goals furthest to the leftare least important.FIGURE 1—Graphical Representation of Health Policy Goal Rankings by (a) 192 Democratic State Legislators and (b) 182 Republican StateLegislators: United States, 2017AJPH EDITORIALSe2 Editorial Pagel et al. AJPH October 2017, Vol 107, No. 10WHATARETHEPOLICYIMPLICATIONS?The largest difference betweenthe parties in our survey was theassigned priority to reducinggovernment involvement: Re-publicans ranked this second,whereas Democrats ranked itlowest out of the 13 goals. Thisstark difference likely reﬂects anideological split on the role ofgovernment. The second-largestdifference was in addressing healthcare disparities due to race, eth-nicity, and socioeconomic status,with Democrats ranking this thirdand Republicans ranking it lowestout of the 13 goals.Assessing PolicyFigure 1 reﬂects many of thegoals of the ACA (Democrats)and proposals for its repeal(Republicans); a Democratic-onlyhealth reform prioritizes improvedaccess and government-led effortsto improve health, whereas aRepublican-only reform priori-tizes reduced costs for individuals,limited government involvement,and reduced government spend-ing. The June 2017CongressionalBudget Ofﬁce estimate of theimpact of the Better Care Rec-onciliation Act suggests that itmeets the latter two goals but hasa mixed impact on the ﬁrst.7Designing PolicyRecent efforts at single-partyreforms have resulted in re-crimination and instability. Analternative bipartisan reformmight reduce acrimony and bemore durable, but likely atthe expense of ambition andcomprehensiveness.Considering the two maps inFigure 1, the most obvious po-tential area for future bipartisanpolicy work is targeting costs—for employers, governmentpayers, and individuals.However, policies to tackle costsmust not have a negative impacton other goals important to eachparty—namely, improvinghealth and smaller government.Moreover, given the seeminglyinexorable upward trajectory inhealth care expenses, expecta-tions for success must be modest.Encouragingly, existing bi-partisan efforts at payment reformalign well within such a frame-work, as they are intended toreduce costs while improving thedelivery of health care services(and, ultimately, improvinghealth).For state ofﬁcials contem-plating their response to thecurrent federal administration’scommitment to increased stateﬂexibility, the ﬁndings areparticularly instructive. For stateMedicaid program or commer-cial insurance market restructur-ing proposals to have broadsupport, theymust balance effectson costs and the health ofpopulations.Messaging PolicyUnderstanding the conﬂictsand congruencies of healthpolicy goals also allows for moreeffective advocacy by thoseworking for change. For instance,advocates for policies addressingthe social determinants ofhealth and prevention shouldemphasize their impact onreducing disparities to Demo-cratic lawmakers and their impacton reducing costs for payers andindividuals to Republicanlawmakers.CONCLUSIONSThe past 10 years of in-creasingly partisan health policyargument have not yet resulted indurable policy solutions to themany acknowledged problemswith the US health care system.Insisting on the rightness of one’sposition will not persuade anopponent.Alternatives to standoffs exist,however, and this survey dem-onstrates that common groundbetween Republicans andDemocrats can be found on thesufﬁciently challenging task oftackling health care costs. Theway forward for more compre-hensive bipartisan health reformis difﬁcult, however. Funda-mental conﬂicts—on the roleof government in providing andsubsidizing health care and ontradeoffs between reducing costsand increasing access—stand inthe way.There is some solace, perhaps,in recognizing that these conﬂictsare not new. We believe thatthe only way forward is to ac-knowledge each other’s goals andwork to improve the US healthsystem by starting reform wherethere is agreement and exploringcompromise where there isnot.Christina Pagel, PhDDavid W. Bates, MD, MScDon Goldmann, MDChristopher F. Koller, MPPM,MARCONTRIBUTORSC. Pagel conceptualized the study,designed and administered the survey,collected and analyzed the data, and wrotethe initial draft. D.W.Bates,D.Goldmann,and C. F. Koller advised on survey designand content, target respondents, expertinformants for the goals of health policy,and interpretation of the results, andcontributed to writing the editorial. C. F.Koller also arranged the focus group ofstate legislators and facilitated endorse-ments from individual state health policyinstitutes.ACKNOWLEDGMENTSSupport for this research was provided byThe Commonwealth Fund (to C. Pagel;other authors were not compensated fortheir time).Wegratefully acknowledgeDonBerwickfor his helpful advice on survey designand content and useful discussion of theresults.Note. The views presented here arethose of the authors and should not beattributed to The Commonwealth Fundor its directors, ofﬁcers, or staff.HUMAN PARTICIPANTPROTECTIONThe institutional review board of Brighamand Women’s Hospital deemed thestudy exempt from review (protocol2017P000077/PHS).REFERENCES1. Oberlander J. The art of repeal—Republicans’ health care reform muddle.N Engl J Med. 2017;376(16):1497–1499.2. Koller CF, Alexander T, Birch S.Population health—a bipartisan agendafor the incoming administration from stateleaders. N Engl J Med. 2017;376(3):200–202.3. National Conference of State Legisla-tures. Former state legislators in Congressand White House. Available at: http://www.ncsl.org/ncsl-in-dc/publications-and-resources/former-state-legislators-in-congress.aspx. Accessed May 26, 2017.4. Butler DM, Powell EN.Understandingthe party brand: experimental evidence onthe role of valence. J Polit. 2014;76(2):492–505.5. Borg I, Groenen PJ, Mair P. AppliedMultidimensional Scaling. 2013 ed. Hei-delberg, Germany: Springer; 2012.6. Garson GD. Cluster Analysis. 2014 ed.Asheboro, NC: Statistical AssociatesPublishers; 2012.7. Congressional Budget Ofﬁce. HR1628, Better Care Reconciliation Act of2017. June 26, 2017. Available at: https://www.cbo.gov/publication/52849.Accessed June 28, 2017.AJPH EDITORIALSOctober 2017, Vol 107, No. 10 AJPH Pagel et al. Editorial e3

A Way Forward for Bipartisan Health Reform? Democrat and Republican State Legislator Priorities for the Goals of Health Policy

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A Way Forward for Bipartisan Health Reform? Democrat and Republican State Legislator Priorities for the Goals of Health Policy

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