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.

On July 1st, the new health care law will begin providing temporary health care coverage to Americans who can’t find affordable insurance in the individual health care market through high-risk insurance pools. The law allows states to decide whether they will participate in a new high-risk health-insurance pool, build on an existing program (if they have one), establish a separate state-based high risk pool with federal funding or do nothing at all, in which case the federal government would come in and administer the program.

At least 35 states are already operating their own high-risk pools but states that choose to build off their existing programs will have to meet new federal requirements. High-risk insurance pools will not be able to impose preexisting condition exclusions, will have to keep their premiums at “standard rates” (or no higher than the average person of that age would pay for insurance in the private market), limit on out-of-pocket medical costs to $5,950 a year for an individual, and insurers will have to maintain an actuarial value of at least 65%. Issuers will also be prohibited from varying premiums on the basis of age by a factor greater than 4 to 1.

Last month Kathleen Sebelius wrote states to ask how they plan to implement the high-risk insurance pool provision and on Friday, most of the states responded:

The states that opted out of the program complained that the $5 billion in federal dollars would not be enough to fully fund their pools and said that they could not cover the uninsured with state funds. “We cannot afford to expose Minnesota taxpayers to added potential costs and administrative burdens now,” Minnesota Gov. Tim Pawlenty (R), said. “Unfortunately Florida is not in a position to authorize new financial obligations,” Gov. Charlie Crist (I-FL) added. Their complaints highlight two important contradictions. First, if the states can’t find enough dollars to cover the uninsured for three and a half years, how in the world would they have enough money to develop reform on a state level, as Republicans argue they should? Second, POLITICO notes that the decision came down across party lines — Democrats agreed to establish state-pools using federal dollars, while “Most Republican governors decided to allow the federal government to establish its own high-risk insurance pool in their states, essentially punting.” But as I’ve pointed out before, this too is counter-intuitive. Republicans are relying on the federal government to cover the uninsurable population, helping bring about the very thing they fear — greater government involvement in the health care sector — while Democrats are employing state-based solutions.

Moreover, the idea of the high-risk pool was first proposed by then-presidential candidate John McCain, who believed that he could cover everyone with a pre-existing condition for just $10 billion. Conservative organizations like the Heritage Foundation supported the idea, but Democrats saw it as an incredibly inefficient way of expanding coverage. Now that Obama has accepted the idea into health reform, Republicans are taking their swings and opting out of McCain’s idea.

(Map designed by Nick McClellan.)