A Way Forward for Bipartisan Health Reform? Democrat and Republican State Legislator Priorities for the Goals of Health Policy

Both the Affordable Care Act (ACA) and attempts to repeal and replace it have been criticized for their highly partisan passage. Many argue that only bipartisan reform can be sustained over time regardless of which party is in power. Bipartisan reforms require that at least some specific, articulated, health policy goals from each party are met.^1,2 A new survey of state legislators’ goals for US health policy provides crucial insights into the challenges and opportunities for future bipartisan reform.

Ascertaining state legislator priorities is important for two reasons. First, with or without an ACA repeal, Health and Human Services Secretary Tom Price has committed the Trump administration to an expanded role for states in determining health policy. As state officials negotiate with federal officials and state legislators debate health care statutes, are there goals on which the political parties agree, and if so, which goals? Second, roughly 50% of national legislators first served as state legislators; state legislator positions can be considered close proxies for those of Congress.^3,4

THE SURVEY

We worked with health policy experts who had experience of one or more of federal or state policymaking, federal or state policy analysis, and health care delivery organization. With their input, we compiled a set of 13 health policy goals covering domains such as costs, access, health, and quality. In late January 2017, we convened a focus group of six current state legislators—three Democrats and three Republicans—to finalize the list. Following final changes, all six legislators agreed that the 13 goals were relevant potential goals of health policy and that the language was nonpartisan.

The final survey contained basic demographic questions and asked legislators to rank the goals in order of importance to them. The survey is provided in the Appendix (available as a supplement to the online version of this article at http://www.ajph.org). Legislators could rank as many goals as they wished and could assign tied ranks to goals; we assigned the lowest rank to any unranked goals.

We mailed the survey to 2973 legislators identified as members of health or budget committees in all state senates and assemblies in March 2017, with reminder e-mails and a repeat second mailing. The resulting 13% response rate (377 responses: 192 Democrats, 182 Republicans, 3 others) was good compared with those of other surveys of state legislators, and was encouragingly representative for geography, party affiliation, and legislative chamber.

HOW DO HEALTH CARE PRIORITIES DIFFER BY PARTY?

There were no differences in priorities for health policy goals on the basis of geography or legislative chamber, but Republicans and Democrats did have very different priorities for health care. We mapped⁵ the Republican and Democratic priorities to see which goals clustered together and how each party prioritized the goals. We then compared the Republican and Democratic maps (Figure 1).

FIGURE 1—

Graphical Representation of Health Policy Goal Rankings by (a) 192 Democratic State Legislators and (b) 182 Republican State Legislators: United States, 2017

Note. The horizontal axis represents the overall importance of the goals; for each party, the goals furthest to the right are most important and goals furthest to the left are least important.

We interpret the identified clusters⁶ as representing four distinct domains of health policy goals: “improving overall health,” “reducing costs,” “addressing health care delivery,” and “smaller government.” Although the clusters are similar between parties, their relative importance is different. The horizontal axis represents the overall importance of the goals; for each party, the goals furthest to the right are most important and the goals furthest to the left are least important. Republicans prioritize reducing costs and smaller government over all other goals, whereas Democrats prioritize improving health and equity and reducing costs.

There is some disagreement among Republican legislators on the relative importance of the goal “improve overall health” versus the goal “reduce government involvement.” Among Republicans, 29.7% gave a top-three ranking to “improve overall health” and a lower ranking (fourth or lower) to “reduce government involvement,” compared with 40.1% who did the opposite. The apparent split within the Republicans on the importance of improving health versus reducing government involvement probably reflects intraparty differences between moderate and conservative points of view.

WHAT ARE THE POLICY IMPLICATIONS?

The largest difference between the parties in our survey was the assigned priority to reducing government involvement: Republicans ranked this second, whereas Democrats ranked it lowest out of the 13 goals. This stark difference likely reflects an ideological split on the role of government. The second-largest difference was in addressing health care disparities due to race, ethnicity, and socioeconomic status, with Democrats ranking this third and Republicans ranking it lowest out of the 13 goals.

Assessing Policy

Figure 1 reflects many of the goals of the ACA (Democrats) and proposals for its repeal (Republicans); a Democratic-only health reform prioritizes improved access and government-led efforts to improve health, whereas a Republican-only reform prioritizes reduced costs for individuals, limited government involvement, and reduced government spending. The June 2017 Congressional Budget Office estimate of the impact of the Better Care Reconciliation Act suggests that it meets the latter two goals but has a mixed impact on the first.⁷

Designing Policy

Recent efforts at single-party reforms have resulted in recrimination and instability. An alternative bipartisan reform might reduce acrimony and be more durable, but likely at the expense of ambition and comprehensiveness.

Considering the two maps in Figure 1, the most obvious potential area for future bipartisan policy work is targeting costs—for employers, government payers, and individuals. However, policies to tackle costs must not have a negative impact on other goals important to each party—namely, improving health and smaller government. Moreover, given the seemingly inexorable upward trajectory in health care expenses, expectations for success must be modest. Encouragingly, existing bipartisan efforts at payment reform align well within such a framework, as they are intended to reduce costs while improving the delivery of health care services (and, ultimately, improving health).

For state officials contemplating their response to the current federal administration’s commitment to increased state flexibility, the findings are particularly instructive. For state Medicaid program or commercial insurance market restructuring proposals to have broad support, they must balance effects on costs and the health of populations.

Messaging Policy

Understanding the conflicts and congruencies of health policy goals also allows for more effective advocacy by those working for change. For instance, advocates for policies addressing the social determinants of health and prevention should emphasize their impact on reducing disparities to Democratic lawmakers and their impact on reducing costs for payers and individuals to Republican lawmakers.

CONCLUSIONS

The past 10 years of increasingly partisan health policy argument have not yet resulted in durable policy solutions to the many acknowledged problems with the US health care system. Insisting on the rightness of one’s position will not persuade an opponent.

Alternatives to standoffs exist, however, and this survey demonstrates that common ground between Republicans and Democrats can be found on the sufficiently challenging task of tackling health care costs. The way forward for more comprehensive bipartisan health reform is difficult, however. Fundamental conflicts—on the role of government in providing and subsidizing health care and on tradeoffs between reducing costs and increasing access—stand in the way.

There is some solace, perhaps, in recognizing that these conflicts are not new. We believe that the only way forward is to acknowledge each other’s goals and work to improve the US health system by starting reform where there is agreement and exploring compromise where there is not.