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The New Health Dialogue

A Blog from New America's Health Policy Program

HEALTH REFORM: Incremental Short on Policy and Politics

Published:  January 26, 2010
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Can we really start over on health reform? Now that the Democrats are down to only 59 votes in the Senate, some are pondering a ‘skinny bill’ that incorporates more bipartisan ideas. But the problem with that, our Health Policy Program Director Len Nichols explained to NPR, is “if you take most of the ideas that Republicans are shopping around at the moment (ideas such as malpractice reform and buying insurance across state lines), ‘then we’re back to a policy that frankly was rejected by the Republicans when they had a majority.’” As he states on the National Journal’s Health Care Experts Blog, Dr. Nichols believes it is a mistake to go “back to the drawing board” on health reform. See what he and other experts have to say on the issue here.

I do not believe we should be entertaining calls for incremental reform because neither policy nor politics support a piecemeal approach. The policy argument is simple -- you cannot reform the insurance market without a requirement to purchase coverage; you cannot require people to purchase coverage without subsidies; and, you cannot (and should not) finance coverage expansion without reforming the delivery system.

The politics are flawed as well. The idea that somehow incremental reform will give way to bipartisan compromise is naïve at best. Most of you know that I am and will always be for bipartisan reform. It is very difficult for America to take major steps toward solving its largest problems without bipartisan consensus. I must say, however, even I do not know what bipartisan health reform means in 2010.

Senator Max Baucus and the Finance Committee tried about as hard as you can try to meld what should be our common goals -- how to get all Americans covered at a cost that families, employers, and governments can afford -- into legislation capable of achieving bipartisan support. The “Group of Six” -- Baucus, Conrad and Bingaman for the Democrats, Grassley, Enzi and Snowe for the Republicans -- met over 30 times for more than 60 hours by one official count. Staff and eggheads spent countless additional hours in the name of bipartisan reform. Yet in the end, only Senator Snowe supported the Finance Committee bill and even she voted against the version considered by the full Senate. Even still, at least Snowe and her Maine-colleague Senator Collins remained engaged throughout the Senate process. I do hope they still might be willing to devise a way forward.

Sadly, however, most Republicans appear to have adopted the DeMint strategy -- say the bill is socialism and just keep moving on a scorched earth rhetorical strategy to destroy the Obama agenda as imagined by the tea baggers. In particular, it makes me sad to hear people as knowledgeable as Senators Grassley and Hatch speak out against changes to the Medicare program. They know Medicare is going broke. If you are not going to drive Medicare toward value through payment policy, how are you going to make the program solvent so it will be there for all seniors in 20 years? These senators and others know better than the RNC talking points.

This rhetoric is one example of why I distrust current offers of bipartisanship. In order to achieve bipartisan reform, Republican leadership must be sincere about solving our problems. Currently, this is simply not the case. Government is required to solve our health care problems. Republican leaders seem unwilling to admit this. The truth is you cannot solve insurance market or delivery system problems without some additional government involvement. The government must play some role in setting market rules to prevent insurers from denying coverage to the sick, in financing the subsidies necessary to make insurance more affordable for many, and in changing incentives and information so that providers embrace value instead of volume to lower cost growth and improve quality.

You can do all of this without initiating a government “takeover” of health care. Indeed, the current legislation in both the House and Senate is closer to Senator John Chafee’s bill in 1993 (co-sponsored by Senators Orrin Hatch, Chuck Grassley, and Bob Bennett, among 16 other Republicans) than it is to President Bill Clinton’s Health Security Act. But you cannot fix our health care system without expanding our commitment to each other to make quality health care affordable for all. Republican leadership seems dead set on opposing this expanded commitment and I don’t know how you “start over” on health reform without it. So, if bipartisan legislation includes serious discussions about how to cover all and improve delivery system value, fine. But if it just involves watered down window dressing that compromises the health of our people and economy as well as an implicit agreement that the tea baggers are right on health care when they are in fact manifestly wrong on many levels, I’m not interested and Democrats should not be either.

Congress should pass the Senate bill and amend it in a reconciliation sidecar that enshrines a critical mass of the conference agreement worked out before the special Massachusetts election. Then, Democrats should explain the bill to the American people over the next 10 months, being sure to contrast it with the full implications of Senator Mitch McConnell’s plans for America’s health care system.

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