Perspective

Press Ahead or Scale Back? The Reform Effort after the GOP Victory in Massachusetts

John K. Iglehart

N Engl J Med 2010; 362:e14February 11, 2010

Article

For almost a century, U.S. presidents have tried and failed to enact comprehensive health care reform featuring expanded coverage.1 In a development never imagined by most Democrats, President Barack Obama's name may be added to this list because his party lost its filibuster-proof 60-vote Senate majority on January 19, thereby imperiling its ambitious reform package. In the wake of Republican Scott Brown's upset victory in the race to fill the seat long held by the late Senator Edward M. Kennedy (D-MA), congressional Democratic leaders and the White House are discussing how to proceed on reform, but no early consensus has emerged. Given the circumstances, Democratic House leaders seem to think they could win support only for a scaled-down reform package, whereas the White House is inclined toward a bolder strategy: House passage of both the Senate-approved reform bill and a second measure that would refine provisions of concern to House Democrats, then Senate passage of the second measure, and delivery of a final package to Obama for his signature. Though Obama will plug health care reform in his State of the Union address on January 27, he may not be able to outline a definitive strategy in the face of Democrats' uncertainty.

Brown, the state senator who defeated Massachusetts Attorney General Martha Coakley by a margin of 52% to 47%, ran a campaign with a low-tax, less-government message that tapped into voters' anger over the high unemployment rate, the increased concentration of power in Washington, and the troubled economy. Brown vowed to vote against the Democratic health care reform proposal should he win the election. Obama said in an ABC News interview that “the same thing that swept Scott Brown into office swept me into office. People are angry, and they're frustrated. . . . You've got really hard-working folks all across the country who have seen their wages flatline and their incomes flatline. . . . And here in Washington — from their perspective — the only thing that happens is that we bail out the banks.”

Public opinion surveys showing disenchantment with the direction in which the country is moving revealed a distinct shift in the attitudes of independent voters, not only in Massachusetts but in the gubernatorial elections last November in Virginia and New Jersey, which were also won by the GOP.2 Independents who were key to Obama's victory in 2008 swung decidedly against Democrats in all three states. Independents went nearly 2 to 1 for Brown in Massachusetts, where voter turnout was the highest for any non-presidential election there in 20 years. Senator Evan Bayh of Indiana, a Democratic moderate, said, “If you lose Massachusetts and that's not a wake-up call, there's no hope of waking up.” However, 68% of the voters in the special election said they supported Massachusetts' health care reform,2 on which the Democrats' national plan is largely modeled.

Brown's victory means he can fulfill his pledge to vote against the national Democratic reform bill, denying the party the 60 votes it needs to overcome a Republican filibuster. Beyond that, the election outcome in one of the country's most liberal states alerted many moderate and conservative Democrats — particularly those who will face voters in November — that the party's reform bill could endanger their own prospects for reelection.

Congressional actions thus far have taken Democrats closer to enactment of comprehensive health care reform than any party has gone before. After months of debate and delay, House and Senate Democrats managed to pass reform bills, but the margins were razor-thin. The vote in the House, where Democrats hold a commanding majority (256 to 178, with one vacancy) was 220 to 215 on November 7. In the Senate, on Christmas Eve, the reform measure was approved without a vote to spare, 60 to 39 — the minimum number Democrats needed to avoid a Republican filibuster.

Within a day after the Massachusetts election, Democrats began discussing possible next steps in their quest to enact the administration's signature domestic issue. At first, in a January 20 interview on ABC News, Obama expressed a leaning toward the crafting and passage of a scaled-down reform bill. Two days later, however, striking a populist tone in an unusually fiery, defiant speech in Ohio, the President indicated that he favored enactment of a robust health care reform measure, without using the word “comprehensive.” “This is our best chance to do it,” he said. “We can't keep on putting it off.” Obama's senior advisor David Axelrod, appearing on ABC's Sunday news program “This Week,” insisted that a comprehensive reform bill was not dead and said that, “as a political matter,” it would be “foolish” for Democrats who already voted for the reform package to “walk away from it.” Axelrod added, “The underlying elements of it are popular and important, and people will never know what's in that bill until we pass it, the President signs it, and they have a whole new range of protections they never had before.”

If the House successfully pursued what seems to be the White House's preferred strategy (which has now been endorsed by a group of 48 respected health policy experts3) and passed the Senate bill along with a second corrective measure, it could mean sidestepping a Republican filibuster — at least if Senate Democrats passed the second measure using a parliamentary maneuver known as “reconciliation,” which requires only 51 votes (though it also requires all provisions to have a direct effect on the budget). This approach could thus avert the need to reopen countless issues that would be entailed in crafting a scaled-down bill. However, when House Speaker Nancy Pelosi (D-CA) emerged from a caucus meeting on January 21, she told reporters that this approach currently lacks the necessary support: “I don't think it's possible to pass the Senate bill in the House. I don't see the votes for it at this time.” Pelosi indicated that her members particularly oppose a Senate provision benefiting only Nebraska's Medicaid program, which was added by Senate Majority Leader Harry Reid (D-NV) as part of the price that Senator Ben Nelson (D-NE) exacted for his vote.

Moreover, some Democratic lawmakers point to public opinion surveys indicating that more Americans oppose action on a comprehensive bill than support it; they therefore argue that a scaled-down reform package is their best hope for success. Such a package could include provisions designed to prevent private insurers from denying coverage to children because of preexisting conditions and a requirement that carriers offer policyholders an opportunity to extend coverage to their children through age 25. Other possible provisions could provide federal financial incentives to states to expand Medicaid to childless adults and parents, grants to states to establish regulated insurance markets (exchanges) through which individuals and small businesses could purchase coverage, some cost relief to Medicare beneficiaries who use multiple prescription drugs, and tax credits to small businesses to help pay for employee health benefits.4

Before they decide to lower their ambitions to such a package, Democrats could heed the advice of Senator Christopher Dodd (D-CT) to take “a breather for a month or 6 weeks” and regroup. Coming out of their caucus meeting on January 26, Senate Democratic leaders were decidedly more pessimistic about quickly resuming the almost-year-long effort to enact a comprehensive measure. Senate Majority Leader Reid sidestepped questions about health care but then said, “We're going to find out how to proceed. But there is no rush.” Many Senate Democrats believe their best hope for enacting a reform bill is to have the House pass the Senate measure along with a package of revisions that would ease the concerns of some House Democrats. But whether there would be enough votes to embrace this strategy is an open question.

No matter the outcome of reform deliberations, Congress is certain to at least address the matter of greatest concern to doctors: a scheduled 21.1% reduction in Medicare's physician fees, effective February 28. The scheduled cut — based on the congressionally prescribed formula known as the sustainable growth rate (SGR) — will most likely be addressed in legislation that is separate from any reform proposal. A House-passed bill that would eliminate the SGR and replace it with a new payment approach has been placed on the Senate calendar. The American Medical Association and its allies have been pressing Congress to expedite passage of this measure, but its hefty 10-year price tag of $210 billion is giving many members pause. On a separate front, the administration and Democratic congressional leaders are discussing a different approach to the fee fix by attaching it to a must-pass measure that would increase the federal debt limit.

Meanwhile, Republicans have their own preferences for a way forward on the overall reform: according to Senate Minority Leader Mitch McConnell (R-KY), Congress should start over and craft a plan that features stronger ways of reducing the growth of health care expenditures. It may be true that, as even a Wall Street Journal editorial concedes, “everyone agrees that the status quo is unsustainable, and if Democrats are really serious about a good-faith compromise, perhaps a modest truce could still be brokered.”5 But the editorial's prescribed approach, like that of most Republicans, is greater reliance on marketplace competition, medical innovation, and their “resulting efficiencies.” By contrast, Democrats favor reliance on greater government regulation, an individual mandate that requires everyone to carry coverage, and a publicly administered national insurance exchange. This sharp division of ideology will continue to complicate and slow action on health care reform and many other major issues facing Congress and the administration.

Thus, a week after the Massachusetts election, uncertainty hangs over Washington. Enacting an entirely new bill, if Democrats choose to go that route, would probably take months and might not be possible before the midterm elections in November — and Congress is unlikely to have the appetite for another protracted reform debate when other pressing issues demand its attention. But perhaps ultimately, one way or another, Congress and the White House will find their way to incremental reforms — which are, after all, how the U.S. electorate generally prefers its policymakers to approach change.

This article (10.1056/NEJMp1000939) was published on January 27, 2010, at NEJM.org.

Source Information

Mr. Iglehart is a national correspondent for the Journal.

References

References

1
Blumenthal D, Morone JA. The heart of power: health and politics in the oval office. Berkeley: University of California Press, 2009.

2
Balz D, Cohen J. Polls finds Mass. vote reflects ongoing trend. Washington Post. January 23, 2010:A1.

3
Aaron HJ, Anderson G, Anderson R, et al. Letter to Nancy Pelosi, Charles Rangel, Henry A. Waxman, and George Miller. January 22, 2010. (Accessed January 26, 2010, at http://graphics8.nytimes.com/images/2010/01/22/health/adopt_senate_bill_final.2.pdf.)