VOICES OF REFORM: AARP'S John Rother Surveys the New Landscape

John Rother, in charge of policy and strategy for the AARP, has been working on health care since the 1970s and he is so steeped in the politics and policy of reform that it didn't take much prodding to get him talking even on vacation. Here are some thoughts he shared the other day, on a cell phone from his own undisclosed location.

The good news: he thinks the landscape for reform is much different than in 1992-94, the Clinton health care initiative. The cost of health care has become too monumental; the quality problems too severe, to ignore. The answer adds up to change.

"Objectively, everything costs so much more and so many more people are without health coverage," he said. "Politically I think the difference now is that business seems to be more interested in playing a role in a solution." A decade or so businesses still thought they could figure it out themselves but "you don't hear that anymore."

Yet in some respects, today's debate is more complex. In 1992, the topic was coverage—how to cover the uninsured. There was a lot of talk about changing insurance models. Managed care, managed competition, HMOs etc. But there wasn't as much talk about changing how we deliver the care itself.

"The concern with costs is leading people to look more closely at health delivery, while the real debate in 1992 was pretty much about insurance," Rother said. "We still thought the problem would be solved if everyone had insurance. Today that's obviously not the case."

Now, the cost, delivery and coverage debates are more closely entwined. We want to bring people into the system. But we want it to be a high quality, efficient system.

Like most analysts, Rother anticipates that the Democrats will keep control of Congress but he still believes that a bipartisan solution is best, both for procedural reasons of getting legislation through the Senate and to make changes in the system last over time. "I do think that, at least in the Senate, you have to have fairly meaningful Republican participation."

But he also sees some pragmatism on the left and right, some memory of what went wrong in the early 1990s, that will make a degree of bipartisanship more attainable. Fewer on the left are demanding a single-payer system. Those on the right have come up with more mainstream ways of using tax policy to drive health reform. The language regarding the scope of reform has changed too. The choices aren't just "comprehensive" vs "incremental." The third option is "sequential," a logical sequence of legislation that will tackle problems big enough to make a difference, but not so enormous that the political system can't digest them.

"There's a lot that's interconnected but we don't have to do everything at once the way we (tried) in 1993-94. We're much more humble this time around. We're all aware of how easily things can go wrong."

Rother said he wouldn't be surprised to see reformers try to avoid measures that would "really provoke strong opposition from very well-funded sectors" that could "gang up and kill it." Rather than sweeping change at a single provocative stroke, the answer may lie in "building blocks" for reform. "We need to think about the structural elements that need to be in place. Health information technology. A functioning market for individuals." The building blocks become the foundation. And then we can keep building on it.

"We can't afford to let the perfect be the enemy of the good. That's easy to say, hard to do. It's very important that we have a win. That we get started. We get this huge cost for delaying and ignoring the problem. We have to get started." Changing the delivery system, the behavior of doctors, the way we reimburse providers — all that may be even more challenging than expanding and financing. overage. But it's necessary. And Rother thinks it's do-able.

Rother isn't a rose-colored glasses kind of guy so when he says things are different this time around, we're happy to believe him.