The National Health Policy Conference in Washington this weekthe most prestigious annual gathering of policy wonks, providers and government officialsoffered some insights into whats possible to expect out of Congress this year.
Or maybe I should say, not possible.
Although a parade of reformers offered up visions of universal coverage and vast changes in the organization, financing and delivery of care, it seemed to many observers that incrementalism is likely to rule the day, that it may take a new president and the end of the Iraq War to remake the healthcare system.
One of the problems may be a surfeit of ideas and authors. As Sen. Ron Wyden (D-Ore.), himself the sponsor of one of the most prominent universal coverage proposals, put it: If you have a Xerox machine you probably have your own healthcare plan.
Indeed, the several hundred attendees looked dazed by the array of ideas being put forth, some of them extremely hazy on how they would be paid for and how they would play out in the real world. (Even New York City Mayor Michael Bloomberg came down to offer his own bromides on healthcare reform.) The upshot is that even well-crafted plans such as Wydens are lost in the shuffle. Also, with every committee chairman and presidential candidate coming up with his or her own proposal, consensus seems farther away than ever. It was particularly interesting to see the reaction of Sen. Max Baucus (D-Mont.), the chairman of the Senate Finance Committee, when asked what he thought of Wydens plan. Though Baucus has just laid out the haziest of health agendas of his own, he looked like he had been asked what he thought of something an irritating uncle had said at Thanksgiving dinner.
Norman Ornstein, a resident scholar at the American Enterprise Institute, noted that Baucus likely wont even be that big of a player in the debate, because his fellow party members havent forgotten his steadfast support of the Medicare Modernization Act of 2003, legislation they campaigned against. It may well be that (legislative) leadership will sidestep the committee chairmen who have waited to have control of the agenda and push an agenda of their own, Ornstein said.
Kimberly Belshe, secretary of the California Health and Human Services Agency, decried the my-way-or-the-highway approach, asking, Is it responsible to have the status quo be everyones second choice when it comes to fixing our healthcare system?
Responsible? No. The way of the world in Washington and elsewhere? You bet. Too many egos and too much ambition.
An even bigger factor in delaying comprehensive reform is the fiscal straitjacket imposed on Congress, which a panel of congressional staffers made abundantly clear. Seldom has there been less room to maneuver, a result of the war in Iraq; Congress own recent past of spending excesses; the resulting forecast of worsening deficits; and new, pay as you go budget rules that demand sponsors find budget cuts or tax increases to offset any new dollars spent.
Washingtons inaction may be why the most popular of the breakout sessions at the conference was one on state coverage initiatives, where Belshe and leaders from Vermont and Massachusetts were on hand. As one attendee said, One of these states is going to be the one to show Washington how to get it done on the uninsured.
From everything I saw at the meeting and from other contacts in Washington, it seems likely we will see some legislative action on healthcare this year, some of it significant, but hardly the kind of bold, systemic action called for by several coalitions that include the big powers of business, labor and healthcare providers.
The most likely change is in the State Childrens Health Insurance Program, which must be reauthorized by Sept. 30. The program is one of the most popular on the Hill, because it only costs about $5 billion a year but provides a huge bang for the buck in covering some 3.9 million previously uninsured low-income children. However, the nonpartisan Congressional Research Service says that just to keep the current children enrolled over the next five years will cost a total of as much as $15 billion over the $5 billion annual baseline. Expanding the program to cover millions of other childrenand even some adults, as some states want to dowould require drastic cuts in other programs.
Still, it may be that Congress will raid the slush fund that pays private health plans a 12% bonus to treat Medicare beneficiaries to pay for the cost of covering more kids. Vetoing that kind of bill would be tough for any president, let alone one with an approval rating as low as President Bushs.
Compounding the dilemma, however, is the need to come up with yet another patch in the physician payment formula. Everyone agrees that docs cant endure a 10% Medicare pay cut this year, but the cost of past patches and another one this year would be more than $22 billion over 10 years. The Medicare Payment Advisory Commission is coming out with a major report in early March on the physician payment system, which may provide everyone in Congress with political cover for making some tough choices.
One measure almost certain to pass this year is mental health parity, meaning insurers would have to pay for behavioral health the same way they do for services for the rest of the body. A bipartisan bill is being marked up in the Senate Finance Committee and House leaders are hoping to push through that same bill this spring. President Bush has long been on record as supporting the idea. This year, it has also won the backing of America's Health Insurance Plans and business groups, all of which used to oppose such legislation.
A health information technology bill also may make it through Congress. Last year the effort stalled over some House members reluctance to allow a major exception to the Stark antikickback laws so that hospitals could make major contributions to the cost of hard-wiring the offices of physicians who refer to the hospitals. Given that the author of the eponymous Stark laws, Rep. Pete Stark of California, is now chairman of the House Ways and Means health subcommittee, the exception provision wont be on the table, so there may be less resistance to the bill.
And that, folks, may be it. Some achievements, to be sure, but each incremental, essentially building on a current system of care that everyone at the health policy conference agrees is fatally flawed.
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