Kennedy Calls for Substantial Government Role in Health Care

In the United States Senate, two committees will play a leading role in drafting health care reform: the Finance Committee chaired by Senator Max Baucus; and the Health, Education, Labor and Pensions (often referred to as the HELP) Committee led by Senator Edward Kennedy. The two chairman have pledged to work together in order to bring one bill to the floor sometime this summer. In the meantime, the committee members are developing policy options, staking out positions, testing the political waters, and all the various other chores required to actually produce legislation.

The Senate Finance Committee has put forward three health care reform option papers. They describe choices the committee will need to make. One option, for example, is to create a government-run health plan to compete with private carriers. Another is to do without a public plan and count on the market to promote competition.

The Senate HELP committee has been taking a less formal approach, but it too has now begun putting its collective thoughts on paper. The Washington Post reports that Senator Kennedy is circulating an outline of the health care reform package his committee is likely to propose. The HELP Committee is traditionally more progressive than the Finance Committee (needing to focus on the cost of things does tend to bring out the pragmatist in most lawmakers) so it’s not surprising that the package, as the Washington Post puts it, “[i]n many respects adopts the most liberal approaches to health reform being discussed in Washington.”

Among other provisions, the Kennedy proposal  would create a government-run plan to compete with private carriers, require individuals to purchase coverage and employers to contribute to the coverage.  According to the Post, the HELP Committee will propose allowing Americans earning up to 500 percent of the federal poverty level ($110,250 for a family of four) to purchase Medicaid (although according to Bloomberg.com the package sets a floor of 150 percent of the federal poverty level for Medicaid eligibility — currently states can set their own financial level for their citizens to qualify for Medicaid).  Bloomberg.com also reports the committee’s proposal would expand eligibility for the State Children’s Health Insurance Program to “children” up to 26 years old.

Inclusion of the public plan will be especially controversial. Most Republicans and many moderate Democrats who have stated an opinion on the topic have said they could not support health care reform legislation that calls for creating a government-run health plan. The fear is that, by underpaying physicians, the plan will force doctors, hospitals and other medical providers to shift costs to the private plans. Since premiums reflect the underlying cost of medical care, the public plan would gain an unfair price advantage. The outcome, over time, would be private carriers would be forced from the market, leaving the public plan as the only option available.

The HELP Committee’s proposal will fuel this fear. Bloomberg.com writes that Kennedy’s proposal would allow the public plan to pay health care providers just 10 percent more than Medicare pays them — which would still be less than the actual costs medical professionals and hospitals incur in treating Medicare patients.

One of the more far reaching ideas Senator Kennedy is calling for are the creation of “gateways” to facilitate the purchase of affordable health insurance. These gateways might at first seem to be similar to the health insurance exchanges many in Congress are calling for, but they go further.  In an opinion piece published by the Boston Globe, Senator Kennedy writes he will seek to create “gateways to better health across America. You can contact the gateways online, by phone, or in person to figure out what policy works for you.”  Going even further, the “gateways would “negotiate with insurance companies to keep premiums and copays low and help you with your premiums if you can’t afford them.”  In this regard, the gateways seem to be a throwback to the Clinton Administration health care reform plan of the 1990s. Central to that effort was the concept of “managed competition” in which purchasing pools would negotiate the cost and coverage of health care available in a community.

While Senator Kennedy repeats the frequently cited mantra of “if you like your current coverage you can keep it,” the elements of his health care reform plan would all but guarantee that your current coverage won’t be around for long.

Health Care Reform is Coming, But it Won’t Be Easy

Personally, I think health care reform is inevitable. The need for change is simply too great. Too many people go without coverage, too many are insecure about the coverage they have. Controlling medical costs is a critical part of fixing the economy: businesses and state and local governments need relief. Political pressure for a solution — from across the ideological spectrum — has reached critical mass.

The reform process is well underway. President Barack Obama held a health care summit at the White House earlier this month. Several proposals are making the rounds. Senate Finance Committee Chair Max Baucus has one.  Senate Health, Education, Labor and Pensions Committee Chair Ted Kennedy and his staff have been actively meeting with stakeholders. Democratic Senator Ron Wyden and Republican Senator Bob Bennett have introduced the Health Americans Act, which is supported by several colleagues from both sides of the aisle. There’s the proposal put forward by President Obama during the campaign and embellished somewhat since his inauguration. Republicans have their plans and think tanks have theirs.

We’ve seen this before. In 1993 it looked like President Bill Clinton’s spent enormous political capital seeking health care reform. He failed. A recent Newsweek article by Katie Connolly outlined several reasons why the health care reform debate now is likely to be much different than the battles in 1993. The Clinton Administration failed in large part because their efforts were politically inept and inflexible. President Obama’s approach is much more open, inclusive and savvy.

Of course, at this stage we’re still dealing with generalities. The specifics, which is where the devil receives his mail, have yet to emerge.  When they do the hard part of the process begins. And that could be any week now.   The Washington Post’s Lori Montgomery and Ceci Connolly reported today that “House Democrats, in consultation with the White House, will give Republican lawmakers until September to reach a compromise on president Obama’s signature health-care initiative ….”  Currently, several committees in both houses of Congress are holding hearings on health care reform. These, however, are more educational in nature, allowing interested parties to provide input and begin staking out positions. With little legislation before them the hard negotiations have yet to begin. Those discussions will have to start sooner than later if Congress is to meet the House Leadership’s September deadline. Given the complexity of health care reform it will require months of negotiations to find common ground. 

Finding that common ground won’t be easy. Already Republican Leaders are identifying deal killers. A National Association of Health Underwriters’ newsletter quotes Senator Chuck Grassley, the ranking Republican on the Senate Finance Committee as identifying the Obama Administration’s call for a national health coverage exchange to compete with the private market as extremely problematic. The GOP won’t accept such a program, according to Senator Grassley, and Democrats are likely to insist on one. There may be a way to create an exchange that satisfies both parties, but that requires a lot more specifics than have emerged yet. 

(Note added 3/20/09 at 7:45 pm: the rift between Senator Grassley’s position and those favoring a government insurance plan is growing wider — and nastier. Carrie Budoff Brown, writing in Politico today, reports on “a four-day ad buy aimed at Iowa Sen. Charles Grassley, the ranking Republican on the Senate Finance Committee who is increasingly vocal in his opposition to the government insurance option.” Health Care for America Now is leading the charge against Senator Grassley. At the White House Forum on Health Care the ranking Republican on the Senate Finance Committee told President Obama that such exchanges were “‘an unfair competitor’ and could run private insurers out of business,” according to the Politico story. The article also notes that Senator Wyden found no Republican Senators willing support his bipartisan legislation if it included a government run health plan. “From a raw political standpoint, having talked to a lot of senators, I wouldn’t have any Republicans on the Health Americans Act as cosponsors if we had a public option,” he told Politico.)

There is a way for Democrats to pass health care reform without Republican votes. If a compromise fails to emerge by September, the House Leadership is pushing for a legislative process that would allow passage with simple majorities in both chambers. This would be accomplished through a process called “budget reconciliation.” Under the reconciliation rules, filibusters are not permitted enabling the Senate to move legislation forward with a simple majority of 51 votes instead of the 60 needed to end a filibuster. Democrats currently hold 58 seats in the Senate (including those of two independents who caucus with them) with one more likely to arrive from Minnesota. (Filibusters don’t exist in the House, making passage by majority vote the norm in that chamber).

But Democrats may have a tough time pulling together even 51 votes in the Senate. Senator Evan Bayh announced on MSNBC on Wednesdaythat 16 moderates in the Senate (15 Democrats and one independent who caucuses with the party) have come together to provide a united, centrist voice to issues such as health care reform. As noted in the press release announcing the group’s formation, their goal is “to pursue pragmatic, fiscally sustainable policies across a range of issues, such as deficit containment, health care reform …” and others. With 16 members, this caucus, currently dubbed the “Moderate Dems Working Group” represents more than a quarter of the Democrats serving in the Senate. If even 10 0f these centrists stick together they’ll need to be a part of any deal struck on health care reform.  (A list of the 16 Senators in the group is below).

At the same time there are liberals in Congress who would just assume have government take over the health insurance industry and create a single payer system similar to that in place in Canada and many Western European countries. At the very least they look to a greater role for the government in providing health care coverage to middle class Americans (the government is already the primary insurer for older and low income citizens).  They won’t go quietly along with a solution they feel fails to assure universal and comprehensive  coverage.

What this means is that while health care reform is coming, getting there won’t be easy. But there is a way. President Obama has long talked of the need to focus on core principles and the desired outcome instead of on how we get there. He has even said that his campaign proposal for a federal health insurance exchange (the deal breaker identified by Senator Grassley) is negotiable. As noted in the Newsweek article, the president said at  the White House summit, “If all Americans could be insured at ‘an affordable rate and have choice of doctor, have flexibility in terms of their plans, and do that entirely through market, I’d be happy to do it that way.'”

This is the approach all lawmakers and interest groups — whether liberal, moderate and conservative — need to bring to the table. The health care reform debate will be heated, passionate and difficult. But if all participants focus on the goals, the means of getting there can be found.  Given the need, it better be.

***************

The 16 members of the Moderate Dems Working Group (who, hopefully, will work on coming up with a better name) are:

  • Evan Bayh (Indiana) – co-chair
  • Mark Begich (Alaska)
  • Michael Bennet (Colorado)
  • Tom Carper (Delaware) – co-chiar and a member of the Senate Finance Committee*
  • Kay Hagan (North Carolina) — a member of the Senate H.E.L.P. Committee*
  • Herb Kohl (Wisconsin)
  • Mary Landrieu (Louisiana)
  • Joe Lieberman (Connecticut)
  • Blanche Lincoln (Arkansas) – co-chair and a member of the Senate Finance Committee*
  • Clare McCaskill (Missouri)
  • Ben Nelson (Nebraska)
  • Bill Nelson (Florida) — a member of the Senate Finance Committee*
  • Mark Pryor (Arkansas)
  • Jeanne Shaheen (New Hampshire)
  • Mark Udall (Colorado)
  • Mark Warner (Virginia)

* The Senate Finance Committee and the Senate Health, Education, Labor, and Pensions (H.E.L.P.) Committee have primary jurisdiction over health care reform legislation.

National Health Care Reform: Later Than Sooner?

Whether comprehensive health care reform is needed is no longer debated on Capitol Hill. The only question is when it’s coming. I’m among those who have been predicting that the Obama Administration and Congress will move quickly to enact comprehensive health care reform. I’m far from alone in this: incoming Secretary of Health and Human Services Tom Daschle thinks so, too. In fact, so does incoming President Barack Obama. Throw in several leaders in the U.S. Senate, including Senators Ted Kennedy and Max Baucus and you’ve got a growing conventional that universal coverage will be coming sooner or later.

But this consensus is not universal. Representative Pete Stark will have a big say on health care reform as chair of the Health Subcommittee of the Ways and Means Committee. And, according to The Hill, he’s saying Congress is unlikely to be ready for a vote on health care reform until “the end of 2009 or the beginning of 2010.”  The problem, according to Rep. Stark, is that there are simply too many competing priorities, including the economy, to get to comprehensive reform. This doesn’t mean less grand reforms won’t happen early in the new Administration (e.g., expansion of the State Children’s Health Insurance Program (“SCHIP”)), but even those could cause a delay in working through a major reform package, according to Rep. Stark.

Rep. Stark, a California Democrat who has served in Congress for 35 years, encourages a deliberate approach to comprehensive reform. According to The Hill he believes the House “needs to build toward health reform through the regular order. ‘I think you have to give everybody a chance to have a hearing,” including interest groups. Of note, Rep. stark pointed out the need to hear from the American Medical Association, the American Hospital Association and the Pharmaceutical Research and Manufacturers of America. He dismissed the need for the health insurance industry to buy-in to the reforms, however. Predicting they would never support a Democratic health care reform package, Rep. Stark said the industry’s opposition won’t change much. “They’re going to be easy to roll because nobody likes insurance companies.”

Rep. Stark is not the only voice suggesting health care reform will take some time. Senator Charles Schumer, who sits on the Finance Committee, in April told The Hill, “Health care I feel strongly about, but I am not sure that we’re ready for a major national health care plan.”

While there is broad consensus that reform is needed, the debate will grow contentious as details of a plan emerge. Current allies may find themselves on opposite sides when the nitty meets the gritty. Or as Michael Cannon of the Cato Institute put it in USA Today, the interest groups “all want to be at the table because they don’t want to be on the menu. Sooner or later, someone is going to be on the menu. You can’t do comprehensive reform without goring someone’s ox.”

Beneath all the flying metaphors is the realization that achieving comprehensive health care reform won’t be easy. It’s also vitally important. The Obama Administration and Congress should take the time needed to get it right. Because there are no do overs when you’re tinkering with 16 percent of the nation’s economy in the middle of a recession.

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.

Baucus Health Care Reform Plan an Interesting Start

Comprehensive national health care reform is coming. The only question is when and what wil it look like. There will be many reform plans put forward during this process. Some will have more substance than others. Some will be more credible than others. Some may even be practical. And a few might make America’s health care system better, not worse, than it is today.

One thing we know pretty much for certain is that a true single payer system is not coming any time soon. President-elect Barack Obama made comprehensive health care reform a central theme to his campaign. it clear throughout his campaign that he saw an important role for the private sector in the country’s future health care system. The Democratic National Platform made this approach explicit. (Irrelevant factoid: this post could well be the one and only time you ever read anyone referring to a party platform — until 2012).

What’s less certain is whether health care reform will be taken up by the Obama White House and/or Congress in the first few months of the new Administration. There are certainly a lot of influential lawmakers seeking to make health care reform an initial priority, including Senator Max Baucus, Chair of the Senate Finance Committee, and Senator Ted Kennedy, Chair of the Senate’s Health, Education, Labor and Pensions Committee. There’s more already entered in this particular derby and many more to come.

Senator Baucus’ health care reform plan is interesting for several reasons. First, any reform package will need to pass through his Finance Committee. Whether it’s his bill or another’s, Senator Baucus will have the ability to influence the final package. Understanding his starting point, consequently, takes on special significance.

Second, Senator Baucus’ plan, which he notes is not intended to be a legislative proposal, but rather a blueprint describing his vision for health care reform, devotes considerable attention to the need to reduce the underlying cost of medical care at great length. Even his discussion of wellness, preventive care, transparency, and reducing waste — standard components of any credible reform plan — goes well beyond the normal discussion. Most significantly, he goes beyond the low hanging fruit to address more controversial approaches. For example, he calls for financial incentives for primary care providers in the Medicare system and suggests funding them by reducing payments to specialists. He also endorses using medicare to test other primary care models especially those that “promote comprehensive care management and coordination, particularly for the chronically ill.”

Third, while the market reforms included in Senator Baucus’ plan should be no surprise to anyone who listened to Senator Obama during the presidential campaign, it does provide more specificity than was offered during the election. So while it contains the expected laundry list of proposals (tax credits, guarantee issue, etc.) it’s the additional details he provides that are significant.

For example, most insurance agents who read this blog will want to know what role, if any, they will have in the government-run Health Insurance Exchange Senator Baucus would create to compete with private sector offerings. A hint is all he provides, but it’s an encouraging one. In the discussion of the proposed purchasing pool, the document states “Plans participating in the Exchange would be subject to oversight by states with regard to consumer protections (e.g., grievance procedures, external review, oversight of agent practices and training, market conduct). ” italics added.

States are to regulate agent practices in connection with the pool. That must mean Senator Baucus envisions some role for agents in connection with the pool. As noted, it’s only a hint, but it’s a welcome one.

During the debate over Assembly Bill X1-1 earlier this year, carriers and agents were able to insert language in the legislation to allow, but not require, agents to sell products offered through the purchasing pool it would have created. Whether agents can educate lawmakers at the national level that the services we provide are worth including and protecting in whatever reforms eventually emerge will be challenging. But it appears Senator Baucus, at least, is open to the idea. And the experience agents have gained in California and elsewhere should aid in this effort.

No one, not even Senator Baucus, assumes his blueprint will be adopted as is. There will be a long and contentious health care reform debate before any kind of consensus emerges. Senator Baucus’ proposal is an important contribution to the stew of ideas that is simmering in the nation’s Capital. It’s an interesting start. But only a start.

Health Care Reform Bills: Coming Soon to a Nation’s Capital Near You

President-elect Barack Obama won’t take the oath of office for more than two months, but the drive for health care reform is about to get under way. Senate Health, Education, Labor and Pensions Committee Chair Ted Kennedy has been working from his home, where he’s fighting brain cancer, seeking to pull together a consensus bill. Meanwhile, Senator Max Baucus, Chair of the Senate Finance Committee introduced his health care reform plan today.

Senator Baucus’ Finance Committee and Senator Kennedy’s Health, Education, Labor and Pensions Committee share jurisdiction over this issue. According to Politico, the staffs of the two committees have been meeting with stakeholders since the summer and the two committee chairs have been in contact. The details of Senator Kennedy’s plan have not yet been released.

Senator Baucus’ health care reform plan contains several elements that align with the reforms President-elect Obama called for during the campaign. These include the creation of government-run “exchanges” to allow Americans to shop for coverage from multiple carriers and a requirement that carriers accept all applicants regardless of pre-existing health problems. Significantly, Senator Baucus goes a step further and would require all Americans to purchase coverage “once affordable options are available.”

Requiring everyone to purchase coverage was a contentious issue during President-elect Obama’s hotly contested primary fight against Senator Hillary Clinton. She was for a mandate to buy; he opposed it. As has been previously noted, a requirement to sell insurance without a requirement to buy results in higher premiums. Senator Baucus apparently agrees noting that the uninsured incur medical costs that are then shifted to those with insurance. By bringing everyone into the system, Senator Baucus believes the average cost of insuring each American will be reduced. By including an alternative for those who cannot afford coverage he avoids one of the most vociferous objections to requiring consumers to buy coverage.

Senator Baucus’ health care reform plan would also allow those between the ages of 55-and-64 to purchase Medicare if they lack access to public insurance programs or a group health plan. According to the New York Times, four million people in this age group are currently uninsured. He would expand the State Children’s Health Insurance Program to include children in families at or below 250 percent of the federal poverty level ($44,000 for a family of three) and he would lift the ban preventing legal immigrants to enroll in SCHIP until they’ve been in the country for five years. Like President-elect Obama, Senator Baucus supports tax credits for small businesses that provide health insurance coverage and for individuals and families, below 400 percent of the federal poverty level, who purchase their own coverage.

We haven’t heard from the Republican side of the aisle on this issue yet, but it shouldn’t be long now. There proposals will likely be more market oriented and less far reaching.

The key question is whether lawmakers in Washington have the bandwidth to fashion a comprehensive health care plan while simultaneously dealing with a crashing economy, a host of international issues and energy policy. Personally I think they’ll make the time. Health care reform is too entwined with people’s sense of financial and is too much a part of the economy to be put off. As I’ve written before, if health care reform is positioned not as a cost item, but as in investment in the nation’s infrastructure, it becomes very compatible with other economic stimulus efforts.

On the other hand, it is interesting that Senator Baucus, the Chair of the Senate Finance Committee, has apparently left out the funding mechanism for his reform package. That in itself is a telling reminder of how difficult achieving meaningful reform in today’s economic climate will be. That it is difficult, however, does not mean it’s impossible.

Note: I haven’t been able to find

President Obama and Health Care Reform Expectations

Senator Barack Obama remains a Senator for another 77 days. Then he becomes President of the United States. His is a remarkable story heightened by his ability to both symoblize and articulate hope. The challenges he will face upon assuming office are daunting, to say the least. Then there’s the expectations.

Every political campaign is about expectations. Candidates make promises because voters want to know what to expect. Democrats and Republicans, Mavericks and Insiders, they all make promises, which means they all create expectations. In this election, both candidates raised expectations that the nation’s “broken health care system” would, at least, be fixed.

I believe there will be comprehensive national health care reform in the next four years. There’s clearly pent-up demand in Congress for change. A bi-partisan group of Senators led by Democratic Senator Ron Wyden and Republican Senator Bob Bennett already have introduced a comprehensive health care reform package, the “Healthy Americans Act.” Senator Edward Kennedy is looking to cap his historic tenure in Congress with health care reform. While battling brain cancer he and his aides have been meeting (both personally and by video conference) lawmakers and advocacy groups to create a framework for health care reform. Many in Washington believe that the Clinton Administration squandered a unique opportunity for reforms that would have greatly benefited the nation over the past 14 years. They do not intend to let another chance go by.

Health Access outlined several reasons for progressives to be optimistic that meaningful reform is coming from Washington, D.C. They note the starring role health care reform played in Senator Obama’s campaign and the Obama/Biden ticket’s endorsement of Health Care for America Now!’s principles. They point out Senator Obama’s resounding victory will give him the political muscle, and his campaign theme and image gives him the credibility, to push through meaningful reforms.

I believe Health Access’ analysis is correct. There’s another reason health care reform is likely: the Obama Administration will take a far different approach than that taken by the Clinton Administration in 1993. They’ll learn from President Clinton’s mistakes. They’ll be far more inclusive and more accepting of input from Congress. They’ll be more willing to compromise on specifics to achieve their principles.  President Obama will bring to health care reform the same superb organization and discipline he brought to his campaign. All of this bodes well for some kind of significant reform coming out of Washington in the next four years.

The Obama Administration will face two challenges in fulfilling the health care reform expectations. First is the complex nature of the problem. A great deal of the upcoming debate will be spent on market reforms (should insurers be required to sell coverage to all applicants?) and access (should all Americans be required to have health care coverage?). These questions alone have brought down many a reform proposal. Yet they’re the relatively easy challenges. Too little attention will be spent on the most vexing problem facing every health care system in the world: the skyrocketing cost of medical care.

Someone has to pay for health care and there are only three sources: taxes, premiums or charity (some people pick up the tab for other people). Medical care inflation historically outpaces general inflation and there’s no reason to believe that will change. Which means it’s only a matter of time before the burden of paying for care crushes every and all of those sources.

This isn’t news. Last year the Henrey J. Kaiser Family Foundation released a study, Health Care Costs: A Primer, that put the discrepancy between inflation rates in perspective. There have been sporadic attempts in Washington to draw attention to the cost issue. In November 2007 the Congressional Budget Office identified the need for policy makers to focus on restraining health care costs. There are a lot of suggestions for controlling medical cost problem floating around. Few of them are easy to implement, especially since numerous interest groups will work hard to defend their current share of the health care dollar. And in the end, for better or worse, health care reform comes down to dollars.

Which leads to the second problem facing President Obama’s health care reform efforts. The nation’s economic house is in disorder. Can the nation afford expensive health care reform during a time of financial crisis?

Well, it depends. If health care reform is viewed as a line item expense on the government’s ledger, the answer is no. Even a liberal Congress is going to be hesitant to run up ever greater deficits by increasing government spending. And it’s not yet clear this Congress will be more liberal than the last. After all, a lot of its newer members came from relatively conservative districts or states. Especially when it comes to budget matters like deficits and taxes, the new Congress may have swing toward the middle.

But spending money on the health care system need not be viewed as a simple expense. By repositioning health care reform as part of a public works-like stimulus package the huge costs involved may be more palatable to the public and fiscal hawks in Washington. President-elect Obama has already declared his desire to increase spending on the nation’s infrastructure in order to create jobs and bolster the economy. Infrastructure is usually defined as roads, bridges and buildings. That doesn’t mean the definition can’t be expanded to encompass the health of its work force. In this context, health care reform is not a cost, it’s an investment.

President-elect Obama has promised voters health care reform during his first term. Upon taking office, however, he’ll face wars abroad and economic crisis at home. Dealing with the latter does not require him to ignore the former issue. By positioning health care reform as part of his plan to rebuild America, he might actually be able to fulfill the great expectations he’s created.

Yes It’s the Economy, But It’s Health Care Reform, Too

In 1992, James Carville wrote down the key messages then Governor Bill Clinton’s campaign had to focus on in order to win.

  1. Change versus more of the same
  2. The economy, stupid
  3. Don’t forget health care

Throw in a cup of national security and you’ve got the same recipe for presidential success in 2008. Anyone listening to a speech by Senator John McCain or Senator Barack Obama will appreciate that their campaigns understand this reality. And given the recent credit crisis and financial maelstrom, the economy has become an even more central part of this election. In interpreting the public’s demand for change, however, the dominant position of economic issues should not hide the fact that voters want health care reform, too.

According to the October Kaiser Health Tracking Poll, no surprise here, the economy is overwhelmingly, the most dominant issue in this year’s campaign. 62 percent of the survey’s respondent’s listed the economy as “the single most important issue in [their] vote for president.” 13 percent of the respondents cited Iraq while 12 percent named health care.

Economic concerns emerged as the key issue long before the current financial crisis, however. In the December 2007 poll, Iraq was the top issue, with 30 percent of the respondents listing it as the most important issue. It was followed by the economy at 23 percent and health care at 21 percent.

In February 2008, the economy had moved into first place, having been named by 43 percent of respondents. The percentage name Iraq and health care as the most important issues remained constant at 29% and 21 percent, respectively.

By August 2008 49 percent of respondents were citing the economy as their top issue while Irag had dropped to 25 percent and health care to 16 percent. The Kaiser survey interviewed “likely voters” by phone between October 8th and October 13th, well after the economic crisis had set in, making the big change in the results understandable.

One might conclude from this that health care reform is moving off the public’s radar as a salient issue. That would be a mistake. The Kaiser survey shows that 75 percent of Democrats and 61 percent of independents believe “it is more important than ever to take on healthcare reform.” Even 42 percent of Republicans agreed with this statement. What it shows is that health care reform and economic security are intertwined and inseparabe. A key aspect of “fixing” the economy will involve “fixing” health care.

According to the Kaiser study, 35 percent of respondents themselves or a family member had put off getting health care they needed because of the economy. 31 percent said they skipped recommended medical tests or treatment and 27 percent said they didn’t fill a prescription. 28 percent of the respondents reported they had problems paying for health care and health insurance as a result of recent changes in the economy.

Restoring consumer confidence is a substantial part of recovering from economic set backs. So it is significant that half of the respondents (51 percent) said that “lower prices for health care and insurance would make a big difference in their family’s financial situation.” That’s more than the 45 percent who said a rebound in the stock market would make a big difference in their situation.

Senator Obama has cited health care reform as one of the top three issues he’ll address as president. There are numerous plans already circulating in Congress to jump start the reform process, including a bipartisan health care reform package backed by 12 Senators, six from each party. Senator Ted Kennedy, who is at home battling brain cancer, is talking with lobbyists, policy mavens and lawmakers from both parties to develop a framework for health care reform for the new president. Senator Kennedy intends to introduce his legislation as soon as the new Congress convenes.

So yes, the economy will be the dominant issue between now and election day. And it will dominate the president-elect’s wait to move into the White House and it will dominate his first months — perhaps his first term — in the oval office. The economy will dominate, but it won’t eliminate other issues. The American people expect health care reform to be among those other issues — and it will be.

What may surprise some is how quickly the health care reform effort will get underway. My guess is the new president will give a major address on the issue before inauguration day. Health care reform is simply too tied to the reality and perception of Americans’ economic security. It’s too important to Senator Kennedy. It’s too important to helping businesses recover and grow. The American people want the new president to address health care reform. And the new president will need to.