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Observation: Remedy for Health Reform Planning May 2009

Remedy for Health Reform Planning

By Richard Nathan
Co-director, the Rockefeller Institute of Government

Richard Nathan

Conservative political leaders sometimes enact tax cuts, hoping eventually that they will force expenditure cuts and reduce the size and scope of government. Liberals, on the other hand, sometimes do the opposite: They pass new programs figuring they can work out the finances later.

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Richard P. Nathan is co-director of the Rockefeller Institute of Government and distinguished professor of political science and public policy at the State University of New York at Albany. Nathan has written and edited books on the implementation of domestic public programs in the United States and on American federalism.

Right now, a special danger is the enactment of health reform without working out the finances ahead of time. And, for that matter, also working out the difficult questions: Who will run the new system? Will they have sufficient clout to do so?

Massachusetts passed universal health reform without working out the finances in advance, so now the state faces a formidable financial challenge as a consequence. It would be irresponsible to have this happen to the country as a whole.

Health care industry and labor leaders recently met with President Obama to discuss cost savings as an intrinsic requirement of health reform. Shortly afterwards, the President met with the press and announced that they had reached agreement on major cost-saving goals. The very next day, however, many of the same industry leaders disagreed with him, and said they had not come to a clear, specific (and also vital) cost-saving agreement. In ways like this and in others, the politics, finances, and management challenges of health care reform have bedeviled the nation for 60-plus years. The power of the moneyed, vested interests in the status quo is extraordinary — and, if anything, has increased recently. A special decision-making mechanism is needed.

How about this?

The president would create a “Fast-Track Action Panel” for health reform (call it F-TAP). He could ask the Congress to name four persons (who are not currently public officials) to this panel — one each by the majority and minority of each body in the Congress. The president would also name four people (also not currently public officials), one of whom he would designate as chair. He would charge this eight-person panel by a majority vote to present a coherent plan, budget and set of administrative proposals for health reform in a designated period of time (say four or six months), setting forth goals and principles for their endeavors. The president could further indicate that he will request fast-track consideration of this plan by the Congress, like a trade agreement, and that he will also request that the plan be considered en bloc, like a base-closing program, whereby it can either be accepted or rejected in full, but not amended. There are, of course, many variants of such a special decision-making mechanism that could be created — possibly even legislatively.

Presumably, the members of an F-TAP panel for health reform would be a representative group of knowledgeable, experienced public servants and experts who know the policy, substantive, fiscal, political, and administrative terrain. They would have sufficient resources to be able hold hearings, conduct studies and engage consultants in their attempt to strike the kind of balance that might work. They might not succeed, but they would have a timeline and a deadline, as well as political insulation and resources for contemplation, mediation, and negotiation. The normal congressional legislative process could proceed on a parallel track, or could be put on hold for some period of time. Should the Congress pass and the president sign a health-care reform law while the F-TAP process is underway, that would be all well and good.

Under such a parallel process, the legitimate authority of elected officials would be preserved. They would have the ultimate authority to determine what is enacted into law. Having two tracks working simultaneously would bring added pressure to bear to get action; it could introduce useful ideas and policy inputs to both executive branch and congressional decision-making processes. It is also possible that the existence of two tracks would involve cross-pollination about key substantive and technical ideas and facts, and administrative practices and approaches.

In the long run, I believe the nation needs to adopt such special institutional mechanisms in this area as in others, like the environment, energy sustainability, and education reform. They are needed in order to facilitate and expedite action in the increasingly competitive world economy and information-age environment in which emerging nations and entities like the European Community can act on a quicker basis than we can to respond to fast-changing economic and societal conditions.


The Nelson A. Rockefeller Institute of Government, the public policy research arm of the State University of New York, conducts fiscal and programmatic research on American state and local governments. It works closely with federal, state, and local government agencies nationally and in New York, and draws on the State University’s rich intellectual resources and on networks of public policy academic experts throughout the country.