If the United States government were a corporation, then the health insurance reform debate would have completely moved into its implementation phase. Essentially, the management and the board would have figured out the course of action, and then figured a way to execute that plan.
If that sounds easy, it's not.
In the corporate world, there's a lot of thought given about how to take an idea and then make it so. Everett Rogers, in his 1962 classic book, The Diffusion of Innovations, shows how "innovation is communicated through certain channels over time among members of a social system." When you have a good idea (or a bad one), the execution runs up against deeply ingrained obstacles. So really smart people spend a lot of time on the implementation of ideas.
In my newspaper career, I worked at large newspapers and small ones. In small ones we could execute lots of approaches, even trying ideas that flopped badly. (The great thing about a small newspaper is if an idea doesn't work, try, try again.) But at large newspapers, well, change of any kind was difficult, slow, and you had to sell the idea over and over.
Rogers demonstrated this problem in graphic form. He divided people in an organization into five groups: innovators, early adopters, early majority, late majority, and laggards.
So you convince innovators and early adopters until you build enough of a success story in order to convince the next group. Of course, some people will never be convinced and that has to be a part of the planning, too.
I'd like to think the Medicare and Medicaid debate followed the Rogers' curve. On July 30, 1965, when the act was signed into law there was much opposition; a majority of Republicans in the Senate and just under half of the Republicans in the House voted 'no." There was no consensus — indeed the bill was labeled (as Obama's is now) as "brazen socialism."
But 40 years of the program — led by early adopters, and then, early and late majorities — changed the face of the debate. There are still laggards, but their ideas don't stand up against popular support. We can, and should, continue the debate about how to pay for these programs and how to do that with the context of the Baby Boom generation (because of its huge size) and the growing span of human life. But that's a different debate than the premise itself of health care coverage for seniors and those eligible for Medicaid coverage.
Will President Obama's health care reform follow the same trajectory? That question is hard to answer right now, but it does show why governing a country is far more complicated than running a corporation.
Remember in the corporate world, once the managers and boards have made a decision, they sell their workers and customers on that change. But in American-style politics, the debate about the premise for the health insurance reform law continues. Resolution is probably years away.
An article in the July issue of Health Affairs says: 'êThere are already many indications that the real fate of health reform will unfold gradually and quietly. The U.S. Chamber of Commerce waged a fierce public campaign against the enactment of comprehensive health reform, but once the law passed, the chamber refused to join the overt conservative Republican drumbeat for repeal, declaring that it would work to influence congressional elections and press for favorable regulatory decisions."
The article by Theda Skocpol, a professor of government and sociology at Harvard, says much of the continued reform debate will be through challenges to "various administrative arrangements, taxes, and subsidies to fund expansions of coverage. The redistributive aspects of health reform will be especially at risk, as business interests and groups of more-privileged citizens press for lower taxes, looser regulations, and reduced subsidies for low-income people."
So what does this big picture debate mean for the small slice known as the Indian health system? It's a call to action. This is an opportunity to become the innovators and the early adopters; demonstrating with stories and data how the health care system can be improved at the patient level. If we do this right, a generation from now, readers will look back at health care reform and wonder what the debate was all about.