As health reformers seek to learn from the experience of states, it quickly becomes apparent that there are fundamental differences in the political possibilities in some states compared to others. While there is growing consensus around the policy of coverage expansion, there are still huge hurdles to surmount in working out the politics of reform, both in Statehouses and among the interested stakeholder groups. Specific reforms may be stymied or suddenly become possible based on the personalities and influence of particular groups in a given state. With that caveat, there are several “lessons learned” related to building political support among stakeholders that can be observed across states.
- Leadership is essential. Leadership in both the executive and legislative branches is critical for reforms to be enacted. If there is no strong political leadership behind a reform effort, it will likely founder as it encounters the inevitable vested interests that would prefer the status quo.
- Be inclusive. An inclusive consensus-building process is transparent and gives stakeholders real input. While it may not be possible to gain the support of all the interested groups, a process that gives the relevant groups real influence and a seat at the table can prove helpful for gathering needed support.
- Build relationships early. It is important to start building trust and relationships with stakeholders early. Once a reform proposal begins to move, it may move quickly and there may not be time to build the alliances that could help support reform. Early relationship building also contributes to a sense that reform is inevitable and participation is better than exclusion.
- Find supporters wherever possible. If it is difficult to get important stakeholder groups to support proposed reforms, it may be possible to convince key leaders who represent those groups. For example, if support from the statewide business organization is difficult to obtain, it may be possible to find support in a local chapter or a key business leader.
- Get supporters on the record. Initial support for reform can fade through a long negotiating process. In addition, key allies may not deliver the needed political and financial assistance to gather support for reform. Gathering supporters early and getting commitments for the ways they plan to help is critical.
- Keep your eyes on the prize—Part I. While legislators or groups may have significant concerns about specific pieces of reform legislation, it is important to not lose sight of the bigger picture in order to maintain strong overall support for reform. Reform efforts can easily fail in the face of strong opposition if support is lackluster or begins to wane.
- Keep your eyes on the prize—Part II. The perfect should not be the enemy of the good. There are states in which a moderate, bi-partisan reform proposal was unable to pass due to opposition from the right and the left. Particularly for those who strongly support universal coverage, it may be worth supporting a plan that is not the preferred option in order to achieve a shared goal of expanding coverage.
While having an open and inclusive consensus-building process has been important in several states, it is possible to overstate its role and importance in health reform. There are examples of reform proposals conceived by a few key individuals in leadership (Maryland 2007) and also of failed state efforts where significant resources were invested in promoting compromise between stakeholder groups (New Mexico 2008). Comprehensive reforms have failed and succeeded for a variety of reasons. Consensus-building is no magic bullet, but key stakeholder opposition to proposed legislation never helps either.
States that have established a consensus-building process around comprehensive health reform have done so for several reasons. These include:
- Government leaders are seeking input and assistance putting a plan together. A given governor or legislative leader may make increased access to health coverage a priority, but needs time and help putting a final plan together.
- A stakeholder process may be a way to educate key interest groups and government officials on the issues related to health reform. Informed leaders will make better decisions than those without much exposure to the issues.
- If a leader has made health coverage a priority but does not have the political ability to pass reform immediately, a stakeholder process may be a way of sustaining interest in the topic until the political situation is more favorable.
- Implementation is notoriously difficult and key stakeholders will be needed during the implementation stage to ensure that any reform proposal is ultimately successful. A collaborative process builds support that will be needed when the program inevitably encounters obstacles later in the process.
