“Acceptably Cruddy”:The Art of the (Health Care) Deal

Finding dissenting opinions in a public health class on policy priorities for the US health system is like looking for stars in the night sky of a city—you know they exist in the bigger world, but they are nowhere to be found in the current setting.  Universal health insurance? Heck yes! Centers for Disease Control and Prevention and Agency for Healthcare Research and Quality? Fully funded! Payment reform? More, now!

A recent effort to help students in the course I teach appreciate the diversity of priorities for the US health care system that exist outside their classroom ended up being much more—a master class in political compromise and consensus building. In the wake of the proposed American Health Care Act’s withdrawal from consideration by the House of Representatives last week, it is an important lesson.

The specific topic was the process by which Montana decided to take advantage of federal funding for Medicaid to reduce its uninsured rate. The instructor for the case was former Democratic Minority Leader of the Montana House of Representatives, Chuck Hunter. No longer a member of the House because of term limits, Hunter reflected on some of the key elements of the expansion negotiation.

The first effort, championed by Democrats in Montana in 2013 in the wake of the 2012 Supreme Court ruling that left Medicaid expansion to the states’ discretion, failed to make it out of the committee in the Republican-majority house, in spite of gubernatorial support and evidence about the costs of people being uninsured and the health benefits of coverage. Chastened, Democratic assembly leaders strategized with Governor Steve Bullock, a Democrat, to learn from their failures.

In 2014, Democrats invited Republicans to out-of-state meetings to learn more about how states were addressing the expansion question. (The Montana citizen legislature only convenes in odd years.) Democrats recognized that Republican objections merited serious consideration. Republican leaders, such as Senator Ed Buttrey, understood the enhanced peace of mind that comes when people have insurance coverage, and the improvements that expansion promised for hospital finances.  He and other Republican colleagues did not have confidence, however, in the ability of state agencies to administer the expansion, and maintained that any expanded coverage had to resemble an expansion of private insurance, not Medicaid.

“We are a big, sparsely settled state,” Hunter explained to my class. “I may be a former state employee, but we do not like big government programs here.” (Hunter had previously administered some of the state’s labor and training programs.)

As they prepared for the 2015 session, Democrats—led by the governor—started negotiating with Republicans on the details of a new expansion bill. It would outsource administration of the expansion program to a private insurer, building off a politically-acceptable model used for the state’s Children’s Health Insurance Program.  It also contained cost-sharing requirements for enrollees, similar to those in private insurance.  Because of federal restrictions, the bill did not impose work requirements for Medicaid beneficiaries, although that was what some Republicans wanted. It did, however, require referrals of working-age enrollees to state-run job centers.

These were hard pills for members of Hunter’s own party to swallow. “I kept reminding them,” he said, “it was not about having a great bill. It was about having an acceptably cruddy one.”

As the session started, Hunter and his colleagues swallowed harder and let their Republican assembly-mates lead the process. Senator Buttrey and a House colleague submitted the bills. “We Democrats stayed out of the debate, which took enormous restraint because we had fought so long for coverage expansion,” Hunter said. “Taking a bigger role would have caused some Republicans to waiver. So we sat on our hands.”  To be sure, a divided government helped. As a Democrat, Governor Bullock could make judicious use of his veto in exchange for the Republican-controlled House and Senate consideration of his priorities, one of which was health care.

And knowing assembly procedure also helped. The coverage expansion bill had more support in the full House and in the Senate than it did in the House committee, and Hunter used his knowledge of house rules at critical times to generate a rare floor vote of the full House, after the bill had been defeated in committee.

Now, less than two years after the bill was signed into law and barely 14 months after enrollment began, 70,000 Montanans are paying part of the costs of their newly acquired, privately administered insurance. “We know more people are getting mental health coverage,” Hunter said.  “And I still have people who come up and tell me about conditions they can have treated because they now have insurance.”

One student in my class told Hunter that she was so interested in the debate over the legislation that she’d watched some of the proceedings.  “There were a lot of statements that were just flat out misinformed,” she told him.

Hunter acknowledged her observation. “In any issue in a citizen legislature,” he said, “there will be a handful of us who are knowledgeable about the issue. But we are ranchers, lawyers, small business people from all over the state. And everybody has to weigh in. That is the beauty of the democratic process.”

Perhaps the tincture of time has made Hunter’s populist lenses a bit rose colored. But he described a process that seemed to work—where divided government, a marshaling of the evidence, good leadership, and a willingness to listen and compromise led to “acceptably cruddy” solutions.

My students listened carefully. It would seem to be a lesson for many of us.