Obama win accelerates drive for health system reform

Washington -- Democratic control of the White House and gains in both houses of Congress have raised expectations for comprehensive health system reform to their highest levels since the early 1990s, when the party last found itself in a similar position.

The results of the November elections prompted physician organizations to predict that 2009 will be an active year for reform. They're calling on President-elect Barack Obama and Congress to expand health coverage to the 46 million uninsured and to take the lead on such issues as fostering primary care and medical homes.

"We think there's that window of opportunity next year to really accomplish something," said AMA Board of Trustees Chair Joseph M. Heyman, MD.

Ted Epperly, MD, the American Academy of Family Physicians' president, said he has never before been so excited about a new president. "I believe that under his leadership we will finally start to make significant change toward health [system reform] in this country."

It won't be long before the new Congress and White House have the chance to test out their power arrangement with a major health access issue. The State Children's Health Insurance Program will expire at the end of March, unless there is an extension or reauthorization. Attempts by Democrats this year to expand SCHIP coverage to millions of additional children were stopped by President Bush and his GOP allies.

With Obama at the helm, Democratic leaders in Congress already have set policy sights much higher. They want to cover as many of the nation's uninsured as possible.

Senate Health, Education, Labor and Pensions Committee Chair Edward Kennedy (D, Mass.) plans to build off private meetings with representatives from myriad groups to seek consensus on comprehensive reform. Sen. Max Baucus (D, Mont.), chair of the powerful Senate Finance panel, detailed some of his plans for reform on Nov. 12. House Energy & Commerce Committee Chair John Dingell (D, Mich.) wrote a Nov. 10 letter to Obama asking to work with him on comprehensive reforms, starting with an SCHIP expansion.

Such individual efforts likely will merge into a single strategy, said Michael Myers, majority staff director for the Senate HELP Committee. "There's a growing recognition that the best way, maybe even the only way, that this gets done is for Democrats to unite behind a single bill."

Following Obama's lead

Obama ran on a health platform of improving the employer-sponsored health insurance system, not dismantling it to try a new approach, such as a single-payer system. Democrats don't plan to buck the next administration on that issue, Myers said.

Obama pledged to allow people who are happy with their job-based health insurance to keep it as is, but he promised that his plan would make it less expensive by creating a new national market for health insurance. He also pledged to cover more uninsured people in Medicaid and SCHIP.

Meetings among Democratic staffers have focused on how to translate the Obama plan into compatible legislation, Myers said. "Everyone in Congress, at least on the Democratic side and certainly Sen. Kennedy, is going to be taking their cues from the Obama White House on this effort."

Obama supporters are mostly interested in getting help paying their health insurance, said Robert Blendon, ScD, a professor of health policy and political analysis at the Harvard School of Public Health. "We don't find the evidence they were thinking of new ways to reorganize the health care system."

Myers said that likely rules out legislation that would overhaul employer-sponsored health insurance, such as Sen. Ron Wyden's (D, Ore.) bill.

Wyden's bill, the Healthy Americans Act, would replace the employer tax exclusion with a standard tax deduction and an individual health insurance mandate. It would shift most Medicaid and SCHIP enrollees to new state-run insurance pools.

But Wyden said his measure shares many principles with Obama's plan, such as strong support for preventive medicine and comparative effectiveness research. The AMA has not officially endorsed Wyden's bill but has been supportive of his efforts to find a bipartisan approach to health system reform, Dr. Heyman said.

Obama's call for fostering greater care coordination through medical homes echoes physician organizations such as the AAFP and American Academy of Pediatrics. He and the AMA also agree on the need to back income-based insurance subsidies and health information technology.

"I'm sure there are more areas where we can agree than areas where we might disagree," Dr. Heyman said. Obama campaigned against ending the tax exclusion for employer-sponsored health insurance and replacing it with tax credits -- part of the AMA's uninsured proposal. The president-elect might be more supportive of expanding public health insurance programs than is the AMA, Dr. Heyman said. Still, both agree on the need for a mix of public and private solutions.

Finding federal funding

Obama gave no indication the economic recession was leading him to scale back his spending plans. Voters who backed him also have high expectations for health care change despite the financial challenges, Blendon said. "He can't say, 'I'm going to do nothing or something very small.' "

The president-elect's health system reform plan would cost at least $65 billion a year, according to estimates by his campaign staff. This figure assumes the reforms he proposes reduce health spending in other areas.

Experts said needed funding will be hard to find. The next Congress is inheriting a $10 trillion debt and has not made plans to address the more than 20% Medicare pay cut that physicians will receive in 2010. The Medicare hospital trust fund also is set to be exhausted by 2019. "This current Congress coming up needs right now to start dealing with that issue," said Phil Roe, MD, an ob-gyn and Republican newly elected to Tennessee's first congressional district.

But Dr. Epperly said the recession actually could further the cause of health system reform. People who have lost jobs and health coverage should be more apt to support new types of health legislation, he said.

Dr. Heyman said adopting comprehensive reforms is not primarily a matter of dollars. "If we have the political will to spend $700 billion in a week's time to cure the economic crisis, which is a temporary problem, we ought to have the political will to spend much, much less money on compromising and finding a solution to this long-term problem."

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