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September 14, 2009

Washington Health Policy Week in Review Archive 9238a8c5-acfe-429d-9530-f3a2ab5887e8

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Percentage of Uninsured Children Declines, But Adults on an Upswing

By Jane Norman, CQ HealthBeat Associate Editor

September 10, 2009 -- The percentage of children lacking health insurance declined in 2008 due to increasing enrollment in public programs and hit its lowest rate since comparable data first was collected in 1987, the U.S. Census Bureau reported in estimates released Thursday.

Health experts said the new estimates show the importance of both Medicaid and the Children's Health Insurance Program (CHIP), which recently was reauthorized by Congress and expanded. Both the Department of Health and Human Services and state agencies have pushed to enroll additional eligible children in CHIP.

However, the relatively good news about children was offset by the estimates for adults. The number of Americans of all ages without insurance rose from 45.7 million in 2007 to 46.2 million in 2008, the census said. While the percentage of uninsured remained statistically the same in 2007 and 2008, at about 15.4 percent, President Obama and advocacy groups said the new statistics demonstrate again the need for change in the health care system.

About 20 percent of adults age 18 to 64 were without insurance in 2008, and the number who received group insurance provided by their employers plunged by about 1 million, continuing a long-term trend over the past decade. While 62 percent of Americans had employment-based coverage in 1987, 58.5 percent reported such coverage in 2008.

Enrollment in both Medicaid and Medicare went up, too. The percentage and number of people enrolled in Medicaid increased to 14.1 percent and 42.6 million in 2008, the census said. As baby boomers entered their mid-60s, enrollment in Medicare increased to 14.3 percent and 43 million in 2008.

David Johnson, chief of the housing and household economic statistics division of the census, told reporters in a conference call that the estimates in the Current Population Survey were collected in March of this year. Those surveyed were considered to have insurance if they were enrolled in a plan at any time during 2008, even for a short period, which census officials say means that the numbers of uninsured Americans likely are understated. For example, some workers may have had insurance early in 2008 and then lost their jobs.

The situation likely is worse now, experts said. The August 2009 U.S. unemployment rate of 9.7 percent is more than two percentage points higher than it was in 2008, when it hit a high of 7.2 percent in December.

Obama, fresh from his health care speech Wednesday night before a joint session of Congress, said that "more up-to-date surveys" have found that since the recession intensified in September, more people have lost their health insurance. Even those who do have insurance "have never had less security and stability than they do right now," Obama said at an event with the American Nurses Association.

"Because they're subject to the whims of health insurance companies, many people fear that they'll lose their health insurance if they move or if they lose their job, they change jobs, or that insurance just won't cover them when they need it most," said Obama, making the case that it's time for Congress to act on the overhaul.

Robert Greenstein, director of the liberal-leaning Center on Budget and Policy Priorities, called the census report "grim" for its findings on health insurance as well as poverty and income. As Americans reeled from the recession, real median household income fell by 3.6 percent to $50,303 in 2008 and the official poverty rate rose to 13.2 percent compared with 12.5 percent in 2007, the census said.

"What's of particular concern is that virtually every figure will look considerably worse a year from now," said Greenstein. He said center researchers expect the number of people living in poverty will hit a 50-year high in 2009, and the number of uninsured will climb toward 50 million.

The census said that 9.9 percent of children under 18 lacked health insurance in 2008, compared with 11 percent in 2007. The number of uninsured children fell from 8.1 million in 2007 to 7.3 million in 2008, the lowest number since 1987.

Among uninsured children, 29.1 percent lived in households with incomes of $29,000 or less, 32.7 percent in households with incomes of $25,000 to $49,999, 18.1 percent in households with incomes of $50,000 to $74,999 and 20.1 percent in households with incomes of $75,000 or more.

Children living in poverty still tend to be more likely to be uninsured, as well as teens. Hispanic children had the highest rate of uninsurance at 17.2 percent, while the rate for non-Hispanic white children was 6.7 percent, for black children 10.7 percent and for Asian children 10.9 percent.

Among regions, the Northeast and Midwest had the lowest rates of uninsured citizens, while the South had the highest. Massachusetts, which requires that most people have health insurance, had the lowest rate at 5.5 percent and Texas the highest at 25.1 percent.

Karen Davis, president of the Commonwealth Fund, a policy research foundation, said all of the estimates would have been far worse but for the growing enrollment in public programs, such as an increase of 3 million people enrolled in Medicaid. She also pointed out that problems with insurance now are creeping up the income tiers. The census estimated that about 20 percent of the uninsured live in households earning $75,000 a year or more. "An uninsured population of 46.3 million Americans is staggering," Davis said.

Scott Serota, president and CEO of the Blue Cross and Blue Shield Association, said it is "unacceptable" that so many Americans lack insurance. He said the insurer wants to work towards a bipartisan solution and supports an overhaul that builds on the employer-based system and changes in the market, rather than "a new government-run health plan that would cause millions of Americans to lose the private coverage they enjoy."

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Emotions Still Swirling on Capitol Hill Day After the Obama Speech

By John Reichard, CQ HealthBeat Editor

September 10, 2009 -- Bipartisanship—to the extent the word has any place in the health overhaul debate—was hanging on by a thread Thursday thanks to a case of perfect attendance at a morning session by the "Gang of Six" Senate Finance Committee bipartisan negotiators.

But if the health overhaul speech of the night before by President Obama psyched Democrats up to get health care done this year, Republicans were in a sour and combative mood Thursday. At a mid-day press briefing, Senate Republican Whip Jon Kyl of Arizona made comments suggesting he felt disrespected by Obama's "disingenuous" address to a joint session of Congress and what he saw as its tinge of "Chicago politics."

And on the steps of the Capitol Thursday afternoon, chants urging a stop to "government health care" could be heard from a FreedomWorks rally across the way in the upper Senate Park as boisterous foes of Obama policies began gathering for a planned weekend march on Washington.

In the first and last venue on Capitol Hill in which bipartisan talks are occurring, Democratic Sen. Kent Conrad of North Dakota emerged from the Finance Committee negotiating session calling it a "productive" meeting, as he has so many times before.

Asked if there is new zeal to reach consensus, Conrad said the group has been making a serious effort all along. "But I think the speech helped. He made some very important offers," he said, referring in part to Obama's pledge to test new approaches at the state level to settling malpractice disputes.

Committee Chairman Max Baucus, D-Mont., also emerged from the talks saying Obama had breathed new life into negotiating efforts in this issue.

Conrad said that "we talked in some detail about how we absolutely assure that those who are here illegally would not get the benefit of any of these initiatives."

He said, "We have had an additional discussion about Medicaid, and staff are going to come back with proposals. . .we've also asked for a staff recommendation on abortion and medical malpractice. The president's speech last night was very helpful on medical malpractice reform, and so we're pursuing that. So this was very good."

But Conrad admitted that "we are not the committee of jurisdiction" on medical malpractice revisions, which Obama offered as an olive leaf to Republicans who insist that changes would sharply lower rising health care costs. Still, Conrad said, "there's no reason why we can't put a suggestion forward and that's what we're going to be meeting on later today or perhaps tomorrow.

"I think we're seeing consensus along the lines of safe harbor for doctors who use best practices," Conrad said, referring to protection in malpractice suits. Also under discussion, he said, is the use of "medical courts" in which health care experts preside as judges, and the use of arbitration rather than full-blown litigation to settle disputes. "I'm anticipating now the staff will come back with recommendations on medical malpractice, abortion and Medicaid."

Each in its own way is meant to buff the allure of the Finance overhaul to moderates or to calm some of the most vociferous criticism of overhaul efforts. Finance Committee negotiators know it is likely that their legislative vehicle that has the best shot of getting through a bitterly divided Congress. They are trying to prepare for the battering that will occur in the days ahead as the committee's proposal is released and enters into the markup phase, set to occur the week of Sept. 21.

Foes of abortion rights are bitterly opposed to Democratic proposals, viewing them as a vehicle to increase the number of abortions despite Obama's insistence in his speech that no taxpayer dollars would be spent on abortion as part of his overhaul plan.

Conrad described the issue of Medicaid expansion costs as one of the most difficult the committee faces. States are mired in the depths of financial crisis, yet under the Finance plan would share in the costs of a Medicaid expansion that could make uninsured Americans earning up to 133 percent of the federal poverty line eligible for Medicaid.

"We have continued to make refinements in the Medicaid area," Conrad said. "We are having discussions with governors, and so we need more refinement." In order for those discussions to advance, Conrad said the committee needs to have a state-by-state estimate of the impact of Medicaid provisions, something that the Congressional Budget Office (CBO) does not provide and that the committee is procuring from outside analysts.

"It is both dealing with the overall cost and it is dealing with how those costs are shared between the government and the states," he said of the Medicaid cost data negotiators are seeking.

Meanwhile, Kyl heard the Obama address much differently, repeatedly calling it "disingenuous."

There was "no reference" to listening to what the American people have been saying in recent weeks, Kyl said, referring to angry protests at town hall meetings in August. "It's basically his way or the highway.

"I was perplexed by the fact that throughout the entire speech, it appeared as if he was trying to ram something through. . .rather than to refer to what the people have been saying to all of us for the last six or seven weeks."

At one point in his speech, Obama said, "I will not waste time with those who have made the calculation that it's better politics to kill this plan than to improve it. I won't stand by while the special interests use the same old tactics to keep things exactly the way they are. If you misrepresent what's in this plan, we will call you out."

Kyl depicted the "call you out" remark as an example of "Chicago politics."

"The president spoke in a very partisan political way last night, a way that I think is unconstructive," said Kyl. "I think it's my obligation to point out the fact that this isn't the way that you get people to cooperate. You don't say that "if you disagree we're going to call you out," and to use all the pejorative terms that he used. It's harsh for me to criticize him for doing that," but "I think it's honest."

As an example of Obama being disingenuous, Kyl said that for months the president has been saying "if you like your insurance you get to keep it." But "it's not true," Kyl said.

Kyl said, for example, that Medicare cuts would lead millions of seniors to lose their current Medicare Advantage plans. Kyl added that according to a Lewin Group estimate, more than 88 million people would get coverage through a new government insurance option as employers stop offering coverage (the CBO has estimated public plan enrollment in 2019 at 12 million).

Joined by House Minority Whip Eric Cantor, R-Va., Kyl sketched out alternatives he thinks should be proposed by Republicans, including a half-dozen individual bills "to try to target specific solutions to specific problems." A big comprehensive bill is too much; it's better to take "one bite at a time," Kyl said.

Kyl said he favors introducing a bill to guarantee that coverage can be taken from job to job, another to allow insurers to compete across state lines, and a third allowing small businesses to band together to get better deals on health care coverage, for example.

Cantor said he does see areas in which Democrats and Republicans can work together, such as portability of coverage, and the creation of pool of "high risk pools" to provide coverage to those with expensive medical conditions who are unable to find affordable coverage.

Senate Democratic leaders took over the press briefing room a short time later, humming a much different tune. Majority Leader Harry Reid of Nevada called the speech a "game changer." Reid also suggested that he is open to compromise on the issue of having a public plan, saying what those plans are is really in the eye of the beholder. Asked if he considered co-operatives as public plans, Reid indicated that he did if they acted as a spur to competition and helped improve quality of care.

Reid also said he hopes that health overhaul legislation can be passed by Congress by Thanksgiving.

But the day made clear that Republicans are very unlikely, with the possible exception of Sen. Olympia J. Snowe of Maine, to be casting "aye" votes.

Republican Sen. Michael B. Enzi of Wyoming announced a CBO estimate of the cost of the overhaul bill passed by the Senate, Health, Education and Labor Committee he said "would balloon the national deficit by more than $1 trillion, drive up total spending on health care and force millions of Americans to lose their employer-sponsored health insurance plans."

And at the rally of Obama foes at the upper Senate Park, House Minority Leader John A. Boehner, R-Ohio, told hundreds of assembled protestors that "people are scared to death" by policies coming out of the White House. "The American people can stop this nonsense in Washington!" Boehner said.

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Reid Says Senate Democrats Will Unite to Move Health Care Bill

By Adriel Bettelheim and Kathleen Hunter, CQ Staff

September 10, 2009 -- President Obama will try to generate momentum from his address to Congress during a meeting Thursday with more than a dozen centrist Democrats whose support he will need to push any health care bill through the Senate.

Majority Leader Harry Reid expressed confidence that Senate Democrats would unite and pass a health-care overhaul by Thanksgiving, with the support of at least "a few" Republicans.

"I hope we can get it done well before Thanksgiving," Reid, D-Nev., said.

Some issues, he said, may have to be resolved on the Senate floor—especially the question of whether some type of "public option" should be offered to individuals and small businesses shopping for health insurance on the exchange, or marketplace, to be created by the legislation.

With initial polls showing Obama scored a rhetorical victory with the public, the administration is keen to reassure wavering centrists that the changes the president is pushing in the health care system would not adversely affect middle-class voters.

Sixty-seven percent of Americans who watched the president's speech said they favor his health care plans, a 14-point gain over the level of support before the speech, according to a CNN/Opinion Research Corp. national poll.

A U.S. Census Bureau report released Thursday offered new evidence of the health coverage problem facing many Americans.

The Census found that the number of uninsured climbed again last year to 46.3 million people, an increase of 600,000 from 2007. The number covered by private insurance, either through their jobs or individual policies, dropped by 1 million. Those insured through government programs increased from 83 million to 87.4 million.

Obama reiterated key points of his Wednesday' night address Thursday morning in a White House appearance before about 150 nurses and leaders of the American Nurses Association.

"We don't need more partisan distractions," Obama said. "If there are real concerns about any aspect of my plan, let's address them. If there are real differences, let's resolve them. But we have talked this issue to death, year after year, decade after decade. And the time for talk is winding down. The time for bickering has passed."

But Obama didn't persuade many skeptics, who note he has yet to produce a detailed legislative plan.

Sen. Bob Corker, R-Tenn., on Thursday formally requested that the White House release details of the president's plan. "No serious debate can take place without details and language, and I am anxious to see the full text of the legislation the president described last night," Corker said in a statement.

Shoring Up Senate Support

The president's description of what he wants to see in a final health care bill tracked fairly closely with the outline of legislation unveiled this week by Senate Finance Committee Chairman Max Baucus, D-Mont.

Baucus expects to release a full chairman's "mark," or draft bill, next week, and he has announced that his committee will mark up the measure the week of Sept. 21.

Baucus met Thursday morning with the other five members of his committee's bipartisan "Gang of Six" to assess their views in the wake of the president's speech.

Obama, meanwhile, prepared to talk about his bottom line with 15 Senate Democrats and one independent. Those invited were Evan Bayh of Indiana, Mark Begich of Alaska, Michael Bennet of Colorado, Thomas R. Carper of Delaware, Kay Hagan of North Carolina, Herb Kohl of Wisconsin, Blanche Lincoln of Arkansas, Claire McCaskill of Missouri, Ben Nelson of Nebraska, Bill Nelson of Florida, Mark Pryor of Arkansas, Jeanne Shaheen of New Hampshire, Arlen Specter of Pennsylvania, Mark Udall of Colorado, Mark Warner of Virginia and independent Joseph I. Lieberman of Connecticut.

Obama has tried to rally Congress around a set of principles, but he continues to defer to lawmakers to fill in key details.

He made clear, however, that he favors mandates on individuals to purchase coverage, and on businesses to offer their workers insurance or pay a penalty to help cover the cost of covering the uninsured. He also insisted that any legislation require insurance companies to cover all who wish to buy policies, regardless of pre-existing medical conditions, and forbid companies from dropping people once they get sick.

While Obama voiced a strong preference for a government-run plan to compete against private health plans in a health insurance exchange, or marketplace, he signalled he was open to alternatives so long as they assured competition and affordable coverage in all areas of the country.

Obama also said the total costs of an overhaul should be around $900 billion—and he linked spending to expand coverage to the approximately 46 million uninsured Americans to cost savings he said can be extracted from the health system.

Obama is likely to need the votes of every Democrat in the Senate and the two independents who ally with them, because only one Republican—Maine's Olympia J. Snowe—has been receptive to the kind of plan the president envisions.

About a dozen Democrats remain on the fence. Most are fiscal conservatives who likely won't commit before the Congressional Budget Office scores the costs of an overhaul. CBO is not expected to provide a score for Baucus's bill until next week.

Getting to Passage
Reid conceded Democratic leaders still face a challenge in getting a health bill to Obama's desk.

"We're working with very narrow margins here," said Reid, who captains a 59-member caucus that includes a significant number of moderates who have expressed concern about the bill's costs and opposition to a government-run public option to compete with private insurers.

Reid said he was confident that moderate Democrats would at least fall in line to surmount any GOP filibuster of a health care proposal—although he would need at least one Republican to join the majority party in order to reach 60 votes.

"We're going to be fine with the moderates," Reid said. "Remember what we're talking about initially are procedural votes ... and we usually get all of them—with rare exception—on procedural votes."

The floor debate will allow senators to hash out whether to include a public option in the Senate bill, and if so, what type, Reid said.

"The ultimate decision will be made on the Senate floor," he said. "We will have votes on different variations of the public option ... There are different types of public options, and we're going to look at all of them."

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The Chance of a Lifetime Arrives for Tom Harkin

By Jane Norman, CQ HealthBeat Associate Editor

September 9, 2009 -- At 69, and after a quarter-century of service in the U.S. Senate, Tom Harkin of Iowa has landed his dream job.

On Wednesday Harkin became the successor to the late Sen. Edward M. Kennedy of Massachusetts at the helm of one of the two chief Senate panels steering health care policy. The son of an Iowa coal miner thus assumes the mantle of a son of America's most prominent political dynasty.

Harkin, a feisty fifth-term liberal Democrat who in 1992 ran unsuccessfully for president, had to give up his post as chairman of the Senate Agriculture Committee to take over the Senate Health, Education, Labor and Pensions (HELP) Committee.

After Kennedy's death on Aug. 25, Sen. Christopher J. Dodd was next in line on HELP, but opted to stick with chairmanship of the Senate Banking Committee.

It could seem on the surface a tough choice for Harkin, a senator from one of a leading farm state who's taken particular pride in promoting conservation, renewable energy (primarily ethanol, which is produced from Iowa's cornfields) and nutrition as he guided the committee through two farm bills.

But Harkin's most significant long-term accomplishments in the Senate have always been tied to health and education, and he is one of the most faithful friends of labor unions serving in Congress.

He was an author of the Americans with Disabilities Act in 1990, which revolutionized the treatment in America of people with disabilities and stemmed from his experiences with his late brother, Frank, who was deaf.

Harkin also has become over the years a major force in the legitimization of alternative medicine, an outspoken foe of tobacco and an advocate of federal funding of stem cell research, all of which brought him his share of criticism from opponents inside and outside Washington.

A top member of the Appropriations Committee, he is the chairman of its subcommittee on labor, health, human services and education—now giving him even more control over policy in those areas.

Dodd filled in for Kennedy on the health care overhaul while Kennedy was ill and will continue to lead committee negotiations on the bill.

But Harkin will have the opportunity to play an even more central role in the debate, along with the senior senator from Iowa—Republican Charles E. Grassley, the top member of the GOP on the Finance Committee. The value of Senate seniority to a small state is abundantly clear.

"To serve in this capacity is to carry on the legacy of Sen. Ted Kennedy, who dedicated his life to ensuring that our economy works for all Americans, guaranteeing every child the opportunity to pursue a quality education and, of course, the cause of his life: access to quality, affordable health care for all Americans," Harkin said in a statement.

"In this last endeavor, I expect to work closely with Sen. Dodd, who has guided the HELP Committee so capably in reporting the Affordable Health Choices Act, and who will continue to play a leading role as health care legislation moves to the Senate floor."

Harkin will remain on the Agriculture Committee, where he's been a member since he arrived in the Senate in 1985. He served on the House Agriculture Committee before then.

Harkin told reporters it was a difficult decision for Dodd to pass up the HELP chairmanship, but he didn't try to influence the outcome.

"These are one of those times when you don't give advice — you can respond, but you don't give advice," said Harkin.

"It's just one of those personal decisions that only he could make. And of course, I told him whatever he decided, I'd support."

Gregory Vadala contributed to this story.

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'Gang of Six' Hopes to Finish Draft

By Drew Armstrong, CQ Staff

September 11, 2009 -- A week after Congress' return from a contentious August recess, a health care overhaul appears to be regaining momentum as the Senate Finance Committee enters the final stages of its efforts to write a bill that can pass the chamber.

On Monday, a group of three Democrats and three Republicans on the panel, led by Chairman Max Baucus, D Mont., will hold what may be its final meeting to put the finishing touches on a draft bill to be released midweek and marked up soon after.

"We're meeting again Monday at 11 o'clock and begin to wrap up," Baucus said. "I'll find out who wants to support the mark and who doesn't. I obviously hope there'll be bipartisan support."

The first sessions with the group started in the middle of June, and for nearly three months the "Gang of Six" has tried to craft a proposal that could win a filibuster-proof 60 votes in the Senate.

The House, meanwhile, appears to be waiting for Baucus to move. And before a bill can get to the House floor, there will be a final day of markup in the Energy and Commerce Committee, where a handful of amendments awaits action. Chairman Henry A. Waxman, D-Calif., has a "gentleman's agreement" with ranking GOP member Joe L. Barton of Texas to finish them.

A spokeswoman for Waxman said Sept. 11 that no date has yet been set for that session. Baucus has said he intends to mark up the Finance Committee draft during the week of Sept. 21.

States' Burden and Illegal Immigrants
As the Gang of Six negotiations have gone on, two of the Republicans—ranking member Charles E. Grassley of Iowa and Michael B. Enzi of Wyoming—have seemed less and less likely to support Baucus' proposal, making comments over the August recess that they might not back the chairman's draft legislation.

"We must begin to reach a resolution, a conclusion, in preparation for a mark to be put out early, middle of next week," Baucus said Sept. 11.

The group has only a few significant issues left to wrap up. They include determining how much states would have to pay as part of a significant expansion of Medicaid and preventing illegal immigrants from getting federal assistance under new programs that will offer insurance coverage to currently uninsured people.

Kent Conrad, D-N.D., said the group would talk with governors to determine how much of the burden states would be expected to carry for the cost of expanding eligibility for Medicaid to 133 percent of the federal poverty level.

"That is still under discussion, and we will be having that conversation with the governors on Monday," he said, "but the federal government will bear the overwhelming share of the cost of those who are newly eligible."

To keep illegal immigrants from getting federal subsidies to buy health insurance or receiving other federal assistance, the government would require a check of Social Security numbers to determine eligibility, Conrad said.

But, he added, people who are in the country legally but might not have Social Security cards could provide visas or other documentation showing their eligibility.

However, nothing would keep illegal immigrants from buying private insurance on their own—a point conservatives have raised in their contentions that illegal immigrants would benefit from a health care overhaul.

"You can't prevent somebody from buying an insurance policy, but it would not be one that is federally assisted," Conrad said.

The senators' Monday meeting will also wrap up details on ensuring that no federal dollars pay for abortions and examining changes in medical malpractice law to reduce the number of lawsuits against health care providers.

Baucus said that when he produces the draft bill that will be the basis for the committee markup, he hopes to have a full scoring of the proposal from the Congressional Budget Office (CBO).

"I want to make sure this is deficit-neutral," he said. "It's very clear, we've got to find a way to bend the cost curve here. I'm very sensitive to the fact that we do need CBO scores."

When the draft bill is released, Baucus will get a true sense of the temperature of his caucus and how much support there actually is for his proposal. He has left out ideas dear to some liberals, such as using a government-run "public option" to compete with private insurers.

But he said he believes he has the backing of President Obama. In a speech to Congress on Sept. 9, Obama gave support to the idea of a public option but made it clear that he cares more about creating more competition for insurers than about the specific method of doing so.

"I think I can speak for most members of Congress—at least Democrats, and also Republicans who are supporting health care reform—that's their goal, too, and they care less about the means," Baucus said.

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Clinton-Era Health Fight Veterans Hold Out Hope for Overhaul

By Jane Norman, CQ HealthBeat Associate Editor

September 11, 2009 -- The environment for major change in the health care system may be even tougher than when President Clinton's attempt failed in the 1990s, but a panel of experts assembled at the American Enterprise Institute on Friday held out hope that the outcome still may be different.

In comparing the period of 1993–94 and now, there are fewer moderate members of Congress equipped to broker a compromise between warring partisans on the left and right, and fewer with detailed knowledge of how the system works, the panel members said. The nation's economic status is more dire and spiraling health costs bog down the federal budget as baby boomers' retirements begin and burden the Medicare program.

The media environment has shifted, with talk radio and the instancy of the Internet supplanting three television networks and newspapers.

Yet William Gradison, a former Republican congressman from Ohio who as the head of the Health Insurance Association of America helped lead a fight against the Clinton plan, said he believes Congress this time will act. So did Dean Rosen, a health consultant who served as a top health adviser to the former Republican leader in the Senate, Bill Frist.

"I think Congress is going to pass a bill—I think for the Democrats to have 60 votes in the Senate and not to pass a bill would probably be legislative malpractice for them, given how much this president has staked politically on reform," said Rosen. "He is way out there. I do not think failure is an option."

The discussion came after a roller coaster week for the health overhaul in which President Obama laid out the outlines of a health proposal in a joint session of Congress, interrupted by a shout of "You lie!" from a South Carolina Republican congressman, and the chairman of the Senate Finance Committee announced his plans to move ahead toward a markup of a bill by the week of Sept. 21.

Obama until now had stayed away from too many specifics, taking a lesson from the Clinton experience, when Hillary Clinton and a group of advisers assembled a health care proposal behind closed doors and presented it to Congress.

But following an August recess filled with loud and sometimes inaccurate attacks on the health care overhaul at town hall meetings, and falling approval ratings, Obama presented an outline that included many of the elements included in the House and Senate bills already approved by committees.

Len Nichols, who was a health adviser at the Office of Management and Budget during the Clinton years, said "Congress did its job" in approving legislation in three House committees and one Senate committee fairly rapidly, but not in time to avoid the town hall troubles.

The atmosphere was similar to the strong negative emotions stirred by the "Harry and Louse" TV ads that helped kill the Clinton proposal, though as Nichols observed "Harry and Louise are now Democrats" and taping ads calling for change.

"So one similarity between now and then is explaining complexity when people are scared is really hard and I'm not sure anybody could do it," Nichols said. "Once you get past the shouting, which indeed with some effort you can, when you talk to people about what it's really about. . . people can be calmed down. There is a broad recognition the system is broken down."

That's different from in the 1990s, when "we were pretty smug" and the American health care system was regarded as expensive but the best in the world, said Robert Reischauer, the former director of the Congressional Budget Office. "A lot of studies have brought that into question now," he said.

Gradison said "the insured do vote" and what polls have found then and now is that they also want to keep the health insurance they have—and pay less for it. He questioned what the reaction will be if Americans can't keep high deductible policies favored by groups such as farmers and ranchers, or if insurers increase premiums to make up for taxes possibly levied on insurance companies to help pay for the overhaul.

Another member of Congress once warned him against voting for legislation that includes "something in there for everybody to hate," said Gradison. "If a bill is rushed through too fast, there may be things in there that once they become public, can cause some real concern among the body politic," said Gradison.

"It has been puzzling to me over the last month or so to hear people arguing for or against the plan, when there isn't a plan to be for or against at this point in time," he added. "Far too much of what has passed for public discourse has been based more on lack of information than it has on misinformation."

One element that's remained consistent and difficult to surmount is that many Americans—and politicians—don't really understand how the health care system works or how care is financed, said Reischauer, now the president of the Urban Institute.

"The American people and many of their leaders remain woefully confused and misinformed about health," he said.

"They don't understand who's footing the bill, the employer or the worker. They don't fully appreciate what the insurance they're receiving from their employer costs. They think the premiums are outrageous even though they're paying a rather small fraction of the total. They're sure they could have the same thing a whole lot cheaper and there must be someone out there screwing them," said Reischauer.

"They don't want to look in the mirror and say, hey, I might be a part of this," he said. "A huge education task lies before us whether we are successful in this round or not."

This year's congressional process may have been smoother had the late Sen. Edward M. Kennedy, D-Mass., not fallen ill and had to step away from negotiations, said Nichols. Kennedy, who died in August, was the chairman of the Senate Health, Education, Labor and Pensions Committee.

"I would say the impact of his illness has already seriously been felt," said Nichols. Two key Republican senators on the committee, Orrin G. Hatch of Utah and Michael B. Enzi of Wyoming, both expected to work with Kennedy on a bipartisan agreement, said Nichols.

"His illness prevented that from being possible," said Nichols. "Unfortunately, that had the spillover effect of taking that frustration and sadness and hurt into the Finance Committee, where it was even harder to deal with."

Both Hatch and Enzi also serve on Finance and Enzi has been a member of the "Gang of Six" bipartisan negotiators, though relations have been very strained at times. Hatch declined to continue with the talks.

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