Health Care Reform 2009 Style

When it comes to health care reform 2009 has been an interesting year. And while comprehensive health care reform legislation will not be arriving on President Barack Obama’s desk this year, it is all but certain that will happen early in 2010. Getting to this penultimate moment has, to put it mildly, taken some doing. And the process says a lot about America and its leaders.

Health Care Reform Activity

President Obama had made clear throughout his campaign for the presidency that health care reform would be a top priority of his new administration. He lost no time making his promise real after his inauguration. Expansion of the State Children’s Health Insurance Plan, a proposal twice vetoed by then President George Bush, along with significant funding for medical technology, were a part of Administration’s economic stimulus package.

President Obama’s health care reform efforts took a serious blow in February when former Senate Majority Leader Tom Daschle was forced to withdraw his nomination as Secretary of Health and Human Services and as Director of the White House Office on Health Reform due to problems with his past tax returns. Senator Daschle is a political pragmatist who is highly regarded by lawmakers from both parties. Would the health care reform debate have been more civil had Senator Daschle led the White House reform effort? We’ll never know. What we do know is that civility quickly left the room as the House and Senate Committees with jurisdiction on the matter began their deliberations. The health care reform debate was passionate, raucous and partisan to the extreme. Neither party and no ideology is blameless for this descent into the dark side of politics. Both have benefited from it (although none as much as the 24 hour cable news channels) and both have sullied their standing with the public as a result.

Given what’s at stake when 1/6th of the nation’s economy is subjected to the legislative process, there may have been no avoiding an ugly health care reform debate. President Obama made clear in a speech in February that he wanted health care reform passed quickly. Many Republicans (and their talk show host allies) made it clear they’d rather see no health care reform rather than anything along the lines being proposed by – or that would politically benefit – President Obama. Meanwhile, the House Ways and Means, House Education and Labor and the Senate Health, Education, Labor and Pensions Committees pushed through liberal bills; anchors on the left in anticipation of the negotiations to follow. The resulting climate promoted intense partisanship.

Eventually more conservative Democrats forced the House Energy and Commerce Committee to slow done and moderate the legislation, although what they passed would still be considered “liberal” by most definitions.  All the House bills passed out of the committees without a single Republican vote. Meanwhile Senator Max Baucus was trying to fashion legislation that might gain the support of at least three GOP members of the Senate Finance Committee. (He would eventually manage to get the support of only one GOP Senator).

The difficulty of finding common ground between liberals and conservatives on health care reform was made abundantly clear during the summer of 2009. The disruption of lawmaker’s town hall meetings were reminiscent of the anti-Viet Nam War protests of the 1960’s. (I suppose it’s ironic that many of those shutting down the town hall meetings had participated in the anti-war protests more than 40 years earlier). The passion and concern of the health care reform protests were as sincere as some of the rhetoric and actions were unfortunate and despicable (death threats and swastikas are inherently contemptible and disgraceful). The protests did assure, however, that Republicans would remain united against the kind of reforms being pushed by the Administration.

Reform was being pushed by the White House even if the Administration was declining to define reform. Instead the White House broadly described the key elements they’d like to see in a reform bill. President Obama’s three core principles for health care reform called for reducing costs, guaranteeing choice and ensuring quality care for all. He would later add other conditions (e.g., reform could not add to the deficit), but the details of the bill were being hashed out in Congress by Democratic lawmakers. The result, much to the chagrin of liberals, was that over time the legislation became increasingly moderate culminating in the legislation passed out of the Senate Finance Committee with the support of only one Republican, Senator Olympia Snowe.

With all the committees of jurisdiction having staked out their positions it was time for Speaker Nancy Pelosi and Senate Majority Leader Harry Reid to pull together the pieces into bills that could pass their respective chambers. Speaker Pelosi succeeded first with the House passing a health care reform in November. The price of passage was high: liberals had to accept language dealing with abortions that sparked outrage in the pro-choice community.  It took the Senate more than a month to follow suit, but eventually they did. Now it’s up to a conference committee to pull the pieces together into one bill that can pass both the House and the Senate. Not an easy task, but with the finish line in sight it’s very doubtful lawmakers will falter now.

The Public Policy Dimension

While the activity swirling around health care reform has been … interesting, the evolution of the substance of the legislation has been even more fascinating. Not all that long ago liberal lawmakers were claiming a health care reform bill lacking a government-run health plan was no health care reform at all. They seemed to believe that a public health plan was the magic wand that would remake America’s health care system into something fair, competitive and wonderful. Or maybe they just thought the public option was a way station on the path to their promised land: a single payer system. While the House bill would create a new government health plan, the Senate legislation rejected the public option. While liberals outside of Congress continue to attack reform without a public option, liberals lawmakers seem to accept the inevitable. What emerges from the conference committee will no doubt lack a public option and liberal lawmakers will still support the reform package.

While liberals were losing a public option an unlikely coalition of conservatives and liberals were also watering down a requirement that all Americans purchase coverage. Conservatives dislike the idea as a restriction on the freedom of people to have their health care reform subsidized by higher health insurance premiums for everyone else. Liberals don’t like it because, apparently, the result is a windfall for evil health insurance companies. (OK, they offer more substantive public policy arguments against the individual mandate, but the rhetoric focuses on freedom and windfalls). Never mind that requiring health plans to sell coverage without requiring individuals to buy coverage before they incur claims is a recipe for higher insurance costs or that many states require drivers to buy auto insurance. As the legislation has moved through Congress the penalty for failing to purchase coverage has drifted toward a slap on the wrist end of the spectrum.

Other issues have taken interesting turns as well. Reimbursing doctors for counseling to seniors concerning living wills and the like was removed from the bill once the discussions were labeled “death panels.” What taxes will be imposed to pay for health care reform is still uncertain. Anti-abortion advocates have done a masterful job of inserting abortion into the debate. Both the House and Senate bills contained provisions that could “bend the cost curve” (which is apparently the new articulation of what was once called cost containment). If all the cost cutting provisions in the current bills were moved into separate legislation it would actually look like a serious effort. Mixed in with the health insurance reform dominating the current versions, however, the provisions appear weak and almost an afterthought.

Health Care Reform 2009: The Human Factor

So what to make of health care reform 2009 style?

First, that the legislative process is messy and can be downright uninspiring. Second, that tackling an issue as important and complicated as health care reform cannot overcome the need for partisans of both parties to put aside the public good for their political stratagems. Third, that the health care reform package that finally passes will be far more moderate than might have been apparent earlier this year. Fourth, criticism that Congress is moving too fast on reform are really complaints that Congress is not doing what critics leveling this charge want them to do. The health care reform bill that will find its way to President Obama’s desk in 2010 will be over a year in the making. Longer if you count the debate on health care held during the 2008 presidential election. Longer still if you include the previous health care reform efforts undertaken over the past several decades.

We elect politicians to hold office because they promise to address problems. No one has ever won a campaign on the promise to do nothing if elected. In 2008 Democrats won, and won handily, in part on a promise to solve the problems posed by America’s current health care system. They are fulfilling that promise. In the process they will create new problems.

Because the fact is we humans rarely solve problems. Instead we tend to replace existing problems with new ones. And if the 2009 health care reform process has taught us anything, it’s that the people who make up the Administration and Congress (and the general public) are only human. Anyone looking at the health care reform package emerging from Congress would find evidence of that reality.

Coming Soon: A Down Payment on Health Care Reform

The battle over the State Children’s Health Insurance Plan (SCHIP) was one of the most emotional battles of between Congress and the White House during the Bush Administration’s waining years. Twice, bi-partisan majorities of Congress passed the reauthorization legislation. Twice President George Bush vetoed the bill. Although the votes for an override were available in the Senate, it narrowly lost in the House. That’s now about to change. Congress is working hard to have a reauthorization of the State Children’s Health Insurance Plan (SCHIP) ready for the new president’s signature as soon as possible — it will be tough, but possibly even on inauguration day.

SCHIP provides health insurance for children in households that earn too much to qualify for Medicaid, but are unable to afford private coverage. States administer the program and, within federal guidelines, may adjust eligibility. They also pay a significant portion of the program’s cost. Currently, about six million children are covered in the popular program.

Congress twice voted to expand the SCHIP program in late 2007, but could not muster enough votes in the House of Representatives to overcome President George Bush’s vetoes. That was then. Now Democrats have stronger majoirites in both the House and Senate. Even more significantly, President-elect Barack Obama is a supporter of the expansion.

According to the Associated Press, discussions on how to approach the SCHIP reauthorization have been underway in Washington.  Although there was some thought of including SCHIP expansion in the forthcoming economic stimulus package, the decision seems to have been made to move forward with the stand-alone bill. While not promising to have the legislation ready for signature on inauguration day, House Speaker Nancy Pelosi promised “we’ll be done soon,” according to AP.

The first test for the SCHIP reauthorization will be in the House Energy and Commerce Committee. The Committee’s chair, Congressman Henry Waxman, called passing the legislation a “down payment on national health insurance.”

Passage of the SCHIP reauthorization would be more than a symbolic breaking with the past. The current recession is placing greater demands on safety net programs like SCHIP. In addition, states pay a significant portion of the coverage provided by SCHIP (from  17 percent to 35 percent depending on the state). Knowing where the program stands — and how much funding they can expect — is of critical importance to state lawmakers struggling with their own hemorrhaging budgets.

How Congress will pay for expanding the program still needs to be worked out. In 2007 the legislation included a 61-cent per pack tax on cigarettes. This was expected to allow the program to insure as many as 10 million children.

SCHIP is a critical component of the patchwork quilt that is America’s health care system. A majority of both Democrats and Republicans agreed it should have happened over a year ago. That it took a new Congress and a new President to get the job done demonstrates how hard achieving comprehensive and meaningful health care reform will be. But to use Congressman Waxman’s terminology, it’s a down payment well worth making.

State Children Health Insurance Program Problems Don’t Bode Well for Health Care Reform

Most of the health care reform packages likely to be considered by the Legislature during its current special session will include provisions to expand the State Children’s Health Insurance Program (SCHIP). SCHIP is known as Healthy Families in California. So the political drama unfolding in Washington concerning SCHIP is critical to the state. It also should serve as a warning, especially to those advocating a central role for the government in delivering health care.

Here’s where SCHIP currently stands: On September 25th the House of Representatives reauthorized SCHIP on a relatively bipartisan vote (45 Republicans voted for the bill; eight Democrats voted against it).  The legislation, H.R. 976, provides additional monies for the program and, most importantly, continues the program past it’s sunset date of September 30th — yes, as in this coming Sunday. The Senate will now consider the bill and is expected to pass it as written. This means no conference committee will be required, the measure simply goes to the President’s desk. So far, so good.

However, President George Bush has committed to vetoing the bill. One reason is the cost: the President wants to increase SCHIP spending by $5 billion over five years; Congress is seeking to increase spending by over $35 billion during this time-frame. More significantly, the White House objects to expanding eligibility for the program beyond it’s current income levels, arguing that doing so is “an incremental step toward the Democrats’ goal of a government-run health care system.” Even with Republican support, the House is unlikely to overturn the President’s veto. HR 976 passed with 265 votes in favor; it takes 290 votes to override the President.

The good news is that the SCHIP program is unlikely to end on September 30th. Congress will either tack on short term funding to an existing continuing resolution. If that doesn’t interim funding could be passed as stand-alone legislation. Then the battle for long-term continuation of the program will start-up again.

There’s more than a political soap opera going on here. What we’re also witnessing is a warning. When the government controls health care, it means health care is political. Decisions are not made to respond to market pressures or consumer demand, but to satisfy the politics of the moment. There likely will be an short-term extension of SCHIP. But then again, maybe not. Remember when President Bill Clinton and the then-Republican Congress shut down the federal government they reached a budget impasse?

2007 has provided advocates of government-run health care with lots of cautionary tales: the California budget stalemate; a California budget which slashes funding for mental illness programs and outreach for health programs like Healthy Families; and now the veto of SCHIP funding. There are problems with the current system, but I can’t help but believe that politicizing health care would only make things worse.