In health care policy circles the acronym “PMPM” usually stands for “per member per month” – a measurement used to describe payments in a capitated system, or prescriptions used by members of a drug plan.  However, after the victory of Scott Brown in the Massachusetts Senate race, it can also stand for health reform “post-Massachusetts post mortem.”

Certainly, many of the health care speakers at the National Academy of Social Insurance conference last week had to scramble and redo their talks, since health reform and the concept of social insurance seemed to have  suffered a critical, if not mortal, blow. Health Affairs Editor-in-Chief Susan Dentzer, speaking at the Friday panel on the fate of health care reform, compared the trajectory of the politics of reform to such noteworthy movies as “Psycho” and “It’s Complicated”.  Judy Feder lamented that it seemed cosmically unfair that health reform was endangered by Senator Edward Kennedy’s death.

In the roundtables, particularly the one on viewing health reform through a state lens that preceded the morning session, there was more emphasis on the nuts and bolts of what is happening in the states despite the desperate economic plight of many states, particularly California. No matter what happens on the federal level, states have to move forward with investments in health information technology, in primary care infrastructure and redesign, and in pushing forward the virtual medical home concept which potentially can work well in local and state jurisdictions. 

Ree Sailors of the National Governors Association pointed out that it was real genius to put money for health insurance exchanges and health IT in the stimulus bill, because it laid the foundation for many improvements that states want to do and insulated the funds from the political vagaries of passing a federal reform bill.  Finally Deborah Chollet of Mathematica noted that, perhaps not surprisingly, Massachusetts believes it can move forward with its reforms on its own and intends to do so.

A focus on the states, perhaps aided by some federal money and initiatives, was also advocated by David Brooks in a January 21 New York Times column. Brooks noted that in an era of distrust of big government, promoting massive change engenders voter insurrection, as evidenced by Massachusetts.  He advised the Democrats to respect the voters’ voice, turn away from concentrating power in Washington, and instead support incremental state-based reforms like those in Massachusetts or those envisioned in a bill proposed in 2007 by Sens. Russ Feingold (D-WI) and Lindsay Graham (R-SC).

Many healthcare policy analysts and political scientists have observed this yin and yang oscillation between reliance on the federal government for promoting reform efforts and viewing the states as the petri dish of innovation. Writing in the pages of Health Affairs in 2005, Richard Nathan wrote about federalism and the states and the advantages of incremental steps in promoting health coverage expansions. In 2004, also in Health Affairs, Henry Aaron and Stuart Butler advocated allowing the states to experiment in any number of ways to provide coverage for the uninsured.