With the expected passage of legislation by the Senate Finance Committee this week, Federal health reform prepares to move into the next phase, i.e. merger of bills in the House and Senate followed by a Conference Committee to meld those two versions.  While this “process” may seem very straight forward, it probably will have subplots as intriguing and complex as many of Shakespeare’s plays.  So below, are some highlight of what may unfold in the coming weeks, (and months), as health reform legislation is finalized and then implemented… perchance.

To Reconcile or Not to Reconcile, That is the Question
The Senate Democrats had set a deadline of October 15th, after which they may use the rules of Reconciliation to pass health reform legislation.  The appeal of Reconciliation is that it only requires 51 votes to pass legislation and not the 60 under normal rules to stop a filibuster.  The downside is that it also places limits on the content of the legislation because all the provisions must affect federal spending or risk being deleted.  In addition, Reconciliation rules also shorten the budget window from 10 years to 5. Of course, the Democrats are not required to use Reconciliation after October 15th – it just becomes an option.

Neither a Borrower nor a Lender Be
Much of the deliberations and political angst about the overall structure of the health reform legislation revolves around the projected impact of health reform legislation on Federal spending and private sector healthcare costs.  In addition, the President has declared that health reform legislation shouldn’t add to the long-term Federal deficit.  The good news is that the Congressional Budget Office’s preliminary assessment is that over the 2010-2019 period the Finance Committee’s bill will reduce the Federal deficit by $81 billion – although those saving almost entirely result from how the provisions produce secondary saving in Social Security spending and revenues.  However, as history has shown, these are projections, not guarantees – despite the media and various stakeholders declaring that “according to the CBO”, (or others), the bill “will” do such and what to costs, coverage, the debt and the deficit, etc. In addition, as the bills get merged and the legislative language refined, the CBO’s cost estimates can change.

Double, Double, Toil and Trouble; Fire Burn and Cauldron Bubble
This may be the mantra for opponents of health reform who are trying to brew both policy and political problems for the Democrats in Congress and the President by creating media and grassroots fires out of legislative smoke and mirrors. Overall, they may be cooking up a politically potent witches’ stews out of “eye of newt and toe of frog, wool of bat and tongue of dog” and other yummy stuff in their attempt to tilt the political and fund-raising environments in their favor for 2010 and 2012.

The First Thing We Do, Let’s Kill All the Lawyers

(From Henry VI, Part 2 Act IV, Scene 2)
DICK
The first thing we do, let’s kill all the lawyers.

CADE
Nay, that I mean to do. Is not this a lamentable
thing, that of the skin of an innocent lamb should
be made parchment? that parchment, being scribbled
o’er, should undo a man? Some say the bee stings:
but I say, ’tis the bee’s wax; for I did but seal
once to a thing, and I was never mine own man since.

While this discussion certainly shouldn’t be taken literally in the modern context, this exchange does reflect some of the challenges that await the implementation of any health reform legislation – particularly related to Medicare, or any provisions that interact with state laws, such as insurance regulation.  As a democracy, the United States is founded upon extensive rules of law, and implementing changes to those laws generally requires public review and commenting on proposed rules and regulations, which are then subject to revision before becoming effective.  This process takes a long time – often years – and even longer when implementation requires contracting with private entities to actually carry out the new laws.  And even more time may pass before laws become effective if any parts are challenged in a law suit – an outcome that is very possible if any industry or group of stakeholders sees itself as losing money or benefits under the new law, since even a losing suit can delay a bad outcome… which also gives them time to seek a legislative remedy… which would further delay any changes.  This is the price of a transparent democratic process. And while killing all the lawyers, (and writers of laws and regulations), might speed up the process, it would also likely lead to a poorer representational system, and a less fair process.

Nobly Onward Into an Undiscovered Country
So given all these contentious steps in the process, what are the Democrats to do? As with Hamlet’s predicament, Democrats in the House of Representatives may face the choice between life for their most progressive priorities – including a public plan option – and the political death of some of their more moderate and junior members who represent purple districts inhabited by voters who look askance at new government programs. As a modern day political Hamlet might ponder:

‘Tis it nobler in the Democrats’ minds to suffer
The slings and arrows of outraged Republicans,
Or to take arms and pens and voices against a sea of contentious voters
And by composing compromise, end the impasse?
To try: to weep; to cajole; No more;
And by try, seek to end the false niceties
The Blue Dog’s heart-aches, and the thousand unnatural media shocks
Enabling a consummation that devours all
To hope: perchance to dream: ay, there’s the rub;
For in that dream of enactment, what ills may come
When we have shuffled out of this policy coil,
And onto the parchment scribbling of rulemaking and implementation,
Must give us near election-year pause: there’s the respect
That makes calamity of incumbency for some, and such short tenure for others;
For who would bear the whips and scorns of seniority, or cut short that dream for others?
The pangs of disprized Members from a law delayed,
The intolerance of voters for officeholders, and the spurns
That patients endure of the unworthy delays,
When he himself might try his diagnosis make
With a bare nogin? Who would care for the bill’s bill,
To grunt and sweat under a weary public debt,
But that the dread of nothing after defeat,
The undiscover’d country of private life, from whose uninsured lands
Few travelers return, puzzled by paper and will
And makes us rather bear those ills we have
Than fly to others that we know not of and cannot afford?
Thus conscience of defeat does make cowards of us all;
And thus the native hue of resolution to use reconciliation
Is sicklied o’er with the pale cast of thoughts of loss,
And enterprises of great change and moment
With this regard, election year currents look far awry,
And could lose the name of action for us and all.

(With apologies to William Shakespeare)

Before the start of the hurricane season, the National Hurricane Center at NOAA issues predictions for how many storms and major hurricanes are expected that year.  Political analysts often put forth such prognostications based upon trends in polling winds, the temperature of the electorate and the country’s economy, etc.  Healthcare is the biggest storm brewing in US politics, and Charlie Cook and Ron Brownstein are both raising hurricane warning flags for the Democrats.

In the last two issues of the National Journal (9/5 & 9/12) they directly and indirectly discuss the political implications of health reform legislation for Democrats in the 2010 and 2012 elections.  Clearly the state of the economy will be a major determinant for voters’ in those elections, but it is also very possible that the content (or failure) of a health reform law will also influence the state of the economy over the next 1-3 years, since – as we’ve heard many times – healthcare is >16% of the GDP and healthcare costs are are constraining economic growth.

From a purely political perspective, it seems that the public plan option is the major hot potato-neutron bomb being tossed around.  Including it in health reform legislation may result in a political communications battle royal, with Democrats seeking to explain to voters how a public plan will reduce costs and improve the economy, and Republicans telling voters that it is a dramatic expansion of government into the private sector on top of the bank bailouts and taking a majority ownership in General Motors – formerly the largest company in the world.

Even without a circumscribed public plan option – or without any legislation being passed at all – the Democratic party’s making health reform such a high profile issue has virtually guaranteed that it will be a major election issue in 2010 and 2012.  At least for next year’s election, the Democrats will be defending their actions, and depending upon the outcome from this year’s legislative efforts, Republicans will likely adopt their own strategy from Rham Emanuel’s philosophy “never let a crisis go to waste.”  For Republican strategists that “crisis” may be their projections of the ill effects the new health reform law will have for the country and the voters, or it may be just the “crisis” in our healthcare system not having being addressed by Federal legislation.  In either case, with expectations being set so high, there will be major fights about who did and didn’t do what and why, with the result being that Members of Congress from swing districts – particularly those without deep rooted home town appeal – may get swept up in the storm and deposited someplace else like poorly anchored boats in a hurricane.

In this blog I try to explain the meaning of different aspects of healthcare reform, delivery, financing, research, etc.  Sticking to that goal has left me a bit stymied in seeking to write about the current state of the “debate” as it is being played out in Congressional town hall meetings and in the press via partisan talking heads.

My simplistic conclusion is that the balance between policy and politics has now swung so far and hard to one side that the needle is firmly wedged against the peg of politics. While the needle may bend from all this pressure, it doesn’t seem to be leading to any improvement of healthcare costs or quality.  It also seems unlikely that the major health industries supporting health reform will do much to move the needle, since they wouldn’t want to antagonize anyone because the needle of politics moves over time, and today’s minority might be tomorrow’s leadership – which is presumably what those promoting the anti-messaging campaign are hoping for.

Clearly the world of health reform policy, politics and messaging will be very different when Congress returns in September than when they went on recess. Whether this altered reality will sink the prospects for national legislation, or just shift its content dramatically – either to the left as the quest for bipartisanship is abandoned, or by shrinking its scope to eliminate the misrepresented provisions – remains to be seen.  Stay tuned, stay cool, and takes some time to smell the flowers – “it” won’t be over soon.

(Flower from my garden – Email me if you want some seeds to plant in your garden next year.)

With the House and Senate unveiling draft descriptions of their health reform bills, national health reform activities are heating up.  The escalating focus on health reform by Congress and all interested parties was illustrated by the cover and contents of last week’s National Journal.

The cover of the June 13th issue of the National Journal featured Karen Ignagni, head of the American Association of Health Plans (AHIP), the health insurance trade association. The main story inside is about Karen Ignagni, and leaders of other key groups, including Dan Danner (NFIB), Andy Stern (SEIU), and Ron Pollack (Families USA), and how their groups are working much more cooperatively than in the fierce fighting days of the early 1990s. (The interesting point about Karen Ignagni that the article notes, but does not highlight, is that she used to work for the AFL-CIO, and thus does not come out of the Gordon Gekko mold that is sometimes used to characterize the health insurance industry, i.e. profit above all else.)

Aside from the 8 page cover story, the inflammation of health reform on the national stage is evident by the magazine’s coverage of health issues in a poll, an article about a Member of Congress’ approach to her personal health challenges, two columns, two short notices, and 5 full page ads:

• National Journal Insiders Poll about “how important is it to President Obama that health care reform be bipartisan?” (74% of Democrats said very or somewhat important, as did 70% of Republicans)
• Article about Representative Debbie Wasserman-Schultz’s approach to her breast cancer diagnosis and treatment
• Clive Cook’s column “Health Reform’s Twisted Economics” about how the balance of priorities between coverage expansion and cost containment has tipped back and forth during the campaign last year and in the current legislative debate
• Ron Brownstein’s column “Insurance for Insurance” about how limiting the tax exclusion of health insurance may escalate concerns about the growing financial strain copayments and deductibles are having for people with health insurance
• Short notices about the bill giving FDA authority to regulate tobacco, and Sen. Conrad’s proposal to morph the public plan concept into co-operative organizations
• Kaiser Permanente ad about disparities in health insurance coverage
• Mars ad about their more nutritious products and eliminating advertising aimed at kids under 12
• McDonald’s ad about their healthier menu options
• Medco ad about how advanced pharmacy services improve clinical and economic outcomes
• Siemens ad about information technology for improving healthcare quality

Health Reform Outside of DC, i.e. the Rest of the Country
All of this coverage (and advertising) is consistent with the mainstream discussions about the fulcrum issues of cost containment, mechanisms for increasing coverage, (e.g. mandates on individuals and/or employers), and the public plan option.  But it should also be realized that this is not the context for health reform discussions across the country.

Last night I went to a gathering of about 60 people in Cambridge, MA interested in health reform.  Contrary to the national debate, their focus was almost unanimously how to push for a single-payer health system.  While this discussion is outside of the mainstream of the legislative debate, I’m sure in other parts of the country, (colored red on some people’s maps), similar groups are discussing how to advocate for limiting the government’s role and involvement in the health care system.  These discussions may be supportive of proposals for limiting the tax exclusion of health insurance premiums that are popping up in the middle of the national debates – even though Democrats’ cautious interest in this idea is based upon the many billions of dollars it could raise to pay for coverage expansion rather than any philosophical support for eliminating employment based health insurance, or dramatically expanding the individual purchasing market for health insurance, or limiting the government’s direct role in the health system.

What will happen?
An accurate crystal ball would be great to have right now, but the only thing that seems certain is that more proposals will be put forth by Congress and others, the Administration will continue to engage in the debate trying to get something substantive that achieves as much of their goals as possible, and many more articles will be written and ads placed in publications like National Journal and Roll Call.  When these ads start hitting the media and airwaves outside of DC it will indicate that the debate has reached the next level, i.e. stakeholder groups will then be trying to educate the general public and activate them to engage their Members of Congress and the Administration about specific proposals and pieces of legislative language that today are still in flux and draft form.