Health policy is never static, but it’s been quite a while since the field has seen as much change and uncertainty as we see now. From the perspectives of people now working in healthcare management and those whose business is to educate and prepare the next generation of professionals, it is not unreasonable to liken the Affordable Care Act (ACA) to the 1965 enactment of Medicare in terms of how dramatically it will change the healthcare landscape in the United States. And while changes will be significant, just what shape they will take remains unknown in many respects. The reform bill is large and complex, and most details of implementation have yet to be worked out. For example, how will ACOs take shape? How can value-based payment formulas be designed so they are effective in a range of situations, e.g., rural areas and urban centers? These and many other questions make health policy a moving target at the moment. Moreover, the constitutional challenges add layers of uncertainty, as do the 2012 elections. Where does that leave educators charged with preparing students for the years to come? AUPHA recently took a look at how the ACA is affecting the way members are teaching health policy. Along with attending the Winston Health Policy Symposium in April, we had an opportunity to interview several AUPHA faculty who have recently been thinking and writing about this very topic: Elizabeth Berzas, PhD, Assistant Professor and Program Director, Our Lady of the Lake College; Paige Powell, PhD, Assistant Professor of Health Services Administration, University of Alabama at Birmingham; Keith J. Mueller, PhD, Gerhard Hartman Professor and Head, Department of Health Management and Policy, University of Iowa; and Karen M. Volmar, PhD, Associate Professor of Health Policy and Administration, Executive Director of the MHA Program, Penn State University.
Conversations with AUPHA faculty, and discussions at the recent Winston Health Policy Symposium, indicate that for faculty, students, and practitioners, the current situation is fraught with challenge and ripe with opportunity. More than one professor observed that there might never have been a more exciting time to be involved in health policy and healthcare management than the coming decade. At the same time, several observed it is more necessary than ever to push students to “do the hard stuff” in order to be solidly prepared for successful and meaningful careers. Mastering the technical knowledge and skills to be an effective administrator is not enough. Today’s – and certainly tomorrow’s – healthcare leaders must be effective problem solvers. That in itself is not a new idea, but there seems to be a new urgency to carry it to the next level. Students need to develop a deep understanding of the way health policy is made – both the “how’s” and the “why’s” – in order to have a theoretical framework for thinking about whatever policies are in place, present and future.
Obviously, using ACA coverage provisions as a framework for discussion requires caveats, at least until the Supreme Court decision in June and the elections in November. So there is both heightened relevance and increased complexity associated with such discussions. Ways in which the substance of discussion is changing include shifting the focus away from lack of access to concentrate on levels of access. In addition, at least one professor is finding new opportunities for interesting and productive classroom discussions about health policy in other countries.
The prominence of health policy reform in the press and at all levels of public discourse is making the instructor’s role both easier and more difficult. On the plus side, specific implications of policy are more real for more people, including students, than has been the case for several generations. This can make it easier to engage students’ interest in policy and create new opportunities to apply interactive techniques very effectively. Discussions with guest speakers, role-playing assignments, and discussion forums including the broader campus community are among the exercises currently in use in AUPHA member programs to engage students in dialogue about health policy. In the current climate, students grasp more readily than before that while policy may seem abstract, it has real and immediate implications for people’s lives, maybe even their own.
On the other hand, public dialogue about health policy tends to be extremely polarized and several faculty noted that classroom discussions typically reflect that polarization. Teachers are challenged to display very high levels of sensitivity so that students do not withdraw from debate before they have an opportunity to move beyond superficial arguments and begin engaging the intellectual tools they need to approach policy at a deeper level. Once that engagement occurs, the discussions are often deeper, richer, and more illuminating. For example, as professionals they will need to bring critical thinking to bear in order to separate policy from politics; and distinguish between arguments rooted deeply in facts, and rhetoric that is only superficially supported by data. Equally important is the objectivity that enables one to see all sides of an argument. There may be more opportunities to model objectivity and nurture critical thinking, but it may require extra care on an instructor’s part as students may be starting from deeply held, if inadequately supported, beliefs.
While the implications of health policy are more directly relevant to many students today, the process by which it policy created can remain mysterious and abstract. Some faculty are placing added emphasis on “the nuts and bolts” of drafting and implementing health policy. Making policy is not a linear process, and whether students aspire to help create it or to find roles administering it, it will be invaluable to understand how it comes about, e.g., not only how budgets work but also how they get built in the first place – how groups and teams of people go about getting things done. Starting with a legislative provision and winding up with policies and regulations for implementing that provision requires collaboration: acknowledging that all stakeholders have legitimate positions, recognizing and working beyond conflicting values, reconciling competing agendas, understanding the role of politics in the process. One approach is to assign teams of students to analyze different parts of the reform bill from the perspective of a specific organization or stakeholder group. Even with so many details of implementation as yet undetermined, the ensuing presentations and discussions offer good opportunities to explore and understand the policy process and the various rationales and agendas that drive it.
It may almost go without saying that successful health administrators must be effective communicators, able to distill information and present it clearly, coherently, and concisely. In the context of health policy, it is also valuable to understand the role that communication plays in the process, e.g., how information gets to Congressional committees, to the press, to the public; and how it can be manipulated through the strategic use of misinformation.
Even in the context of health policy legislation, the timeline for implementing the ACA is a relatively long one. While so much remains unresolved, one apparent certainty is that the uncertainty will continue for several years. Knowing that, according to at least one faculty member, students are apt to see process as more relevant than they might otherwise. And that opens the door to challenge them to look beyond a narrow lens of operations or management and develop a broader perspective by studying the whole system.
Many of the ideas encompassed in the ACA are not new, e.g., ACOs, which have been around but had not previously captured significant attention or interest. From a teaching perspective, the legislation provides new opportunities to discuss such ideas and explore how they might play out post-reform. For example, in the case of ACOs, to start to see how they have worked on the private side with a view toward how they could work for Medicare.
Some faculty pointed out that, intellectual challenges aside, focusing on policy in a less pragmatic and more academic way can be frustrating, at least initially, for students whose primary orientation has been acquiring operational and managerial skills. Teachers must establish relevant linkages between the abstractions of policy-making and the realities of the professional environments students will shortly enter. At least one plans to invite more alumni in to speak to classes, giving students opportunities to hear directly from the front lines.
The overall consensus: it’s a very challenging time to be teaching health policy and to be learning it, full of unprecedented challenges and opportunities. And it is very exciting. While some seasoned professionals may be nervous about what so much disruptive change will bring, or may carry baggage accumulated in past battles and campaigns, those preparing to enter the field will have tremendous opportunities for innovation as they move the system forward.