Wednesday, September 22, 2010

Negotiated Rulemaking committee Day 1

The HRSA negotiated rulemaking committee to reconsider health professional shortage area (HPSA) and medically underserved area (MUA) designations got underway today. There was a great deal of process work today, with the group discussing what consensus would mean. The statute that created the negotiated rulemaking process defines consensus as unanimous agreement....which gives me a bit of pause and makes me worry we are wasting our time. However, the facilitators have quite a bit of experience and said that many groups have been uncertain about their ability to reach consensus, but have been pleasantly surprised. They went on to further give a practical definition of what it would take for members of the committee (all 28 of us!) to agree: 70% comfortable with what was decided (no one will like it completely), with 100% willingness to publicly support the result of the committee process.

We also worked on the rules governing our committee and how we would work together. This seemed laborious to me, but is important ground work.

General Thoughts from day 1:
  • The committee is filled with passionate advocates for underserved persons and groups.
  • Most committee members have a fairly clear sense of 'who they represent' on the group. For me, I do not have such a clear sense. I was involved in research in this general area for most of the 1990s, but honestly had given it up because past efforts (in 1998) to reconsider many of these issues had failed and it seemed intractable. So, I have a history with the topic and an interest (it was my dissertation research), but have been away from it for a decade. I don't feel as though I am representing any particular group, and most want to ensure that we allocate scarce resources to aid underserved groups in the best way possible.
  • There will be a great deal of technical discussion around data and the like. A big challenge will be to remember the main point: looking at a means of allocating scarce resources to best aid the disadvantaged and underserved in our nation.
  • We need to get it right. History shows a great deal of inertia in such efforts to designate aeas and groups. The MUA and HPSA methods are largely unchanged since I was in elementary school and middle school. No pressure guys, but we don't need to screw it up...
  • We need to land the plane. The Clinton Administration sought to reconsider these designations in 1998; the Bush administration did so in 2008. In both cases the plans went on the rocks due to lots of negative comments from those who expected to be adversely affected by any changes. We will have to navigate this.
  • In several instances, people said 'what does the law say?' meaning PPACA which specified creating this negotiated rulemaking committee, or the Public Health Service Act provisions in the 1970s that did things like create the National Health Service Corps which is why HPSAs were created....often the laws are fairly vague. So, the committee will (and HHS for the past 35 years has) had to exercise a great deal of discretion in working out the nuts and bolts of these designations and programs.
A member of the committee this afternoon said, 'pie in the sky' what would you do if you could do anything? My first answer is, "I am not sure." My second answer is that I would try and figure out a way to tie extra resources to the underserved, disabled and disadvantaged individuals in a way that helped to create a market to provide care to these marginalized groups, who do not have good access to medical care, even if they have insurance. Not sure how to do that....

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