Thinking and Doing

“Knowing is not enough; we must apply. Willing is not enough; we must do.” These words of the German poet Goethe grace each final report of the Institute of Medicine (IOM) of the National Academy of Sciences in Washington, DC—and are meant to inspire or compel readers to link theory and practice, thinking and doing.

The IOM exists to “…help those in government and the private sector make informed health decisions by providing evidence upon which they can rely.” It regularly convenes panels of scientists and practitioners to address issues in health care as varied as health standards in space flight and ensuring the safety of stem cell therapies. Recently, advisory panels have taken on issues such as Medicare and geographic variations in care and payment and how the federal government defines essential health benefits.

I have served on IOM panels—and it’s an honor. Smart, experienced and public-spirited people gather to investigate, debate, and develop consensus positions on important and complex issues. Opinions are not enough—there is a required rigor in the work of the IOM, using published evidence to support findings and then conclusions.

So it was my privilege to assemble a panel in April with Alan Weil, then Executive Director of the National Academy of State Health Policy, for the IOM’s Health Care Services Board, briefing them on actions taken by states to implement the Affordable Care Act (ACA).

The Board is advisory to IOM staff. Most of them have worked in Washington as researchers and administrators in various parts of the policymaking process. Although they come from a range of political values, they share a commitment to rigorous analysis and probably some understandable skepticism at the prospects for progress on health care policy. After all, they have seen administrations, Congresses, and policy proposals come and go—and have dealt with the increasing political gridlock that has left so many jaded. Even in the wake of the ACA, the most significant piece of social legislation in 45 years, its implementation is the stuff of conjecture in Washington, a succession of would-be crises and attempts to spin them for political gain.

Not so much in the states. Federal law pre-empts state law. Decisions have to be made and implementation must happen. Budgets have to be balanced, legislators briefed, and constituents—who know your cell phone number, the public meetings laws, and your boss—responded to.

Alan Weil and I knew we had good stories to tell and an excess of riches from which to draw. There are a slew of hard-working leaders in the states who handle Medicaid expansion today, health insurance exchange policy decisions tomorrow, and delivery system reform the day after. They are implementing and improving, accepting the roses and brickbats tossed their way, and moving on to the next issue.

In the end, we landed on three representatives, and they did not disappoint. John Colmers, chair of Maryland’s Health Services Cost Review Commission, spoke of the complex renegotiation of their unique Medicare waiver that continues all-payer rate setting and sets them on the path to a statewide budget for all medical care expenses. Greg Moody, Director of Ohio’s Office of Health Transformation, reviewed the Buckeye state’s Health and Human Services Innovation Plan that simultaneously modernizes Medicaid, streamlines the Health and Human Services Administration, and implements provider payment reform in both the public and private sectors. Finally, Jim Haveman, Michigan’s Director of the Department of Community Health, led the Board through Governor Snyder’s ambitious efforts to broaden Medicaid eligibility, re-procure managed care services, and improve the effectiveness of Medicaid services to high-needs populations.

The Board, by their own admission, was a bit taken aback. Here was action, not talk—thinking and doing. They asked many questions. They went over the allotted agenda time. They cornered John, Greg, and Jim at the break. Afterwards they commented on the size and comprehensiveness of the ambitions. They pondered the implications for other states.

I took away several lessons from the states’ presentations:

1. Insurance access. Expanded coverage is the beginning, not the end. Battles over Medicaid expansion and Exchange implementation make for good headlines but they are only a prelude to the really hard work that comes next—stimulating delivery system reform and population health improvement.
2. Federalism. Cultures are different—John Colmers could never sell Maryland’s payment solution to Ohio. The ACA continues to place more responsibility with the states and raises questions yet again about state accountability, acceptable levels of policy variation between states, and the balance of authority between federal and state governments. Stay tuned.
3. Leadership. States that are moving to improve their performance in health care have governors, legislators, and senior staff who see the ACA as an opportunity, not an imposition—a chance to get a much bigger tool box of laws, financing, and models with which to construct things that work for their state. They are not shy about taking advantage of the opportunity or sharing the credit.
4. Accountability. The Center for Medicare and Medicaid Innovation’s State Innovation Models Initiative forces states to look at their whole health care system and how the pieces should fit together. Accountability to the federal government for Medicaid and health insurance exchange performance is essential. Public performance measurement helps. Finally, state officials are accountable for their performance—in their budgets, their public hearings, and ultimately the ballot. These have a way of focusing one’s performance.

In the end though, mostly I was just proud of the state folks. Proud of their efforts to serve their communities and improve the health of populations. Proud of the way they represented their colleagues in their home states and others. In a town known for talking, they were relating their accounts of doing. They were linking thought and action; putting the truth to Herr Goethe.