Non-Partisan, but Not Neutral

Bipartisanship in health policy is hard to find. Pick your topic—Medicaid expansion, Medicare reform, or health insurance exchanges—and voices are shrill, slogans are wielded like swords, and opinions ossified. Powered by easy ideologies and campaign cash, the outcomes of partisanship are misunderstandings, distrust, and a lack of progress on important issues.

The Milbank Memorial Fund, in an attempt to combat this, explicitly seeks to bring state health policymakers together in non-partisan settings to fulfill our mission of “improving population health by connecting leaders and decision makers with the best evidence and experience.”

Our signature effort in this arena has been the Reforming States Group (RSG). Now approaching its 25th year, the RSG convenes Republican and Democratic-elected and -appointed state and county officials, spiced with international colleagues, to learn from the evidence and one another’s experience. The dynamic effect on people of exchanging a diversity of ideas and dialogue in a safe, respectful space is startling to witness.

But non-partisanship—and its pleasing harmony—is not the goal of public policy work: nor is using objective evidence, working collaboratively, or building effective relationships in the course of the work. All of these are values the Fund explicitly espouses, but they are employed toward the greater goal of improved population health. And population health is not neutral—it is a goal.

Population Health – A Collective Priority

Kindig and Stoddard define population health as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” Making population health a collective priority puts it in conflict with other societal goals. It can result in laws that limit my personal liberty to make choices that negatively affect my health or that of others—smoking indoors in public places, not vaccinating my kids—but might make me feel pretty darn good. It can dictate expansive and expensive roles for government, and threaten, at least for some, standards for civic and personal responsibilities.

Having a goal, or a priority does not make an organization or a person partisan. The markers of partisanship instead are the reliance upon selective anecdotes, the rejection of objectivity and intellectual curiosity, and an unwillingness to attempt to understand differences of values and priorities and to find common cause across those differences.

For the RSG, no current issue better illustrates this distinction between non-partisanship and neutrality than Medicaid expansion. The evidence supporting expanded insurance coverage (or the elimination of financial barriers to medical care) as fundamental to improving population health is clear and convincing. No one in the RSG would dispute that. Committed to improved population health, the Fund accepts and disseminates this evidence; thus, we should not be considered neutral on this topic. We do not shrink from it.

Significant differences of opinion exist among RSG members, however, about Medicaid expansion as the best policy for improving insurance access. Some offer full-throated support for straight Medicaid expansion. Others conclude that revisions in benefits and expectations are necessary for the program to be more effective. The evidence of the effectiveness of these revisions remains to be seen, but one must acknowledge that the sky has not fallen on such Medicaid innovators as Indiana and Arkansas. Still others in the RSG believe that the goals of state budget sustainability and reduced tax burdens trump those of population health—at least as offered by any current version of Medicaid.

So, while the necessity of expanded insurance (and reduced financial barriers to health care) for improved population health is incontrovertible, in our Federalist model there is no single right answer to the appropriate means of insurance expansion. Given the Affordable Care Act in its current construct, we at the Fund have committed ourselves to helping RSG members develop a Medicaid expansion that works for their constituencies.

That is an artful position, but not a neutral or partisan one. We maintain that leadership is required to help states design an acceptable Medicaid expansion, and we accept the differences in values that exist in different parts of our country. Burlington, VT is not Birmingham, AL; the calculus of population health, personal liberty and responsibility, collective action, and economic value is performed locally not nationally.

A Commitment to Leadership and a Repudiation of Partisanship

What the Fund believes should be absolute is a commitment to identifying policies that allow all people to live long and fulfilling lives, and a repudiation of partisanship and its hallmarks. We will continue to synthesize evidence and experience on population health improvement efforts for policymakers, and promote collaboration and effective personal relationships among public leaders who share these goals.

It is a small but, we hope, significant aid to those who do this hard work. For all its compelling evidence, insurance access expansion will necessitate compromise and won’t happen overnight. The need to compromise in this work can mean that each policymaker has his/her own gauge of what constitutes success.

And often not getting to 100% is okay. As one RSG participant from a non-Medicaid-expanding state declared at a recent meeting, “I’m an 80 percenter.”

“Hell,” his tablemate—from another non-expansion state and a different political party—responded, “I’m a twenty per center.”

Improved population health is the goal. Non-partisan, yes. But not neutral.