Diminishing Expectations

Throughout the presidential campaign, words like "sweeping" and "ambitious" and "reform" have been commonplace in descriptions of President-elect Barack Obama's healthcare agenda. But in recent weeks—and especially since Obama was elected—some very different words have been popping up in discussions of what the next president will really be able to accomplish in the healthcare arena: "incremental" and "phased" and "limited," to name a few.

With a struggling economy and two wars draining resources and leaving much less money to work with than Obama no doubt envisioned, the general consensus from analysts around the country is that Obama's lofty plan—there's another descriptor, "lofty"—will be scaled back considerably. We have a story coming on this topic in December's issue of HealthLeaders magazine, but in short, creating a public plan for the uninsured and expanding SCHIP and expanding Medicaid and investing billions in healthcare information technology and doing everything else Obama wants to do would require, as all of you know, hundreds of billions of dollars—some estimates say more than $1.5 trillion over 10 years.

And when it comes to changing the U.S. healthcare system, our next president has more to worry about than just money. "He is going to face a very difficult road in any event, given the current budget situation and given the projected long-term budget situation and given the complexity and political difficulty of making major changes in so large of an industry," says Henry Aaron, a senior fellow at the Brookings Institution. "We can't afford healthcare reform. But the principal obstacle to achieving it is not the cost but the complexity of the interests and the policy changes involved in healthcare reform."

OK. So a presidential candidate may not be able to deliver everything he promised during the campaign. In the words of Gomer Pyle: Surprise, surprise, surprise. But what about the quality arena specifically? Is the industry likely to see any significant movement?

Here's an abbreviated review of Obama's quality agenda, summarized from his Web site:

• Promote patient safety—require providers to report preventable errors.
• Align incentives for excellence—providers seeing patients enrolled in the new public plan will be rewarded for achieving performance thresholds.
• Comparative effectiveness reviews and research—establish an independent institute to oversee research on comparative effectiveness, with research focused on comparative information on drugs, devices, and procedures to determine which options create the best outcomes.
• Tackle disparities in healthcare—tackle the root causes of health disparities by addressing differences in care access; promote prevention efforts; require hospitals and health plans to collect and analyze quality data for disparity populations.
• Reform medical malpractice while preserving patient rights—strengthen antitrust laws to prevent insurers from overcharging physicians for their malpractice insurance.

At first glance, some of these seem painfully obvious and read like so much campaign propaganda. "Promote patient safety." Really? What a novel concept. "Tackle disparities in healthcare." In the description of how that will be accomplished, verbs like "address" and "promote" reek of trivial generalization.

Still, patient safety is, in fact, a critical issue. Disparities in care access do exist. And aligning incentives for quality care is a noble idea (assuming the "incentives" are meaningful). In other words, the issues are basically on target. But Obama is likely to encounter the same conflicting agendas and same monetary challenges in implementing quality initiatives as he does with the rest of his plan. Personally, I don't see a lot of slam dunks here. Actually creating an independent institute to oversee research on comparative effectiveness, for example, will face both strong financial headwinds and resistance from people who don't think it's a good idea, anyway. I do agree, however, with the general consensus that momentum remains strong for reform of some kind, even if it is more limited and protracted than Obama's early campaign promises.

What do you think? Which parts of Obama's plan have a real shot, and which parts are already doomed? Send me an e-mail and let me know your thoughts.