Congressional leaders continue to advance plans for a major health care
system overhaul next year, although many of the features remain undefined.
Congressional Democrats—especially in the Senate—have increased
their push since the election for a major expansion in health care access. The
stepped-up effort comes as President-elect Barack Obama has largely held back
from discussing his own health care plans, devoting most of his public
statements to the country's worsening financial crisis.
"There is no way to fix the economic crisis without fixing the health
care system," said Sen. Max Baucus (D-Mont.) last month at a press
conference where he outlined his approach to overhaul health care. His health
care proposals have been closely watched because Baucus chairs the Senate
Finance Committee, which has jurisdiction over Medicare and Medicaid.
A key feature of Baucus' plan would allow those who already have health
insurance through their employers to keep their coverage but would add a
nationwide insurance exchange for those who are unable to get coverage or who
have lost their insurance. The insurance exchange would be a centralized
registry of nationally available insurance plans that meet minimum coverage
guidelines, provide affordable options, and do not bar coverage for people
with preexisting conditions. The exchange plans would be available to any
American who needed insurance. Other aspects of the Baucus plan would permit
Americans aged 55 to 64 to "buy in" to Medicare coverage and would
broaden Medicaid so that it was available to all Americans living below the
federal poverty level.
The Baucus plan also would encourage collaborative care among health
professionals and make changes to Medicare's physician payment system. The
sustainable growth rate formula would be replaced with a system based on
quality of care provided. Although many of the details of such a quality-based
approach were not spelled out, the Baucus plan would create new systems for
tracking and rewarding positive patient outcomes and add more quality-of-care
Among the more controversial features in the Baucus plan is the source of
some of the funding for what will be a costly reform. Baucus said financial
assistance to encourage more medical students to become primary care
physicians—another facet of his plan—will likely come from cuts in
federal reimbursements to specialty physicians, mainly within Medicare.
Another feature likely to generate controversy is a potential requirement
that all Americans either obtain private coverage or sign up for
government-assisted health insurance.
"This step is necessary for insurance-market reforms to function
properly and to end the cost shifting that occurs within the system,"
Among the people for whom the mandated coverage approach is likely to be
controversial is Obama, who strongly opposed a similar mandate proposed by his
primary campaign opponent, Sen. Hillary Rodham Clinton (D-N.Y.).
The expectation of many congressional observers and health care advocates
that the Senate will take the lead on health care reform—reversing its
role as the place where the 1993 health care debate ended—is also based
on the efforts of Sen. Edward Kennedy (D-Mass.).
Kennedy's staff has been holding meetings since the summer on the health
care expansions that are most-needed and most likely to succeed early in an
Obama administration. Although details of Kennedy's approach haven't been made
public, he signaled his commitment to the issue by identifying senators who
would help him advance legislation early in 2009.
"I will also continue to lay the ground work for early action by
Congress on health reform when President Obama takes office in January,"
Kennedy said in a written statement after returning to Congress in
mid-November. "We've been making real progress in our discussions about
a consensus approach, and I'm optimistic we'll succeed."
That consensus approach will require the support of at least some Senate
Republicans, several of whom also have highlighted health reform as overdue.
Sen. Mike Enzi (R-Wyo.), for example, has repeatedly called for full insurance
for "every single low-income child who needs insurance" through
future legislation to reauthorize the State Children's Health Insurance
Program, an idea that was rejected by President George W. Bush as an
overextension of the program.
The efforts of Senate Democrats to lay the groundwork for early action and
to involve Republicans aim to avoid traps that doomed the 1993 overhaul effort
led by former President Bill Clinton. His health-reform team debated the plan
in private and handed Congress a complex, fully crafted plan with little room
for negotiation. That approach quickly fell apart as interest groups fought
against provisions that conflicted with their goals.
The House of Representatives is expected to take a lower-profile role in
health care reform, in part because of Rep. John Dingell's (D-Mich.) loss of
the chair of a key committee to Rep. Henry Waxman (D-Calif.). Dingell has
introduced universal health care legislation every year since he took office
and calls universal access the defining goal of his career.
Waxman has a strong interest in health care, but it may be the Democrats'
large majority in the House that will help them pass any type of health care
access expansion on which they can agree.
One potential hurdle for any health care overhaul is funding concerns
raised by so-called Blue Dog conservative Democrats. This voting block gained
members after the November election, and its leaders have insisted that any
new spending be offset by cuts elsewhere or tax increases.
Baucus, Kennedy, and other congressional leaders have answered some calls
for financial restraint by touting an expansion in access to health care as a
key step to addressing the ongoing financial downturn by controlling cost
increases in health care, which for years have far exceeded inflation. It's an
approach echoed by many health care reform advocates.
"As the economy worsens, and growing numbers of businesses and
families are unable to pay fast-rising health care costs, it is essential that
we move expeditiously to enact health care reform," said Ron Pollack,
executive director of Families USA (see Enrollment Spike Pressures Medicaid's
The Baucus plan, "Call to Action: Health Reform 2009,"
is posted at<http://finance.senate.gov/healthreform2009/home.html>.▪