Washington Health Policy Week in Review

Washington Health Policy Week in Review is a weekly newsletter that offers selected stories from the daily newsletter CQ HealthBeat.

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Hope Still Alive for Comprehensive Health Care Overhaul, Democratic Aides Claim

By John Reichard, CQ HealthBeat Editor

Feb. 9, 2010 -- Democratic health aides asserted at a Washington conference Tuesday that they remain hopeful that Congress will still pass a comprehensive overhaul of the health care system this year, with Wendell Primus, senior health aide to Speaker Nancy Pelosi, D-Calif., saying approval could be completed by "close to the Easter recess."

But two Democratic aides implicitly acknowledged that their expressions of optimism are not widely shared in the current political climate. They described themselves as playing the "role" of optimists on a panel that at times came close to describing the health care overhaul effort in the past tense.

The aides spoke at a conference sponsored by the health policy magazine Health Affairs and the health services research organization AcademyHealth. All but one of the aides requested anonymity in order to be able to speak more candidly.

"I do think that there is still the possibility that Congress can move on health care reform this year," a top Democratic health policy aide on the Senate Finance Committee said. "It will take both the House and Senate pulling together."

Senate Finance Committee Chairman Max Baucus, D-Mont., issued a statement later in the day reiterating that an overhaul must be completed this year. "Over the past 10 years, health insurance premiums have doubled while wages for middle-class workers have remained flat," he said. "That's no coincidence — every dollar a business spends on insurance premiums is a dollar that cannot be used for wages or hiring. Passing health care reform will help boost our economy, create jobs and lift the burden of higher costs off American families, businesses and the federal budget, which is why we must pass reform this year."

The predominant view among the aides seemed to be that the only way a comprehensive overhaul would occur would be through use of the controversial budget reconciliation process that would allow overhaul legislation to move through the Senate with 50 votes and an "aye" vote by Vice President Joseph R. Biden Jr. But Republicans may have the power to offer amendment after amendment to stymie the effort.

"I don't think comprehensive health care is done by any means," Primus said. He quoted his boss as saying that if the fence is too high "we're going to pole vault in or if it's way, way, too high we're gonna parachute in." It's "quite rare" in the legislative process to get both House and Senate passage and then the legislation fails, he added.

But Primus outlined a complex process that would be required to get the legislation through using reconciliation. The House would have to pass some fixes to the Senate bill (HR 3590) that, when taken up by the Senate, would entail the use of reconciliation, he said.

These would have to include changes to Senate provisions taxing health plans with "Cadillac" benefits; increasing "affordability credits" to increase subsidies for buying coverage; "fixing the Ben Nelson fix" that would give Nebraska alone full federal coverage of Medicaid expansion costs; and closing the gap in Medicare prescription drug coverage known as the doughnut hole.

"We could have a pre-negotiated package [of fixes to the Senate bill], much like a conference report," he said. "The House would have to take that up first because it would involve revenue changes and then the Senate would pass it." With the conclusion of that legislation, "the House only then would take up the Senate health bill [HR 3590] and pass it. The trick in all of this is that the president would have to sign the Senate bill first and then the reconciliation bill would be signed second and the parts of the reconciliation bill would trump the relevant portions of the first-signed bill." That, along with "maybe a few tricks in the drafting process," would allow a big overhaul to occur.

A Senate GOP health aide noted polls showing the unpopularity of Democratic overhaul efforts and said Democrats misread the lessons of the failed 1993-94 health care overhaul effort. Democrats thought they needed to get legislation done quickly and to let Congress rather than the White House write the bill. But the aide said other lessons should have been drawn and heeded from the earlier effort.

One was that a comprehensive overhaul is too large and too worrisome given the possibility of unintended consequences and unexpectedly high costs. Another is that an overhaul must be bipartisan. He quoted the late Democratic Sen. Daniel Patrick Moynihan as saying "Never pass major legislation that affects most Americans without real bipartisan support. It opens the door to all kinds of political trouble."

The aide said there is common ground on such issues as bundling payments to increasing efficiency of care, spurring provider teamwork through "accountable care organizations," tax credits to help the chronically ill pay for health coverage, and ending exclusions from coverage based on pre-existing medical conditions.

A House GOP aide suggested that Congress would yet pass scaled-back health care legislation. "I don't think it's that people don't know what's in it" and can be brought around to a big overhaul by educating them about its provisions, the aide said, it's that they don't like what's in it. The 85 percent of the public with coverage wonder "what's in it for me" and their concerns differ from those without coverage, he added. Republicans do in fact have alternative legislation (HR 4038) that would widely lower premiums even though it only would cover 3 million people, he said, citing a Congressional Budget Office estimate.

A House Democratic aide objected to complaints that Democratic legislation does not do enough to control costs. There are "tremendous delivery system reforms" in both the House (HR 3962) and Senate Democratic bills, the aide said. "We really can't do more until and unless more people are covered and some of the other building blocks from the bills are in place," the aide later explained.

Political opponents of the overhaul and "defenders of the status quo" decided it was best to "demagogue" the effort, the aide said. But "where there's a will there's a way and there is a way — so hopefully there is a will."
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