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Rx for Health Care Overhaul: Pass Something Already

By John Reichard, CQ HealthBeat Editor

December 12, 2007 -- Scarred veterans of the failed attempt to overhaul health care in the early 1990s offered their advice Wednesday to those who would wage the struggle anew, urging them to make passing overhaul legislation the first order of business of the next administration and to avoid specifying every detail needed to change the system in the legislation.

"The answer is 'pass it, pass it, pass it," said George Washington University Professor Christine Ferguson at a forum on "Health Reform Do's and Don'ts" sponsored by the non-partisan Alliance for Health Reform and the Robert Wood Johnson Foundation.

Speakers added the next president should be prepared to expend all of his or her political capital in the effort if it is to succeed. "You're not going to come out smelling like a rose," said Ferguson, who served as a top aide to the late Republican Sen. John H. Chafee of Rhode Island, a key player in the failed effort by centrists to create a bipartisan overhaul plan.

Speakers agreed that an overhaul would be extremely difficult to pull off, in part, they said, because the political atmosphere is more partisan than it was in the early 1990s. But they were not without optimism that a new system of universal health coverage is possible.

"I'm very optimistic about the prospects," insisted David Nexon, formerly a top health policy advisor to Democratic Senator Edward M. Kennedy of Massachusetts and now a senior official at the Advanced Medical Technology Association. However, Nexon quickly added that his optimism "may be like the guy on his third marriage—a triumph of hope over experience."

Although there was some defense of then-President Bill Clinton's proposed Health Security Act, no one on the panel of policy insiders defended Clinton's strategy of presenting Congress with a fait accompli—an extremely complex piece of legislation not designed to be modified or to have certain elements filled in later by Congress.

"We don't want to get lost in the details," cautioned David Colby, vice president of research at the Robert Wood Johnson Foundation and a former analyst at the Medicare Payment Advisory Commission and the Congressional Budget Office. "You do have to make some decisions and postpone some decisions."

The recent successful effort in Massachusetts to pass legislation creating a system designed to achieve near-universal coverage in the state shows that not every element of the new system has to be resolved right away in law. The approach at a national level should tilt more than it did in the Clinton era to "we'll fill in the technical details as we go on," Colby said.

Karen Pollitz, a Georgetown University professor who served as assistant Health and Human Secretary for health legislation during the Clinton era, agreed that it's not necessary to "spec out" every element of a new system in overhaul legislation, but cautioned that "not just anything that will pass can work."

Pollitz also traced much of the complexity of the Health Security Act to Clinton's decision not to seek higher taxes to pay for universal coverage.

The proposal had many provisions to hold down costs as a way to fund universal coverage, she noted. If an overhaul plan is going to be less complex and coverage is truly going to help people when they need it, higher taxes are going to be needed to pay for it, she said. And because private coverage in the individual market has too many loopholes, regulations are needed to make sure coverage is comprehensive, she suggested. Leaders in the overhaul effort must find a way to bring in more revenues and to delineate a government role in a compelling way, she said.

Dean Rosen, formerly a top health care advisor to former Republican Sen. Bill Frist of Tennessee, warned, however, that "philosophical differences today are more pronounced" than they were in the early 1990s. Republicans have more fully developed ideas than they did then on how to change health care, he said. And he noted that funding Democratic plans for universal coverage would entail ending tax cuts Republican voted into law.

Nexon agreed the political environment is more partisan, but suggested that the more developed ideas Republicans now hold on health care present an opportunity. Many Republicans have been talking about funding wider coverage through tax changes and in some cases, by mandating that individuals obtain coverage, he said. That suggests there is a basis for a compromise with Democrats that could lead to wider coverage—and even to universal coverage, he said.

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