This article first appeared in the St. Louis Beacon, Jan. 27, 2010 - Timothy McBride was among economists and social scientists who forecast last year that the time was ripe for health reform. That prediction looked like a certainty until last week's Senate race in Massachusetts when Scott Brown, a Republican, was elected to replace the legendary late Sen. Edward Kennedy. The election deprives Senate Democrats of the magic filibuster-proof 60 votes needed to enact a sweeping health-reform bill.
McBride, a professor at Washington University and dean of the school's Master of Public Health program, thinks Democrats are left with four options, but he says President Barack Obama will probably signal his approach in his State of the Union address.
The options, McBride says, are:
- to resort to parliamentary maneuvering in the budget process to allow Senate Democrats to amend the bill to make it acceptable to the House, then pass it with a simple 51-vote majority. The House would then approve a bill for Obama's signature.
- to drop the health-reform bill "because of a feeling that the public really wants to focus on the economy rather than health care"
- to write a new bill, starting over in effect
- to break the existing Senate proposal into pieces, passing some of the more popular provisions.
Most of these options are unrealistic, he says. Democrats aren't in the mood to start over on health reform after working for months on the existing bills, and writing a new bill would offer no guarantee of bipartisan support.
"But I don't think the Democrats want to drop the whole thing yet," McBride says, adding that the best option probably is to revise the current Senate bill taking out provisions that don't relate directly to providing health insurance.
"There's a whole title in the bill on public health, for example, expanding it, focusing on preventive care and community-based health initiatives. That may not be necessary and can be handled separately."
But he says the focus on insurance reforms and affordability must remain in the bill.
"A lot of people say why not just pass insurance reforms, such as (covering) pre-existing conditions, which are popular. But you have to pass insurance reforms, plus subsidies for expanding coverage. They need to stay. If we pass reforms (without subsidies for expanding coverage), it won't work because of the economic reality."
He adds that Democrats could make the legislation more acceptable to some Republicans by embracing two issues that the GOP wants -- malpractice reform and allowing insurance companies to sell policies across state lines.
"The effect of malpractice reform is overstated, but I don't see any reason it couldn't be included. But selling insurance across state lines would lead to more competition and lower costs. It would give people more choice, and it certainly wouldn't hurt, so why not try it?"
Even with the election in Massachusetts, McBride says most elements making reform possible are still there: a rising crisis of the uninsured, affordability issues and a president "who would provide executive leadership, and the right number of votes to make it happen." Still, he concedes the president's popularity is down "and that's one of the problems we're running into."
McBride said one message from Massachusetts was that the Democrats were focusing on the wrong issue: trying to fix health care instead of the economy. Another message, he said, was that the public was losing patience and was upset about the process of health reform.
"It took a long time and the bill was very complicated and what the public heard about was the wheeling and dealing and that it has taken a year and nothing has passed," he said.
He adds that Congress needs to fix both the economy and health care and that doing one without the other won't make things better.
Make insurance affordable
John Arensmeyer heads the Small Business Majority and is former owner and CEO of a highly regarded e-commerce company whose clients have included John Hancock, Bank of America, and other major corporations.
Neither the House nor the Senate offered perfect bills, he said, "but both are much better than the status quo in addressing the four key issues that we think are important to small business: insurance reforms, an exchange, tax credits for health care and cost containment."
Going back to the drawing board will be a problem, he says, because Congress seems to have other priorities, such as fixing the economy. Important compromises came out of the discussion, including eliminating pre-existing conditions as part of obtaining insurance. "But none of this is going to work without cost containment. Having an insurance exchange for individuals and businesses to buy insurance is a critical part of lowering cost, so I can't see that being eliminated."
It's essential that the final bill retains tax credits and subsidies to make insurance affordable, he added.
Arensmeyer sees nothing wrong with Democrats trying to get a bill through with a 51-vote simple majority. "We certainly much prefer having a bipartisan bill, but the issue is that if (Republicans) don't want to be part of the process, we have to get health-care reform. ... It's really up to them to decide whether they want to be part of it or not."
That view is by no means shared by all business groups, including the Missouri Chamber of Commerce. It argues that the Democrats' legislation is flawed in so many ways that the party should simply scrap what's on the table and start over. The chamber argues that the Senate bill includes mandates that would lead to additional increases in health-care costs.
Focus on Quality of Care
Louise Probst, executive director of the St. Louis Area Business Health Coalition, says Congress needs to strengthen provisions involving the cost and quality of care.
"There's a need for more cost containment and quality improvement initiatives in reform," she says, adding that business, labor and consumer groups all agree on the importance of payment reform, more disclosure of quality differences in medical services and more initiatives to improve the quality and reduce the cost of health care.
Transparency in patient treatment remains an issue, she says, because of the "big difference in the quality of care and the cost of care. That needs to be made more public. Physicians and consumers don't always have good information from which to make good health-care decisions. The current system really rewards providing more service and not the quality of service."
One example, Probst says, is a study of the risks of radiation in CAT scans.
The radiation risk of scans "has been known for a long time, but maybe the public didn't really understand it. Maybe we need better information so people understand the value that that (CAT scan) will bring in relation to potential risks. Rarely do consumers have that information. They just know that this is what is recommended, so this is what I need. They don't really know how that's going to affect their long-term outcome."
Probst says transparency and access to more information could help curb costs and lead to better decisions. She cites research by Dartmouth University and others that "shows that when people are fully informed, they will choose a little less intervention."
Probst adds that Congress should establish an independent commission to advise Congress and make payment policy recommendations for both the public and private sectors. She would like a system that covers all providers and prevents any group from negotiating its way out of payment policy recommendations.
"We need to align financial incentives in a way that makes it easier for good doctors to do the right thing," she says. "I'm hopeful that (the final bill) will expand public reporting of quality trends and that (health) organizations and providers are recognized when they deliver better value. (We need to) get away from just paying for every unit of service and pay instead for improvements in health."
Support for Moving Forward
Mary Becker, a spokeswoman for the Missouri Hospital Association, hopes Congress doesn't abandon health legislation or decide to start from scratch. Hospitals want expanded coverage, she said, but also want to "have reasonable rates that are above Medicare reimbursement rates. We're in a wait and see position, but we're supportive of a compromise bill. Right now is the best opportunity for something to happen."
St. Louis' Max Starkloff, formerly head of Paraquad Inc., who has since set up the Starkloff Disability Institute, urges Congress to "keep fighting for health care for Missourians."
As a disabled person who uses a power chair and a vent, and needs a personal attendant to live independently, Starkloff says he knows first-hand that people with pre-existing conditions still need "protection from discrimination and price gouging."
Kirsten Dunham, associate policy director of Paraquad, says the plight of the disabled might not be visible to many of those engaged in the health-care debate.
Paraquad frequently hears "stories from people who become disabled or their disability progresses to the point that they can no longer work," she says, "They lose their health insurance. At a time when they have lost their income, they cannot get affordable coverage on the individual market or the state high-risk pool. If they have any savings or are married, they are very likely not eligible for Medicaid."
An example, she says, might be a person who suffers a head injury in an accident and who would benefit from rehabilitation in the first months afterward.
"If someone has private health insurance, they can quickly max out their lifetime benefits, leaving them either on Medicaid, which does not cover all the rehabilitation and therapy services necessary, or (end up) without health coverage as they wait for Medicare."
The disabled, she said, "are scared of losing their homes, causing financial stress on their family, and going without necessary medical care and supplies." She says the reforms would give people with disabilities "security and peace of mind that they won't be discriminated against."