It’s Time for President Obama to Define Health Care Reform

Now comes the fun part. With the Senate Finance Committee poised to pass its version of comprehensive health care reform we get to one of the more difficult segments of the Kabuki dance: Speaker Nancy Pelosi and Senate Majority Leader Harry Reid must now reconcile the bills passed by multiple committees into a blended proposal. Which means the time is right for President Barack Obama to publicly define what, exactly, is “Obamacare”.

First some background. In the House, different versions of health care reform legislation have been passed by the House Ways & Means, Energy & Commerce, and Education & Labor committees. To be more precise, while the legislation moved forward by Ways & Means and Education & Labor were very similar, moderate Democratic members on the Energy & Commerce committee gained significant changes in that committee’s version. Speaker Pelosi will now combine the three versions into a “Manger’s Bill.” This is the version that will be debated and voted upon by the full House.

What’s makes Speaker Pelosi’s mash-up of the House Committee’s health care reform bills important is that any changes must be imposed upon it. Her version of the bill is the “default” position. From a legislative process perspective, this puts those seeking changes to the legislative language at a disadvantage.

The same blending process is underway in the Senate. There the task is even harder. The Senate Health, Education, Labor and Pensions Committee passed a liberal version of health care reform; the Senate Finance Committee’s plan is much more moderate. The gap between them is far greater than that between the three House committee’s bills. The Associated Press describes Senator Reid’s efforts to blend two disparate health care reform bills as “mission seemingly impossible.” Given the differences in the how the two Committees addressed costs, taxes, whether there should be a government-run plan, the obligation of employers to provide coverage and other controversial items, “seemingly impossible” may be an understatement.

Unless President Obama dives deeper into the details than has publicly been the case. The White House has been engaged in Congressional health care reform negotiations for some time. According to news reports, White House Chief of Staff Rahm Emanuel, formerly part of the House Leadership, has been the Administration’s point person in these discussions. Until recently, President Obama has been willing to let Congress thrash out the thorny issues related to health care reform, setting forth broad principles. Beginning last month the president has offered more specifics, but hardly enough to clearly define what his version of health care reform looks like. At least not publicly.

With all the Congressional committees having taken a position, the time has come to get specific. Yes, the White House could leave it to Speaker Pelosi and Senator Reid to fashion compromises that can pass their respective chambers, but that only postpones the Administration’s day of reckoning. For after the House and Senate passes their differing versions of reform, a conference committee (made up of both Senators and Representatives) will convene to fashion the final bill. If President Obama waits until the conference committee convenes to publicly engage in the nitty-gritty of reform, it could be too late. Legislators will have been forced to make numerous politically challenging votes. The political payback if the White House then makes those votes unnecessary would be … ugly.

President Obama needs to make his health care reform vision known now, before those votes. He needs to say “this is acceptable;” “this is not.”  He needs to spend his political capital to define Obamacare, to give lawmakers the cover they need to make tough votes, and to rally his considerable grassroots organization behind specific legislation.

Publicly defining what he wants in the bill is a huge political risk for President Obama. His positions will anger some supporters and give opponents mounds of ammunition to use against him. Whatever changes Congress makes to the president’s reform plan will be described by the jabbering cable network pundits as a defeat for the Administration. If he accepts those changes he’ll be accused of weakness and flip-flopping. (One of the most insightful columnists around, Richard Reeves recently explained the value and wisdom of political leaders capable of changing their minds).

But the greater risk to the Administration is failing to achieve meaningful health care reform. And if health care reform does pass, the messiness of the process will be soon forgotten. The odds of President Obama getting a health care reform bill sent to his desk increases exponentially if Congress – and the public – have a clear understanding of the Administration’s legislative ambitions.

The policy and political pieces are all on the table. Selecting from among the various provisions contained in the five variations of health care reform passed by Congressional committees won’t be an easy, but it is necessary. President Obama wanted Congress to participate in the reform process. They have. Now it’s his turn.

Obama Health Care Reform: Early Tea Leaves

As President-elect Barack Obama’s administration takes shape some hints as to the direction health care reform will play out are beginning to drop. While the clues are preliminary and a lot can change in the 47 days before the inauguration. But it’s never too early to read tea leaves. Who knows, some of these predictions might actually be right. Among those tea leaves:

Health care reform will be addressed sooner rather than later. The issue was too central to the President-elect Obama’s campaign to be put off for long. And there’s too much pent up demand for change to delay. Plus there’s a host of reform proposals already, or soon to be, in play. Some are plans bi-partisan, some are being offered by Congressional heavyweights like Senators Max Baucus and Ted Kennedy. All of these proposals have a lot in common, which means health care reform 2009-style will be off to a much better start than the Clinton Administration effort (fiasco?) in 1993.

Former Senator Tom Daschle will play a major role in fashioning health care reform. Although his nomination to be Secretary of Health and Human Services isn’t yet official, it’s received the controlled leak treatment that has presaged every other nomination. Senator Daschle has spent much of his time since losing his Senate seat in 2004 thinking and writing about health care reform.  That thinking has led him to argue, according to Time magazine, that health care reform is essential to dealing with the nation’s financial woes and that delay in implementing reforms is unacceptable.

As a Senior Fellow at the liberal Center for American Progress has described the current health care system as seriously broken. Writing in an undated statement on the Center’s site, Senator Dashcle claims “Efforts to reform our health care system have been undercut by myths that hide the weaknesses of our current system and overstate the challenges of reform. One myth is that the United States has the best health care system in the world. There is no doubt that some Americans have access to the best care anywhere, but not all care is excellent.”

He continued, “We need to move beyond ideology and partisanship and meet our common health care system challenges with commonsense answers to provide affordable, quality health care to everyone in this great nation. This is not a weak alternative; it is the only one.”

These statements summarized the findings in a white paper on health care reform entitled, “Paying More but Getting Less: Myths and the Global Case for U.S. Health Reform.” The reforms called for in the white paper overlap those advocated by candidate Obama during the campaign. One encouraging note: Senator Daschle spends considerable time in his analysis on the need to control health care costs. This means he should find an ally with the new Director of Office of Management and Budget, Peter Orszag.

Controlling costs will be central to Obama’s health care reform plan.Although it got fewer headlines than the debate over whether his proposal would lead to universal coverage or not, candidate Obama focused more than most of his opponents on the need to restrain skyrocketing medical costs. As a candidate, President-elect Obama’s proposals were, to put it kindly, somewhat general in scope. Yet he’s bringing on board people who clearly get the importance of this task. As noted, Senator Daschle is one. Incoming Director of the Office of Management and Budget, Peter Orszag is another. In his current job as Director of the Congressional Budget Office, Director Orszag has long called for a focus on controlling medical costs. At the CBO Director Orszag pushed for evidence based assessments of new technologies and expansion of research into the effectiveness of treatment. He also called for new incentives in order to change provider and consumer behavior. His move down Pennsylvania Avenue from Congress to the White House is unlikely to change this emphasis. And given the impact health care reform will have on the economy (and thus the nation’s budget) his will be a loud and attended-to voice in the debate.

Emanuel may have a lot to say, too. Incoming White House Chief of Staff Rahm Emanuel will no doubt weigh in on health care reform, but he’s not the Emanuel I’m referring to. The one to keep an eye on is his brother, Ezekiel Emanuel, currently Director of the Clinical Bioethics Department at the National Institute of Health. Dr. Emanuel is a strong advocate of a voucher system. His proposal has gained significant attention, if not support. But with his brother holding the door open it’s highly likely the doctor will have a voice in shaping the Administration’s health care reform plan.

Reforming America’s health care system won’t be easy. The need for comprehensive health care reform is widely shared across the political spectrum. And as the Los Angeles Times, recently reported, there’s a growing consensus supporting universal coverage that includes business, unions, doctors, hospitals and insurance companies. Yet sharing a goal is a far cry from agreeing on solutions. As history has shown, once details emerge, so do objections. I believe health care reform is coming, but there will be vigorous debate and substantial compromises along the way.

A Single Payer system will be part of the debate, but not the solution. Supporters of a single payer system have a nearly religious zeal for their approach. They speak in terms of the morality of covering everyone and throwing those earning profits from the health care system. A government-run system accessible to all and paid through taxes is the salvation they preach. Advocates of a single payer system will not go away and they have many supporters in Congress. Yet, their chance of success has not been this bleak in years. The consensus building in Washington focuses on an employer-centric system. While expanding government health insurance programs is explicitly supported, all the major proposals currently gaining traction implicitly reject a single payer system. There will be sound and fury around this approach, but as a solution, it’s a virtual non-starter. This doesn’t mean that what emerges from the coming health care reform debate isn’t dangerous to health insurance agents and others important to the current system. It just means the truck heading our way is not being driven by Michael Moore.

Change is coming. Stay tuned. For those who care about America’s health care system, 2009 will be a watershed year. Something is coming. It’s broad outlines are becoming more clear as the new year draws closer. But the system won’t be changed by generalities. It’s the specifics that matter. And it’s time that is required to shape those details into reforms that make the system better, not worse, for the effort. The opportunity for meaningful, positive reform has never been greater. While there are risks to current stakeholders, there’s a good chance they may emerge stronger from the process. What’s clear is that the process will take months, maybe even years, before the coming change arrives. And make no mistake, change is coming. No tea leaves are required for that prediction.