The healthcare reform plan approved by the House Ways and Means health subcommittee last week likely will be remembered for its political importance more than its substance as it undergoes major surgery in the full committee, health policy experts predicted.
The vote on the plan-an alternative to President Clinton's proposal-was viewed as critical to maintaining the momentum behind reform (See related story, p. 29). But some major portions of the measure, drafted by subcommittee Chairman Rep. Fortney "Pete" Stark (D-Calif.), were viewed as short-lived.
"The obvious issue is that healthcare reform emerged from the health subcommittee alive and generally well," said Bruce Fried, senior vice president and deputy general counsel for the Wexler Group, a political consulting firm whose clients include the Catholic Health Association.
Now, the real question is whether the proposal is even "a viable starting point" for full committee deliberations, or whether Ways and Means Committee Chairman Dan Rostenkowski (D-Ill.) will produce his own approach, said Richard Pollack, executive vice president of federal relations at the American Hospital Association.
"Pieces of (the Stark plan) may be (viable)," Mr. Pollack added. But it's unlikely that Mr. Rostenkowski will keep the entire plan intact, he said.
The full Ways and Means Committee is universally viewed as more conservative than the subcommittee. Even in the subcommittee, Mr. Stark's proposal teetered as moderate Democrats fought for changes right up until the last minute.
Michael Bromberg, executive director of the Federation of American Health Systems agreed that while the panel's action "moved the process forward," the substance of the plan "will get changed dramatically, and should."
Like many healthcare executives, Mr. Bromberg objected to the scope of government regulation, price controls and the expansion of public programs contained in the proposal.
During a week of day-long public deliberations, subcommittee members considered dozens of amendments to the Stark plan, which would require employers to pay at least 80% of the cost of employees' health insurance to guarantee insurance for all, set global budgets and Medicare-like provider fees to control costs. It also would expand the Medicare program to provide coverage for the unemployed, the poor, current Medicaid recipients and small businesses that opted for government rather than private insurance coverage.
Another feature of the measure is a $350,000 limit on medical malpractice awards for pain and suffering, a provision aimed at restraining healthcare costs.
Mr. Stark's proposal differed from Mr. Clinton's in three major respects. It rejected mandatory health purchasing alliances in favor of voluntary groups; it called for public coverage of the poor through Medicare instead of private plans; and it would put price controls on providers rather than insurers.
In the end, no Republicans voted for the Stark plan, and Texas Democrat Mike Andrews, who supports a pure managed-competition bill, joined them in voting against it.
"I wouldn't feel right voting for something I'm so much against," he said before the vote. Afterward, he warned fellow Democrats than no plan would survive the "full committee, much less the House" unless it had bipartisan support and urged them to "move toward the center."
Even some of those who voted for the measure said they were only doing so because they knew key portions of it would be changed in the full committee. In fact, no sooner had the panel cast its perilously close 6-5 vote for the proposal than Mr. Stark announced that it likely would undergo radical alterations.
"It's not a perfect bill," Mr. Stark said after the vote. "No doubt the approach will be modified, probably substantially, as it moves through full committee."
Mr. Rostenkowski is expected to scrap the plan's entire financing scheme, which includes a $1.25-a-pack increase in the cigarette tax, a 1% assessment on businesses that self-insure and have more than 1,000 workers, a 20% copayment on home healthcare services, and additional financial obligations for states.
In addition, Rep. John Dingell (D-Mich.), chairman of the House Energy and Commerce Committee, is floating a plan that would retain employer-mandated health insurance, but with smaller contributions from small businesses and a cap on federal health spending.
While the subcommittee's public deliberations often broke down into nasty partisan jabs, the biggest rifts were among the panel's Democrats, who caucused behind closed doors to develop a financing scheme that would satisfy members seeking greater protection for small businesses.
Rep. Sander Levin (D-Mich.) had threatened to vote against the plan unless an across-the-board 0.8% payroll tax, which would have raised $24 billion annually, was stripped away. Because Mr. Stark refused to settle for a plan that lacked full financing, armies of administration accountants helped devise substitute financing measures.
Mr. Stark said the 6-5 vote in favor of the plan gave the American public "reason to believe that Congress can and will act to assure universal coverage."
The panel rejected most Republican alternatives on a 7-4 party-line vote. Republicans moved for a vote on the president's plan to discredit it by showing it had no supporters. Democrats tried to evade an outright rejection of the measure by voting "present."
The panel also turned thumbs down on a single-payer plan offered by Rep. Jim McDermott (D-Wash.) on a 7-4 roll call.
Two plans garnered some bipartisan enthusiasm, losing in 6-5 votes: a managed-competition bill sponsored by Reps. Jim Cooper (D-Tenn.) and Fred Grandy (R-Iowa) and a plan crafted by moderate Senate Republicans. That plan would require individuals, rather than businesses, to purchase insurance.