BALTIMORE – With close to 700 health policy experts, bureaucrats and state administrators gathered three weeks before the country elects a president and most of Congress, you'd expect some political chatter.
Not so much.
Compared with last year when much of the agenda -- as well as hallway talk -- revolved around the Supreme Court's impending decision on health care reform, "what-if" discussions about the November election were conspicuously absent at this year's National Academy for State Health Policy national conference.
The dearth of discussion is not because there's not as much at stake this year. Republican presidential candidate Mitt Romney and many GOP congressional candidates have promised to repeal the Affordable Care Act if they're elected.
The difference this year is that it's political, not legal. Partisan politics are rough waters for policy wonks.
"I think it speaks to what this group is about," said NASHP Executive Director Alan Weil. "These are people who have to work in a daily environment with people who may not share their political views, but they have to not only get along, they have to move forward and be productive. They can't get caught up in the partisan stuff."
For many states -- the undecided, as well as the loudly and publicly opposed to the ACA -- November's election could trigger a change of course. Victory for President Obama and/or Democrats in Congress might be cause for states resisting reform -- such as Florida, Louisiana, South Carolina and Texas -- to revisit their positions. No matter who wins, legislative leaders in undecided states may begin leaning toward one side of the fence or the other on Nov. 7.
For California, New York and other states embracing health care reform, the November election looms less large. California health officials, who earlier this year pledged to move forward with reform no matter what the Supreme Court decided, may feel the same way about the November election, but they're less likely to talk about it.
Supreme Difference Between Court, Politics
Not only was the level of pre-Supreme Court discourse higher, the timbre was different as well. Policy leaders picked sides and eagerly debated the law last year. This year, if the election arose in conversation -- as it did before and during the second presidential debate last week -- voices were usually subdued and conversations short.
"Elections come around all the time but a Supreme Court decision of that import doesn't come along that often -- especially not in health care," said Andrea Rosen, interim health plan management director for the California Health Benefit Exchange.
"Another big difference is the potential ramifications. If the Supreme Court had struck down part or all of the law, the effects would have been obvious. What's going to happen if Romney wins is a lot less clear," Rosen said.
"If Obama is elected and Congress doesn't change dramatically, there will still be obstacles and a lot of work to do, but the path forward is a lot easier to see. The road is much less clear in a Romney administration," Weil said.
Finding Ways To Move Forward
In speaches and breakout sessions over three days, state policy leaders discussed a variety of issues including Medicaid expansion, state insurance exchanges, essential health benefits, payment reforms, health care workforce, children's health coverage and long-term care.
In a session titled "A 'Waive' of Innovation: Recent Medicaid 1115 Waivers," efforts to change the system were outlined in two politically disparate states -- California and Texas.
CMS offers states the option of applying for waivers from business as usual to test new ways to deliver and pay for health care through Medicaid and the Children's Health Insurance Program. Separate from and not dependent on the ACA, waivers are in effect in most states.
"The key element of waivers is that they are demonstrations or experiments," said Victoria Wachino, director of CMS' Children and Adults Health Program Group. "One of the best parts about working on waivers is getting to know states really closely -- what works well where," Wachino said. "And the learning is definitely a two-way street. All of CMS' work with states is making Medicaid and CHIP as strong as possible."
California's five-year waiver, known as the state's "Bridge to Reform," is the country's "first, largest and most comprehensive waiver and the one I've learned the most from," Wachino said.
Wachino said she's also learned a lot working on waivers for Texas, where the approach to health care is much different politically than California's. Words used in the waiver label tell part of the story. In Texas, it is called a "Healthcare Transformation Waiver." The word "reform" is not used much.
"Unlike California, Texas has not yet made decisions about Medicaid expansion or about an exchange," said Lisa Kirsch, Medicaid/CHIP deputy director for the Texas Health and Human Services Commission. "We're waiting until next spring."
Texas' waiver revolves around 20 regional partnerships between hospitals, providers and other stakeholders that employ many of the tactics prescribed in the ACA, including payment reform and Medicaid managed care. If the Texas Legislature decides not to expand Medicaid, there is talk that some of the partnerships may apply to CMS for their own version of a waiver.
Despite different political climates, policymakers find ways to learn from each other.
"I'm admiring how you expanded the idea to regional health care programs," Len Finocchio, associate director of the California Department of Health Care Services, said about Texas' regional approach. "California is more focused on facilities. In a partnership approach, seeing how they gelled and didn't gel -- that's something that all of us can learn from."
Kirsch was reticent to talk about Texas' future. Gov. Rick Perry (R) has said Texas will decline Medicaid expansion and should not build an insurance exchange. The state Legislature has yet to weigh in.
"The election might make things more clear. We won't have guidance in a lot of directions until January," Kirsch said.
'Like Waiting for Godot'
Finocchio compared pre-election policy leaders to the two main characters in Samuel Beckett's play "Waiting for Godot." While waiting for someone neither knows very well and probably wouldn't recognize if he arrived, the two characters share food, philosophies, songs and ultimately contemplate suicide.
Godot fails to show but is expected the next day. The play ends with the two characters still waiting.
"I think that's very fitting," Finocchio said.