In this off-cycle election year, things were anything but quiet last week in Ohio.

At stake was repeal of Senate Bill 5, which significantly restricted collective bargaining for Ohio’s public employees. Polls showed the legislation was likely to be repealed, a repudiation of Republican Governor Kasich’s efforts. The final vote for Issue 2 was 61% to 39% in favor of the repeal. Democrats and union leaders declared a resounding victory.

In contrast, on the same ballot was Issue 3, a referendum making it unconstitutional to require a person to buy health insurance. This vote went to the heart of the national healthcare reform legislation, the individual mandate. Wouldn’t the same majority in Ohio be sympathetic to a critical cornerstone of President Obama’s healthcare legislation? Not so. The constitutional amendment passed with more votes than the public employee collective bargaining Issue 2.

The Washington Times headline read “Messages mixed on unions, health care in Ohio Vote.” But was the message really mixed? With a record turnout in an off-year cycle, was there a common message?

Repealing Ohio Senate Bill 5 wasn’t a cry for more taxes. In fact, the vast majority of school districts in Ohio that requested additional property taxes were turned down. Many Ohioans also recognized the need for the public sector unions to pay more for their benefits as stipulated in Senate Bill 5. But the prevailing view was the bill went too far. One party controlled the Governorship and the State Legislature when it passed.

Likewise, many Americans are sympathetic to the issue healthcare reform was meant to address: growing healthcare expenses and the uninsured. But the healthcare law to this day suffers from a lack of popularity. The Kaiser Foundation latest poll reported only 34 percent have a favorable view of the Patient Protection and Affordable Care Act. One party controlled the Presidency and Congress when it was enacted.

The Road to Change

The common message is most likely this: Change is possible but the process of change is as important as the change itself.

Above all else, we see over and over the need for creating an honest conversation that speaks to our aspirations, realities, and choices. One could argue that in healthcare there was lots of conversation. But the feeling for many was the legislation was on a pre-ordained path to passing and the talking points rang hollow. Time and time again, we heard that if you like your health insurance you can keep it, not necessarily a call for transformation.

Likewise in Ohio, Republican leaders focused on Senate Bill 5 as a means to give local government the tools to fix their financial issues. Somehow likening the dismantling of decades old collective bargaining rights to a toolbox fell short.

In both cases, many people were unsettled and unsatisfied. The march to change hit a roadblock. Dwight Eisenhower once said, “Leadership is the art of getting someone else to do something you want done because he wants to do it.”

In the middle of America, we have the Ohio lesson. Winning an election is one thing, winning the hearts and minds of those you lead is another. The challenges of our country are great, including tackling our healthcare crisis and the impending insolvency of Medicare in just over a decade. Let’s hope leaders understand this if needed change is to become possible.

My son calls him Teddy and he has a prominent place in my son’s room.

We came by Teddy at a weekend hockey tournament where we found ourselves in the ER room of the local hospital after my son took a spill and hit the side of the rink. Mother’s intuition said he was going to be okay, but more than anything I wanted to be assured.

The doctor recommended that we do extensive scans based on my son’s pain.  As I signed papers, the doctor briefly mentioned that there were risks to these scans but that it was best to be safe.

The staff and ER physician could not have been more kind and attentive.

After three hours we got a clean bill of health. And finally they brought in Teddy. My son willingly accepted him and said, “He is great.”

All in all it was experience of thankfulness and appreciation; that my son was okay, everyone had been so kind and that the care was so expedited.

Then the bill came – $10,000. I have been in healthcare for many years.  This one made me grab a chair.  My insurance company had paid roughly 80% leaving us with an approximate $2,000 bill.

The pit in my stomach grew even larger when I read an article about the dangers of exposure to radiation from CT-scans and the relative quickness in which physicians are choosing to scan.

I called the hospital, sharing my concerns both financially and medically. Within a month, the hospital came back to me.  They would reduce my bill in half if I could make prompt payment. The hospital medical review committee had also reviewed the course of action taken in the ER. My read. The alternative course of a careful neurological and physical exam and monitoring seemed equally appropriate. This option had not been discussed at time of treatment.

As I reflected on this episode I thought how telling it was of healthcare, the good and the bad.  The hospital staff was very caring. We had quick access to state-of-the-art care in a small town, but the price tag for the care was expensive. Interestingly the ER physician’s payment was one of the smallest components, several hundred dollars, while the specialist received significantly more. As most people are, we were taken aback with the cost of the care, but fortunately our insurance company paid the majority of the bill. Finally, our doctor’s clinical decisions steered towards a “more is probably best” model versus a more open conversation with the patient about the options, risks and benefits in a shared decision making model.

So where did this leave us? Unsettled. Thankful for my son’s well-being and relieved that the hospital had helped lessened the financial burden. We were fortunately able to pay the bill, now only $1,000. But many would not be so fortunate. And as I thought about the care, I saw how quickly we processed through almost a pre-ordained plan. We were participants but not really.

From this narrow mother’s perspective, looms a larger cloud, a U.S. debt linked to a public healthcare system set to go bankrupt in a time horizon I no longer consider someone else’s problem. I think of my son and his future. The real bill for Teddy is the huge and growing national debt and the burden it will place on my son and his children. The grand bargain to raise the debt ceiling hands over these challenges to yet another commission.

As we continue to look at our healthcare equation, the issue is not as simple as just lowering prices. Our situation showcased that how care is delivered is ripe with opportunity. Some estimate that 30-40% of healthcare costs are unneeded or inappropriate.

Why is that? Duplicative services in an inefficient system, a demand for more, new technology that drives up prices without clear-cut benefits, strong interests holding on to the status quo?

As a public we stand accountable as well. A low health literacy that in my county alone is estimated to create $152 million in unneeded healthcare expense.  And a public that while on one hand overwhelmingly wants to see a balanced budget amendment but does not want to see cuts to Medicare and Medicaid. There really is no short answer, just complexities and interests.

Bottom line is that a $10,000 teddy bear has come to symbolize our healthcare.  We hold onto our companion, feeling a sense of false security. Meanwhile the storm clouds outside the bedroom window continue to grow. In a time of crisis, perhaps first and foremost we, the public, need to be willing to see Teddy for what he really is, an old friend that we have to let go of as we find a new path forward.

Albert Einstein once said, “The significant problems we face cannot be solved at the same level of thinking we were at when we created them.”

For me this quote captured the opportunity we squandered with healthcare reform last year. While peppered with new and old ideas, the crux of the mammoth plan built off of systems already in place. To give an analogy, we had a train, and we had added a few cars to the end (the uninsured). We didn’t dramatically change the destination of the train – a cliff.

The cliff? It is a fact that our basic entitlement programs of Medicare, Medicaid and Social Security are on a path in the not so distant future to consume 100% of all government revenue. Most specifically, Medicare and Medicaid are the engines of that train driving us to that financial cliff. In an industry set to consume 1 out of every 5 dollars in America by 2020 – the decades 2030, 2040 – when my husband and I would be accessing these programs, look bleak.

However several weeks ago the conversation changed. House Budget Committee Chairman Paul Ryan, put forth a 2012 budget that would cut spending by $6 trillion over 10 years. He took aim at the very engine of our growing debt and deficit – Medicaid and Medicare. More notably from a citizen’s perspective, he did what most politicians instinctively avoid, taking on a conversation that would be considered too risky politically.

Why is this important? As Einstein said, how we approach problems makes all the difference in how we solve them, as expressed in my original Healthcare Letter To Americans.

First and foremost, in the last few weeks, Americans are hearing a much more candid conversation about our fiscal situation. This was made all the more real with Standard & Poor’s recent downgrading of the future of American long-term debt to “negative” for the first time.

Indeed this isn’t a new theme. The Bowles-Simpson Debt Task Force put forth compelling ideas to reduce our nation’s debt, taking on taboo subjects such as retirement age, but fixes to Medicare and Medicaid were not hallmarks of the plan. Unfortunately the 2012 budget put forth by President Obama that has our country borrowing 40 cents of every dollar spent, gave a different message. It was as if someone turned down the volume on the TV. Appropriately so, a Gang of Six, three Republican and three Democrat Senators, took up the leadership mantle and have been working to find some plausible solution to our financial crisis. Their work continues.

But for the average citizen, it is important to understand what the House Budget Plan has done. It is not a speech, a call for a new task force, nor is it Mr. Ryan’s Roadmap for America. It is a specific piece of legislation that has been passed in the House, a stake in the ground that we can actually see. The result speaks for itself. It is hard not to pick up a newspaper, magazine or turn on a news program and not encounter discussion about this plan. President Obama followed suit with his deficit speech at George Washington University. So first and foremost the conversation has changed, and the volume is turned back on.

Second, the House Budget Chairman defined a very specific problem – the growing debt and deficit and the causes. If you look back at healthcare reform, I would argue it tried to do all things for all people at the outset. It was the grand potpourri of legislation and good causes. It didn’t define the problem and parameters clearly. Why is this so important?… because while Americans support sacrifice in general, when it comes to very specific programs, we cower from any changes that could affect benefits to which we’ve become accustomed. To paraphrase one of my favorite writers, David Brooks, in why he was wavering in his support of the healthcare bill, “If we get our cake now, we will not eat the spinach later.”

If as a country we are eventually to make difficult decisions, we need to ensure we understand why we are doing this. Medicare can no longer be treated as the sacrosanct program that can’t be touched. By defining the problem so visually, we give the ensuing options critical context.

Finally, as David Dranove, a Professor of Health Industry Management at Kellogg has said, the best ideas are sometimes those most “pure,” i.e. simple and clear. Once people are prepared for a conversation about a defined problem, the best ideas must be generated. Engineers do this routinely. They test different options for integrity. Compromise is needed in the end to reach the finish line, but the idea generation should bring clarity to an array of solutions.

One of the best examples of the eloquence and power of simplicity is former Governor of Tennessee Phil Bredesen’s framework for reforming our healthcare system outlined in his book Fresh Medicine, a must read. At only 276 pages, it could be read on the beach. Another “pure” idea is the one being put forth by Vermont in its move to create a single payer option. Mr. Ryan’s plan is based on a voucher system. In contrast, the most recent regulation set forth by the government for Accountable Care Organizations, a key piece of the new healthcare law, represents a complex array of requirements that most certainly will be a boon to consultants.

Most importantly, none of this is to say you should agree with Congressman Ryan’s proposal to solve the problem nor the other solutions I have mentioned. You may in fact think them to be on the wrong track. But as an engaged citizen, I am grateful for the change in the conversation, for specifics I can get my arms around.

We have a chance for a different dialogue that we missed last year with our healthcare debate. We have a chance to look at, as Einstein said, “different thinking.” Let us join our fellow citizens in that dialogue and encourage more ideas. As Jacob Weisberg said in “The Ryan Reaction,” a recent Slate article, “You can’t win the future with a government defined by the past.”

Note: In interest of disclosure, Mr. Ryan is my husband’s brother.

Am I having a flashback… is it the healthcare debate all over again? Recently Wisconsin, my home state, leaped into the national limelight because of our fight over the state budget and our Governor’s efforts to restrict collective bargaining for public unions except for wages.

The parallels are obvious: protests and vilification, both sides believe they have the moral high ground, shouts go out too fast, too soon, passions run high. Issues of financial solvency are the backdrops; we have to bend the cost curve because our state is broke. The issues touch the heart and soul of society: patients’ rights, education for our children and assumptions about retirement and protection.

Drama is rampant, some would even say escalating. In healthcare, there was the midnight House vote on Christmas Eve while Santa filled our stockings. In Wisconsin’s case, 14 Democratic Senators have taken a page from Texas Democrats’ playbook and fled the state. In my hometown of Janesville, Facebook reveals how raw nerves are, and just how close to home this really is.

Yet as we lurch forward, I want to reflect on what this all signifies. The United States is at a crossroads. President Obama speaks of “winning the future.” Mitch Daniels, Governor of Indiana and potential Presidential candidate, talks of the looming national debt as the new “Red Menace.”

The Great Recession shook us to the core. As human beings we don’t usually change by choice; we change to adapt, to survive. We were jolted. Assumptions about retirement age, prospects of getting a job out of college, the price of oil, the life our children will have are all being challenged.

As painful as it is and awful as it may sound, maybe this is what our country needed, a wake up call. Standing at these crossroads, the way forward will need clear-eyed leadership. More importantly, this journey will require demanding citizenship. By that I mean citizens ready to make thoughtful mandates.

One of my biggest disappointments with healthcare reform was the missed opportunity to address the issues that were impeding the true transformation of healthcare. On the positive side, millions can now count on access to insurance. But more dangerously we added to empty promises such as if you like your insurance now, you will be able to keep it. The reality is settling in that our costs are still out of control, we can’t keep pushing costs to the private sector and Medicare/Medicaid is the number one driver of our growing debt.

Today the battle raging in our state has reached my hometown. Our local school budget faces a $10 million gap even without a cut in state aid. But I wonder if things are changing or if there’s just more of the same. There are those who still throw empty labels at each other and retreat to their respective “sides.”

However, encouragingly we are starting to talk more vigorously and openly about difficult issues. We are beginning to address once sacred cows. We have leaders taking very bold steps on both sides. On the national front, leaders are saying things once thought political suicide. Chris Christie spoke publicly about the need to increase the retirement age for Social Security. Mitch Daniels discussed the medical expense for end of life care on a national Sunday talk show and Democratic Governors like Andrew Cuomo are making dramatic changes to programs like Medicaid that were once thought politically inconceivable.

And there are more hopeful signs – closer to home. Our local newspaper, The Gazette, is asking officials questions they would not have considered before publicly. People are writing letters to the editor who have never written before. Yes, the traditional power brokers of business, government and unions are still in the ring. But in taverns, coffees shops, Facebook, and beauty parlors, we are finding our voices as individuals, and not just in protest but also in dialogue. As Winston Churchill said, “Difficulties mastered are opportunities won.”

Slowly but surely, are we as a country stepping up to the plate, to say “We get it?” Is this our time? Maybe it isn’t just more of the same after all.

As we think about the year ahead for our country, we can anticipate tremendous work to be undertaken by many to improve healthcare. While 2011 can yield positive change, I believe it is paramount to be realistic about the challenges we face as we select our priorities for action.

As I reviewed articles and opinions from last year, I was struck most notably by a June 2010 interview in Health Affairs with the President and CEO of Geisinger Health System, Glenn Steele. This organization has received national attention as being an innovator in trying to improve outcomes and costs.

In the interview, Dr. Steele offered an example of developing an acute hospital-based product, ProvenCare, that lowered cost and improved outcomes for cardiac inpatients. He noted that this type of innovative product would be offered to all their patients, not just those with Geisinger insurance. However other non-Geisinger insurance payors were not knocking down the doors to participate. “Many of them have done well in the old-fashion way, and it’s really hard to change if you’ve done well in that manner.”

To me the story underscored that too often the best intentions of healthcare fall prey to the status quo. In his new book Fresh Medicine, which I highly recommend, Phil Bredesen, former Tennessee governor, writes, “Until we accept that solving the healthcare cost problem is going to create conflict, make various interests mad, and result in winners and losers, we won’t get anywhere.”

Embedded in these words is the notion of competing, competing for a slice of the healthcare pie. We have heard these themes before. Many promote using more free market mechanisms as a means to overcome inertia. From the Affordable Care Act one might see the government moving in the opposite direction, exerting itself to address the inequalities of the marketplace.

But Mr. Bredesen’s comments, echoed by health economists, strike at something even more profound to me. It is the very notion that there are going to be disruptions, if we are to transform healthcare. Period.

But if we want to encourage disruptions, how do we know which ones are good or bad, if benefits are accruing to too few or if we are indeed increasing value to a majority of society? It seems to me that the first disruption to the status quo needs to be one that allows us to measure benefit or value. In a recent post on The Healthcare Blog, healthcare consultant Joe Flower writes:

“So what’s different between classic economics and healthcare economics? Classic economics pictures a buyer and a seller. There is a constant, dynamic feedback loop between the many buyers and the many sellers in a market that establishes not only what things cost, but even what’s offered for sale, and on what kind of terms.”

This feedback loop is incredibly important but doesn’t readily exist in healthcare.

Take my recent and probably typical surgery experience for repairing a torn ACL. The hospital system gained pre-authorization from my insurer. When I inquired with my insurance provider how much they might expect to pay, the telephone agent said it could vary significantly. Knowing I was close to my out-of-pocket limit, I stopped pursuing cost information. Four weeks post-surgery I received both an explanation of benefits and an invoice. The insurance company paid approximately 50% of the official “list price” charge, and I paid a couple thousand dollars out of pocket.

Prior to receiving that statement, the only discussion of cost that even marginally surfaced was during my pre-op rehab visit. At the time, the therapist provided me with a cooling chest to use post-surgery but also gave a quick caution that it might not be covered by insurance. No price was given at the time, although I can imagine it was a tiny percent of the overall cost. Ironically this device proved crucial to my excellent recovery, though I might have foregone it based on that one comment. Perhaps we do have feedback loops but they send the wrong messages.

This issue of price transparency isn’t new. The title of a seminal 2003 article in Health Affairs hits the nail on the head: “It’s the Prices, Stupid: Why the United States Is So Different From Other Countries.” But almost ten years later, little progress has been made to shed light on healthcare prices. Today there are only a handful of states that even make comparative cost data by procedure available to health care consumers.

Changes as simple as listing your prices could be transformative. This fall the Milwaukee Journal Sentinel profiled a Wisconsin physician, Dr. Willett, who declared he was tired of working seven months just to cover the overhead of his office. Instead he adopted a strategy of simplicity. He has a clinic that offers reduced rates that are clearly published in a two-page menu for all patients to see. They include $500 for a vasectomy or $39 for a 15-minute check up. He accepts no insurance and avoids the associated cost of billing.

Other efforts are underway to increase transparency of costs to consumers. Costs of Care, a nonprofit 501(c)(3), is a social venture that helps doctors understand how the decisions they make impact what patients pay for care. They recently offered $1000 prizes for the best anecdotes from doctors and patients that illustrate the importance of cost-awareness in medicine.

All the efforts mentioned above are laudable with many more needed, but fundamental to building on these changes is a shift in our mindset that healthcare is free once we have paid our deductibles and out of pocket expenses. My surgery wasn’t a few thousand dollars procedure. It was much higher. In the end we do pay for these costs, through lower wages and higher taxes and insurance premiums. One of our best New Year’s resolutions could be to recognize that healthcare prices matter even when you have insurance, and the more we embrace transparency of such prices the better.

The 2010 election is over, and we have ample analysis and opinions on the outcomes. We have read or heard about the major concerns that swept the Democrats out of power in the House and in many state elections. In my own state of Wisconsin, we went from being an almost solidly blue state to a red one, including the defeat of three-term incumbent Senator Russ Feingold.

We know the issues: bad economy, healthcare reform, lack of trust in big government – a turbulent forecast for politicians in general.

As to the implications of healthcare reform on the elections, polls showed that 58% of voters disapproved of the healthcare bill and 48% wanted its repeal. Many believe Pelosi’s push for healthcare reform was a main driver of losing the House, a point she strongly denies. President Obama, while not speaking to healthcare directly, continues to point to the struggle that his administration has had in communicating the significant and positive work that has been accomplished.

Articles continue to speculate that the President just doesn’t get it; that the healthcare reform he delivered is not what Americans wanted, communication techniques aside.

Interestingly one of the most provocative articles I read came from Slate. Titled “Pelosi’s Triumph,” the article posits that the political leaders in power knew exactly what they were doing. As the author, William Saletan, writes, “Legislative majorities come and go. This healthcare bill is forever… a party that loses a legislative fight against a middle-class health care entitlement never restores the old order.”

It is a compelling argument but may be shortsighted. What Saletan pays little attention to is the fact that the healthcare reform bill is vulnerable to being gutted, because of the very nature of the bill which makes this easier to do. While huge in size, the legislation ironically left much of the regulation to be written. Additionally, requests for leniency or reprieve from certain provisions are flying off the shelf. The massive funding required leaves even more doors open. Ultimately, the way the reform was passed left it wide open to these attacks.  There is also the 2012 election which could impact reform before some of the larger provisions are set to begin in 2014.

Which is why you see some of the tone changing in academic and policy circles from asking how do we implement healthcare reform to will it be jeopardized with this political uncertainty?

Which brings me to a fundamental question: what do we as citizens hope for in this New Year and from our government?

There was a book released in the last year titled, If We Can Put a Man on the Moon: Getting Big Things Done in Government. The authors, Eggers and O’Leary, share a stunning statistic. When surveying members of the Senior Executive Service, the elite ranks of federal managers, 60 percent said the government was less capable of executing large projects today than it was 30 years ago.  They go on to say that this process by which we travel from idea to results is too often broken.

My take away from this survey and how it relates to the election, healthcare and government: The issue is basic competency. We need people who are competent not just at campaign rhetoric but also at leading people in setting and executing coherent, thoughtful ideas that can then be carried out to attain a specific goal or outcome.

There were ample examples in the healthcare reform rhetoric where identified outcomes didn’t match political rhetoric. The most glaring was the notion that if you like your insurance today, nothing will change. Juxtapose this statement with the goal of bending the cost curve, and it isn’t a rational promise. We are seeing this play out today.

There are leaders emerging across the country who hold political office who have demonstrated leadership competency including the need to be transparent about competing interests. At the state level, they are the Phil Bredesens and Mitch Daniels of the world. They may not fit the profile of charismatic “rev up the crowd” leader, but when I hear them speak or read about them, I come away with confidence, not hope or anger.

Perhaps the question I should have posed is not what can we expect of our government going forward, but rather how can we as an electorate become more adept and astute at job interviewing? We will see if that was what this election 2010 was really about or not.

I still think fondly of Chao Phya, a beautiful male Siamese cat who became my dependable companion when I was 24. At the time I brought him home to my apartment, my resources were very limited. But this was my first motherly responsibility as a young adult, and so I gulped and parted with $600 for neutering, supplies and care for the first year.

Luckily for new pet owners now, that loving concern doesn’t have to automatically translate into a financial challenge. Recently a friend was looking to have her dog neutered. The fee quoted at a local veterinary clinic was just over $450, not inconsequential. As do many these days, my friend sought more information and options. Through the internet, she came upon Spay Me!, a high volume, low cost spay/neuter and wellness clinic located in Sun Prairie, WI that, despite its low prices, claimed high quality.

The price was not $450; nor $250. The price for the same procedure was only $75! But it gets better. Included in that cost were two vaccinations. And as if in an infomercial, Spay Me! even offered transport to and from a few designated locations for only $25 more, thus providing choices and convenience while saving many pet owners time and money.

If you are thinking low quality, back alley service and “too good to be true,” think again. As my friend discovered, the providers were professional, showed compassion to the animals, and provided a good clinical outcome. Wouldn’t we like all our healthcare experiences to be like that?

Spay Me!’s website is informative and should be a model for healthcare. Prices, post-surgical care and payment options are all clearly spelled out on-line. You might think there would be red tape to qualify for such a heavily discounted service, perhaps proof of financial hardship or something similar. But, no, the goal as stated on their website is “to make the procedure affordable to everyone. There are no income guidelines and no residency requirements; anyone can bring their animal to us. We have licensed veterinarians and certified veterinary technicians on staff and they focus on high volume procedures.”

My reaction to reading this is if we can do this for our furry friends, why can’t we do this for ourselves?

Over the last several weeks, we have heard how the healthcare insurance landscape is changing. As insurers and employers react to the new healthcare law, inevitably changes and even disruptions are happening. Some rates are rising, certain policies are no longer being offered, and negotiations for exemptions from regulations are on the rise. Employers as well as insurance companies are hedging bets. States are watching their insurers closely, and federal regulators are working as quickly as possible to implement a law that leaves much to be determined.

This was to be anticipated. Why? At the core of the healthcare reform was the goal of providing wider access through regulatory intervention, while innovations in care delivery were left much less well defined, being only vague and promissory in the legislation itself. Transformative service delivery, price transparency, and real competition seem like far off dreams.

Many miles away from D.C., Spay Me! in Wisconsin lowered costs by focusing on an operational strategy – high volume, high quality specialized procedures driven by a mission that customers trusted. Is this a novel approach? To healthcare perhaps yes, to other industries no.

There is no question we love our pets. If we love ourselves, we might take a lesson from our furry friends and realize how we deliver healthcare must change as much as how we pay for it.

Woof woof, meow!

Last month I titled my blog, You Might Want to Duck, with emphasis on the various battles that were unfolding around implementation of healthcare reform.

Interestingly, the recently released August Health Poll from Kaiser Family Foundation reported a noticeable change in public opinion on healthcare. It found that “support for health reform fell over the course of August, dipping from a 50 percent favorability rating in July to 43 percent, while 45 percent of the public reported unfavorable views.”

This drop in support suggests that healthcare reform will be very much an issue in voters’ minds as we approach the upcoming mid-term elections in November.

From my perspective, the healthcare issue, always deeply divisive, continues to be linked for better or worse to our economy. As Americans see our country continue to struggle economically with record-breaking deficits and unemployment still near 10%, the picture becomes murkier for many as to the immediate benefits of the reform. Add in the well-financed interest of competing stakeholders, and you have the makings for quite a windstorm this fall, requiring that we as citizens redouble our efforts to become and remain well informed on the fundamental facts and issues.

In rapid fire last week, news broke about the battles being waged on the healthcare front.

Viriginia made national headlines when the Federal District Court refused to throw out this state’s lawsuit against the individual insurance mandate, a key component of the healthcare reform law. Led by Attorney General Cuccinelli, the suit challenges “whether the federal government has the power to compel individuals to purchase a particular consumer good — not as a prerequisite to some other privilege, such as driving, but merely because they live and breathe.”

There are nineteen other states that jointly have filed a similar suit.

And while the courts initially spoke, the “show-me” state of Missouri also made headlines. As the New York Times reported, “ Missouri voters on Tuesday overwhelmingly approved a measure aimed at nullifying the new federal health care law, becoming the first state in the nation where ordinary people made known their dismay over the issue at the ballot box.”  Known as proposition C, it was intended to turn over the requirement that individuals must have healthcare insurance. The measure passed with 71% of the vote.

On the public relations front, the White House touted a new report by Medicare Trustees based on information from the Office of the Actuary at the Center for Medicare and Medicaid Services.  The report said that Medicare will save about $8 billion by the end of next year, and as much as $575 billion over the rest of the decade.

The debate on whether the Patient Protection and Affordable Care Act will create savings continues not just in policy and political circles. Various government institutions responsible for measuring the financial impact of legislation produce different “scenarios”. The variation comes from interpretations of what is likely to happen. For example there are provisions for automatic cuts if Medicare costs accelerate. Some estimates factor in that Congress will not have the political will to follow through on these cuts.

In addition criticism continues that the Administration is double counting savings that are being used to improve the financial solvency of the Medicare Trust Fund but at the same time using those savings to pay for benefits for those previously uninsured.

If you feel as if you are watching a tennis match, please know you aren’t alone. The debate will ebb and flow over time with significant influence coming from the outcome of November’s election. There are clear tensions rising between the states and the federal government that we see playing out not just in healthcare but in other areas as well, most notably, immigration.

While the political national discourse continues, I am trying to spend more time focusing on how those who provide healthcare are reacting to the new legislation and how states are addressing their own healthcare reform.  As consumers, I think it is imperative that we don’t lose sight of those who are stepping up to the plate to innovate, regardless of the political battlefields.

At the end of June, the Congressional Budget Office (CBO) released what many have called an alarming picture of our financial health. From the analysis, the CBO projects that government spending as a share of the economy will double by 2043, up from its historical average of roughly 20%. The long-term budget outlook continues to worsen with each passing year Congress fails to act. Debt held by the public will eclipse the size of the entire US economy by the year 2023.

Healthcare role? CBO projects that if current laws do not change, federal spending on major mandatory health care programs will grow from roughly 5 percent of GDP today to about 10 percent in 2035 and will continue to increase thereafter. Those projections include all of the effects of the recently enacted health care legislation, which is expected to increase federal spending in the next 10 years and for most of the following decade.

The Government launched its HealthGov website. The look and feel is very consumer friendly. It underscores the government’s desire to market the new healthcare plan and its benefits. I applaud efforts to bring information to consumers about choices. On the flip side, one can become cynical after reading the CBO report highlighted above compared to the rosy picture painted on the website.

The big political news was that Dr. Donald Berwick’s nomination to head the Center for Medicare and Medicaid by-passed the Senate confirmation process through a recess appointment. It just underscores how tense the implementation process is for healthcare legislation… summer is not the only thing bringing heat to DC. I wrote about his appointment in my June 7^th blog.

From a legislative impact perspective, we have now entered the period of “temporary” high-risk exchanges until permanent exchanges are in place in 2014. Under the new law, people who have been denied coverage due to a pre-existing condition and who have been uninsured for at least six months may qualify to buy insurance.

Maine became the first state to ask for a reprieve from the medical-loss ratio of 85% mandated by legislation. Again this underscores the immensity of the negotiations and discussions going on, especially amongst the federal government, the states and insurance companies.

From across the seas, the new UK government just announced the biggest changes to the National Health Service (NHS) since its founding. They are in many ways breaking up how the NHS functions with the hope of reducing bureaucracy and management layers and giving consumers more choices. It is a call for decentralization. These are incredibly interesting times to see how different countries are approaching similar financial challenges.

I just finished reading my June Health Affairs as the July issue arrived on my doorstep. It is my “academic” resource into the world of health policy. June’s issue focused 100% on reform. I’d summarize the thirty-plus papers as a picture of optimism and historical opportunity interspersed with pessimism and warnings of naïveté. Many authors underscored that the current political landscape will make an already challenging implementation all the more difficult, an issue all sides clearly understand. It underscores to me that the process used in developing reform legislation is having a material impact beyond the legislative process.

The takeaways? We are moving into August when Congress will recess and we’ll see the 2010 election campaigns heating up. My tip for fellow readers is to look to candidates who are willing to talk in concrete terms about the challenges we face and solutions to those challenges. I also encourage people to spend time focusing on state elections. From my readings, much of the legislative detail will be developed and shaped by how states approach healthcare reform.