With 21 states suing the federal government over the constitutionality of health care reform and another 15 refusing to participate in the high-risk insurance pools, there is little to suggest that implementation will be any easier than the 15 month battle to pass health care reform. Nobody understands the importance and perils of implementation better than Jon Kingsdale, director of the Commonwealth Connector Authority. In today’s Boston Globe, Kingsdale outlines the lessons learned from implementing near-universal coverage:

1. It’s a campaign: In any successful campaign, continuous progress must be demonstrated and broadly communicated. In Massachusetts, we built partnerships with private and public groups, so that people heard and read about the law everywhere — at Fenway Park, in church, while shopping, or riding the subway. We launched this effort with the Red Sox, and held more than 300 educational forums across the state, the equivalent on a national scale of 15,000 outreach meetings. As a result, voter support for reform has remained high, ranging from 59 percent to 75 percent.

2. Adequate resources: The Massachusetts Legislature appropriately funded implementation with $35 million in the first year; the equivalent on a national scale would be $1.65 billion. Never were shortages of time, expertise, or resources allowed to stand in the way of meeting legislated deadlines.

3. Coordination: Somebody has to be on point to drive implementation across federal agencies and the other organizations needed to execute this undertaking. The Health Connector used multiple consultants and outsourcing strategies, while staffing up, to meet deadlines. With 50 states and far broader legislation, the federal effort will require a Herculean coordination effort.

4. Experiment and evaluate: This effort is new and not everything will go as planned. For example, running an exchange means offering customers what they want to buy, but that’s neither obvious nor unchanging. Massachusetts’ exchange is a learning organization. Key initiatives were launched as pilots, and we have not been afraid to revise them and try again.

5. Transparency: The biggest challenge Washington faces in “helping’’ Americans gain access to care is their distrust of government. Transparency is the antidote: making tough decisions in public; meeting endlessly with employers, unions, insurers, clinicians, and citizens; and both talking and listening out there, in at least 15,000 communities. These are essential to building trust.

6. Harness the market: State exchanges are essentially stores that sell insurance, combining government’s responsibility to protect consumers with a retailer’s need to serve customers. Brow-beating various industries may be good partisan politics, but the Health Connector has worked diligently at creating solid, long-term working relationships.

In other words, the get out the insurance enrollment campaign will probably be more important than the mandate penalties, Congress may have to appropriate more dollars for implementation, and lawmakers have to prepare for the reality that Congress can’t possibly “know enough to specify for every community, the exact design for care that is safe, effective, timely, patient-centered, equitable and sustainable.” They’ll have to allow regulators to experiment!

“The executive branch has 3 1/2 years to work with 50 very different states in bolstering popular support and executing effectively. That will require massive amounts of technical expertise and project management, combined with public outreach and creative communications,” Kingsdale writes, in what I suspect is a great understatement. But Kingsdale himself is not ducking the challenge. He has announced that he will step down from his position in June and while it’s unclear if he’ll come to Washington to lend his Massachusetts experiences to the national effort, he will likely remain an important source of “expertise.” You can read my earlier interview with him here.

Roll Call is reporting that medical interests spent “more than $876 million in lobbying expenses during the 15 months beginning in January 2009 and ending in March, when Congress passed the sweeping overhaul” and were “responsible for one out of every five dollars doled out on lobbying during that period.” Here is a partial breakdown, according to the CQ MoneyLine analysis:

While all of the health care interest groups won important concessions from the new law, none were more successful than the hospital industry, which negotiated an early deal with the Democrats “to provide $155 billion over 10 years to defray costs for uninsured Americans” and avoided more serious cuts. For example, currently the government pays about $45 billion dollars a year in DSH payments to help hospitals afford uncompensated care. Since health care reform will insure 34 million Americans over a 10-year period, the number of ‘uncompensated’ care cases will decrease by as much as 80%, but DSH payments will only be cut by some 15%.

As Thomas Scully, who ran CMS from 2001 to 2004, explained at a recent roundtable for Health Affairs, “That may not work out as well for inner-city hospitals with high levels of indigent care, but the bond prices and stock prices will tell you that most hospitals are winners, at least in this bill. Assuming there are no subsequent bills, hospitals are probably the biggest winners. They got hardly touched and got a lot of new money.” Hospitals are also protected from cuts under the Independent Payment Advisory Board through 2019 and can expect to net as much as $16 billion from “reimbursements for newly insured patients who would be covered under the overhaul plan.”

The pharmaceutical industry also did well, accepting approximately $80 billion in cuts, while holding off policies like direct drug negotiation and re importation, that would have resulted in higher loses.