March 2013
For the past three years, Dick Nathan, an expert on public management and bugeting, has been digging into how government health programs work and how decisions are made about them. His particular concern is the constant, frenetic, politicized way federal budget issues have been decided lately in a steady-state crisis mode. Over the last thirty years, the federal government has enacted only three budgets.
Nathan brings a political science and management focus to bear. In this paper, he presents his analysis of the five major players in the health care economy. His emphasis is on governance. And his principal concern is the lack of both the time and expert input on health programs and finances in the fast and often furious hard bargaining that goes into budget deal making.
He advocates, and spells out further in this paper, what he believes should be “invented” as institutional machinery that will provide knowledge-based, more measured, and contemplative inputs into health care budgeting, which has been so central to current debates about government finances. His proposals for new institutional capacities to adjust health care policies and programs are especially important now as the Affordable Care Act is being put in place and the Congress shows some signs of moving toward a regular budgeting process.
Nathan’s recommendations do not take politics out of process. They are modeled on the Simpson-Bowles deficit reduction commission to bring research and expertise to bear on ways of adjusting government policies and program, but always with the ultimate decisions subject to presidential and congressional action.
In this paper Nathan says that whatever you think is going to happen to health care programs and finances (some experts predict increased budget pressure; others are more optimistic that costs will moderate), there should be a central place in government to monitor and adjust health policies.
