Only recently did insurance exchanges rise to the fore of the shouting match over federal health reform.
Dozens of mostly Republican states have said they'll take no part in creating and running the Web-based insurance portals, delegating the task to the feds.
But the irony, says political strategist Ken Bowler, is that the most anti-federal states will now have exchanges run by the federal government.
Bowler was among a group of health policy gurus who headlined a public health class at the University of Utah last week taught by former state Department of Health Director David Sundwall.
Sundwall has opened the graduate-level class to the public, free of charge, in the hopes of fostering an informed, ideologically unbiased discussion about what he calls the country's "No. 1 domestic policy issue."
Health reform is of unparalleled importance, he says, "because of its cost and impact to peoples' lives, and because of our growing embarrassment over our health rankings internationally." Americans spend more on health care than any developed nation, but have some of the poorest outcomes.
But lecturers at Wednesday's class bemoaned the partisan gridlock barring Congress from finding common ground.
Health policy debates have become almost "tribal," partly due to the disappearance of moderate Democrats from the South and moderate Republicans from the North, says Bowler, a Democrat who served on the staff of the House Ways and Means Committee from 1974 to 1989 and held top public and government affairs posts for the LDS Church and Pfizer.
The fight over exchanges, once an idea championed by Republicans, shows how far conservatives will go to stop "Obamacare," he says.
Implementation of the Affordable Care Act will be disruptive and uneven, varying from state to state, he predicts. "There will be calls for changes and delays in effective dates, and there will be adjustments in the bill."
But such is the messy business of politics, adds Bowler, noting other federal programs, such as Medicaid, rolled out in similar fashion.
John T. Nielsen, former Utah Gov. Jon Huntsman's health adviser, expects the same of Medicaid expansion.
Just as states gradually embraced Medicaid, so too will they adopt the optional provisions of the Affordable Care Act to expand the program to cover more of the nation's poor, he says.
Nielsen headed government affairs for Utah's largest hospital chain, Intermountain Healthcare. As Huntsman's adviser, he had a front-seat view of Utah's own attempts at health-care reform, including a health exchange like the one in Massachusetts upon which Obamacare is also modeled.
House Republicans, however, wouldn't sign off on a mandate to force Utahns to have insurance, thought to be the only way to goad the young and healthy into the insurance pool and keep prices affordable.
Then-Majority Leader David Clark, R-Santa Clara, was prepared to sponsor the bill, says Nielsen, who dropped by then-House Speaker Greg Curtis' office one day to pitch the plan.
It didn't go well, recalls Nielsen. "[Curtis] said, 'If you think you can come in here with a bill that has an individual mandate and sell it to the Legislature, you're not as smart as I thought you were.' "
Curtis, R-Sandy, warned if Clark did run the bill, "It might be the first time the majority leader fails to get a bill out of [the] rules [committee]," says Nielsen.
Once a loyal Republican, and now "squarely in the independent camp," Nielsen sees no immediate relief from the nation's worsening political divide.
But he told students they hold the key to healing it. Get engaged, know your elected officials and, most important, understand Utah's "broken" caucus system, where a small number of delegates pick nominees at political party conventions instead of voters at large doing so in a primary election, he urged.
"It's there where you can make a difference."
Going to health class
What • Former Utah Department of Health Director David Sundwall is opening to the public, free of charge, his University of Utah course on health policy. The class features lectures by industry leaders on "the most important health policy issues" facing the country, including: doctors going digital, soaring health care costs, the rebirth of managed care and a comparative analysis of how health care works in other countries. For a schedule of the lectures, call 801-587-3315.
When • Wednesdays from 6:30 to 8:30 p.m. through April 3.
Where • University of Utah Department of Family and Preventive Medicine, 375 Chipeta Way, Suite A, in the public health classroom 203.