Democratic leaders in both the House and Senate last week neared completion of their healthcare reform bills, but the substance of the plans was almost secondary to the political fight for the support of members who have yet to pledge their allegiance to any of the several reform camps.
The fighting stemmed in part from a political vacuum created when President Clinton apparently retreated from his stated goal of 100% coverage of the medically uninsured and his tacit acknowledgement that lawmakers on Capitol Hill would pursue their own reform plans rather than push his Health Security Act legislation (July 25, p. 2). Congressional leaders told the president his plan lacked sufficient support for passage.
In the House, Majority Leader Richard Gephardt (D-Mo.) was poised to release his version of reform, which mirrors the bill passed in late June by the Ways and Means Committee. At press time, members working on the plan said it would include a requirement that all employers pay at least 80% of the cost of their employees' health insurance.
Lowering the employer burden to 50% of the cost of insurance was being considered. However, according to acting Ways and Means Chairman Sam Gibbons (D-Fla.), the cost of such a move would be prohibitive.
Mr. Gibbons said that to reach the same level of workers being covered by health insurance, an additional $1 billion in government subsidies for coverage would be required for each percentage point the employer ratio is lowered.
The Gephardt plan also includes essentially the same financing as the Ways and Means plan, including $110 billion in Medicare growth constraints over the next five years, according to members. Those Medicare cuts have been criticized in an ad campaign sponsored by the American Hospital Association.
However, in a letter sent last week to all members of Congress, Mr. Gibbons accused the AHA of distorting the level of cuts "to scare the American people and protect hospitals' bottom line."
Mr. Gibbons argued that the AHA had ignored the revenue gains hospitals would receive through the elimination of uncompensated care. Including those revenues would mean that the net reductions in hospitals' projected revenues would be less than $25 billion over a five-year period, he said.
The AHA responded by gathering the support of more than 100 members of Congress in a letter to Mr. Gephardt calling for fewer reductions. But Rep. Benjamin Cardin (D-Md.) said the cuts would not be significantly reduced in the Gephardt plan.
"The evidence is overwhelming for moderates not to be too concerned about the level of Medicare cuts," Mr. Cardin said.
A separate group of moderate-to-conservative House Democrats and Republicans also was nearing completion of its own market-based, incremental reform plan late last week. According to members drafting the plan, it will combine insurance reforms with subsidies for the poor and unemployed but will not include an employer mandate and will not have any "global budgets," a euphemism for national spending limits.
Progress on the Senate side is coming much more slowly.
Senate Majority Leader George Mitchell (D-Maine) is crafting a plan that will likely be released this week. At press time, it appeared Mr. Mitchell would recommend that if a certain percentage of Americans, probably 95%, are not covered by 2001 or 2002, employers could be compelled to pay at least 50% of the cost of their employees insurance. Smaller firms might be exempted.
While Democratic leaders wrangled over the substance of their plans, they also were fighting with Republicans and moderate splinter groups for the support of the remaining uncommitted members.
In the Senate, Republican Leader Robert Dole (R-Kan.) and Mr. Mitchell are both seeking the support of the bipartisan group of moderates that was responsible for crafting the Senate Finance Committee compromise that passed last month.
"Right now it is 40/40/20 in the Senate; (Mr.) Mitchell has 40 votes, (Mr.) Dole has 40 votes, and there are 20 undecideds," said Washington healthcare lobbyist Frederick Graefe. "The 20 are where the action is."
The search for support also extends to subgroups within party lines. Mr. Dole and Sen. John Chafee (R-R.I.), who is the leader of the bipartisan Senate moderates, have been fighting for weeks for the votes of Republicans, many of whom have co-sponsored both the Chafee bill and the Dole plan.
On the Democratic side, a group of 25 liberals, known as the "Coverage Coalition," also is trying to drum up support for a guarantee of universal coverage with an employer mandate. They hope to persuade moderate Democrats who might otherwise join the Chafee group that voting for universal coverage is a smart political move.
Meanwhile, in the House, things are even messier. Mr. Gephardt last week held marathon sessions with members trying to persuade them to support his plan. At virtually the same time, the group that favors market-based reforms held its own meeting, calling on some of the same members for support.
"It's really crazy," said one Democratic House staff member. "Everyone wants you to sign on to their bill. Members are being pulled 18 different ways, and that doesn't even include the private-sector groups."