Perspective
The Democrats' Last Ditch — Reconciliation or Bust
N Engl J Med 2010; 362:e39March 18, 2010
- Article
The endgame has begun: with Republicans staunch in their opposition, the Obama administration and its congressional allies are poised to go it alone on a tortuous path toward enactment of ambitious health care reforms. To achieve their elusive goal, congressional Democrats may have to wield a controversial parliamentary maneuver and persuade 50 senators to vote for legislation designed to carry their reform bill to victory (Vice President Joseph Biden could then cast the 51st vote). But the first move in this three-step gamble is for the House Democratic leadership to persuade some of their more conservative colleagues who favor either more stringent abortion restrictions or greater fiscal restraint to vote for a bill that barely cleared the Senate on Christmas Eve. Although Republicans have used the parliamentary maneuver known as budget reconciliation, which enables the Senate to pass a bill with 51 votes rather than the 60 that have become necessary for contentious measures, in order to pass large tax cuts and other major measures, they now assert that using it to enact a Democratic health care reform proposal “would be an unprecedented, dangerous and historic mistake.”1 Nevertheless, Democrats believe it is their only remaining hope for securing approval of President Barack Obama's major domestic initiative.
This showdown comes 14 months after Obama took office, determined to achieve a goal that has eluded the Democratic party for decades: securing “affordable, accessible health care for every single American.” With Democrats commanding the White House and Congress, the stars seemed to be aligned. After the House approved its Democratic reform bill on November 7 by a vote of 220 to 215, with only 1 Republican in support, and the Senate approved its measure on December 24 by a vote of 60 to 39, most Democrats assumed that all that remained before they could claim victory was reconciling the two measures. But a political bombshell struck on January 19, when Republican Scott Brown won a special election in Massachusetts to succeed the late Democratic Senator Edward Kennedy. Brown's victory cost the Democrats their filibuster-proof 60-vote Senate majority, imperiling their reform hopes and sending them in search of a new strategy.
Even before Brown's upset victory, another factor had begun to spell trouble for reform. In 2009, unprecedented federal actions were taken to stimulate the economy using trillions of tax dollars and to rescue companies deemed “too big to fail.” As unemployment rates rose along with the federal deficit, the electorate grew restive over the thought of another costly government intervention, and public opinion surveys documented substantial erosion in the level of support for the Democratic health care initiative. The public disenchantment with Democrats registered not only in Massachusetts, but also in New Jersey and Virginia, where Republicans claimed gubernatorial victories.
Responding to the Republican victory in heavily Democratic Massachusetts, Obama first signaled that he favored scaling back his party's reform ambitions but soon expressed support for a more robust reform measure. His mixed messages reflected divisions within the White House and among Democratic legislators.
Recognizing the public anger over the partisan rancor that has stifled progress on many issues, Obama sought to put health care reform back into play by inviting leaders of both parties to a White House–sponsored health care summit on February 25. Four days before the televised event, Obama had unveiled his own reform proposal, reclaiming ownership of the issue while striving to strike a compromise between House and Senate Democrats on issues that divided them.
From the outset of the unprecedented 7 hours of televised discussion, in which Obama acted as moderator and chief defender of the Democratic proposals, it was clear that the Republicans were in no mood to find common ground. The Republicans' first speaker, Senator Lamar Alexander of Tennessee, urged Democrats to abandon the House- and Senate-approved reform bills and start over. The Democrats rejected the idea and instead emphasized that there were reform issues on which the two parties could agree. In reality, the divide is fundamental (and has been for many years): Democrats believe that strong government intervention is the most viable prescription for covering the uninsured and slowing the growth of expenditures in the world's most expensive health care system. By contrast, Republicans believe that greater market competition is the better antidote in a society driven by capitalism.
The parties seemed to agree that private insurers should be more tightly regulated, given the steep premium increases they are seeking in the individual and small-group markets, but Republicans favor bolstering the authority of state regulators rather than accepting Obama's proposal to turn the task over to the federal government. Throughout the February 25 meeting, they disagreed over whether the government could afford to subsidize the coverage of millions of uninsured individuals at a time when Medicare is headed for bankruptcy and deficit spending is out of control. The Democratic proposals would cover some 30 million uninsured people over a decade, whereas Republican reform proposals would extend coverage to about one tenth of that number. Senator John Barrasso (R-WY), an orthopedic surgeon, asserted that Americans would make less costly coverage choices if they carried only catastrophic insurance that required them to pay for more services out of pocket. In response, Obama wondered aloud whether Barrasso would hold the same view if he earned $40,000 rather than a senator's salary of $176,000.
Although the sometimes heated exchanges failed to bridge any real divides, they did seem to stiffen Obama's resolve to go for broke with the Democrats' comprehensive reform package. At the summit's end, Obama suggested that if the parties could not reach agreement, Democrats were prepared to press ahead alone, letting voters be the ultimate judge. “That's what elections are for,” he said. Senator Tom Coburn (R-OK), a physician, responded, “I'm concerned that the majority in Congress is still not listening to the American people on the subject of health care reform. By an overwhelming margin, the American people are telling us to scrap the current bills” and start over with a clean slate.
In a conciliatory gesture to Republicans made in a March 2 letter to top congressional leaders, Obama wrote that he was “exploring” four ideas that GOP legislators had proposed at the health summit: an appropriation of $50 million for states to accelerate their testing of alternative solutions to resolving medical malpractice disputes; the engagement of medical professionals in conducting random undercover investigations of health care providers who receive payments from Medicare, Medicaid, and other federal programs; increasing Medicaid's payments to physicians; and expanding through insurance exchanges the availability of health savings accounts used in conjunction with high-deductible health plans.
It was Coburn who raised the idea of enlisting medical professionals as undercover agents to combat waste, fraud, and abuse in health care. Although Coburn still practices medicine, his idea may well raise hackles with other physicians who might regard participation in such oversight as an inappropriate role for practitioners. Nevertheless, Obama is likely to incorporate all four ideas in a revised version of his reform proposal, which the White House plans to release on March 3. His concessions do not reach the core of Republican objections to the Democratic reform proposals, but the White House hopes they will be seen by the public as another attempt to close the deep partisan divide that has stifled progress.
With a single roll-call vote, the House could send the Senate version of health care reform directly to Obama for his signature. But too many House Democrats object to provisions in the Senate bill. House Speaker Nancy Pelosi (D-CA) and her Senate counterpart, Majority Leader Harry Reid (D-NV), have been weighing for weeks potential “fixes” that would address the objections of House Democrats. They've concluded that their best hope is to resort to the difficult three-step process, with the House first voting on the Senate-passed bill. If it passed, House Democrats would take up a second measure addressing their concerns about key differences between that bill and the one the House passed in November, including the Senate bill's less restrictive language regarding the availability of abortion services, the scope of a new excise tax on “Cadillac” health plans that could affect middle-income families and union members, and the cost of reform. On the cost issue, House Democratic leaders are most concerned about the coalition of some 50 fiscally conservative Blue Dog Democrats, 24 of whom voted against the reform bill last November.2
In an appearance February 28 on ABC's “This Week,” Pelosi acknowledged that voting for reform will take “courage” and may jeopardize the political careers of some Democrats, but she added: “Why are we here? We're not here just to self-perpetuate our service in Congress. We're here to do the job for the American people, to get them results that give them not only health security, but economic security.”
Should the House approve the Senate reform bill and this second measure, the Senate would have to approve the second bill as well. Because Republicans would unanimously oppose it, Senate Democrats would have to resort to the budget-reconciliation process to win its approval. Under this parliamentary procedure, the Senate can approve a budget-related bill with a simple majority, rather than needing 60 votes to defeat a filibuster.
Given all the factors that could thwart this process — unanimous Republican opposition, a public soured on costly government efforts to rescue the economy with little immediate effect on job growth, and the wavering support of an increasing number of Democrats concerned about their reelection prospects in November — securing victory for reform would be nothing short of a political miracle. Should the effort fail, however, the problems that reform was designed to address will only worsen.
The erosion of employer-sponsored health insurance, a trend of the past several decades, has accelerated during the recession, with about 3 million more workers losing their private coverage. The Centers for Medicare and Medicaid Services projects that between 2009 and 2019, national health care spending will almost double, from $2.5 trillion to $4.9 trillion.3 If this projection proves accurate, health care expenditures will grow from 16.2% of the gross domestic product in 2007 to 20.3% in 2019, and public payers will become the largest source of funding for health care in 2016. With such rapid growth of expenditures, one can imagine a scenario in which policymakers are forced to adopt far more draconian measures to slow health care spending in order to address more urgent claims on public resources, such as national defense, rebuilding of the military, and improvement of the education system so that the next generation can better compete in the global economy. In such a case, policymakers might well have to put aside their ideological differences and engage in a bipartisan and more conclusive search for ways to stop the bleeding.
This article (10.1056/NEJMp1002479) was published on March 3, 2010, at NEJM.org.
Source Information
Mr. Iglehart is a national correspondent for the Journal.
- References
References
1
Frist B. A historic and dangerous Senate mistake. Wall Street Journal. February 26, 2010:A15.
2
Stolberg SG, Pear R. Wary centrists pose challenge in health vote. New York Times. February 28, 2010:A1.
3
Truffer CJ, Keehan S, Smith S, et al. Health spending projections through 2019: the recession's impact continues. Health Aff (Millwood) 2010 February 18 (Epub ahead of print).
