... is how Chris Frate aptly characterizes the Democrats' state of mind on how to proceed with health care reform. It doesn't help that President Obama and his White House staff are sending mixed signals.
It seems as if there are only a few options left:
- The House passes the Senate bill "as is" but with a commitment to modify parts of it through a separate budget reconciliation bill. This has the advantage of not requiring 60 votes because a filibuster is not in order in the Senate for a bill that has already passed and is awaiting action by the other chamber. Any changes made through budget reconciliation can also be passed by a simple majority. But as the Washington Post reports today Speaker Pelosi has rejected this option, at least for now.
- The House and Senate could drop the current bills and start anew with drafting a new bill to be passed strictly through budget reconciliation on a strict majority vote. This though creates all kinds of political and procedural hurdles - including the need for the committees of authorization to have to "mark up" a new bill. The reconciliation bill could only include provisions with a direct effect on federal spending and revenue, so popular regulatory provisions, like banning pre-existing conditions exclusions, likely would have to be left out. And, with the Democrats eager to get health reform behind them, I don't see them wanting to start anew.
- Reid and the White House could reach out to a small handful of Republicans, like Olympia Snowe (R-ME) and Susan Collins (R-ME), to get them to support a compromise that gets them to 60 votes. Not impossible, but difficult, because the Democratic leadership may have burned bridges with them, and the few Republicans who might be "in play" will be under tremendous pressure from their party not to play ball. Compromises to get GOP votes will run the risk of losing votes from Democrats, and I would not be surprised to see some of the Senators who voted for the current bill having second thoughts. The back-and-forth negotiations that would be required would drag the process out longer and lead to more deal-making, the last thing the Democrats want.
- Or the Democrats could themselves break the bills up into individual parts and force Republicans to vote for or against provisions that may be popular. The likely result would be a far less expensive bill that would make modest changes (like banning pre-existing conditions and voluntary pooling arrangements, maybe with Medicaid expansion and some limited subsidies targeted to the poor). This too, though, would require new committee "mark up" and drag the process out for months, with no certainty of success. And disaggregating the bills could lead to an unworkable result: for instance, requiring that insurance companies accept people with pre-existing conditions (popular with voters) likely will require a mandate that individuals buy insurance (less popular) and subsidies (very expensive) to make coverage affordable.
- The White House and Congressional leadership could just walk away from the process of trying to get health reform passed and try to blame it on Republican obstructionism, making the midterms a referendum where both sides would point figures on why health reform failed.
Where does this leave ACP and its public policy agenda? We don't control the politics, process or procedures of health care reform. Our agenda is determined by our own policies - not the politics of the moment. As such, we will continue to advocate that Congress enact legislation to advance our four priority areas: coverage for all, workforce and primary care, payment and delivery system reform, and medical liability reform. We have been pushing this agenda long before the latest political developments, and will continue to do so until progress is achieved.
There is no easy way forward. But if health reform fails, the best opportunity we've had to advance fundamental reforms to achieve key policy objectives - like reforming Medicare payments to support primary care, training more primary care internists, funding research on comparative effectiveness, and of course, affordable coverage for all - will be set back. And if health reform fails, health care spending will rise at a rate that that the country simply can't afford.
Kevin Pho, MD, may have said it best, in his admonition to his colleagues on the Right:
"With the potential defeat of ObamaCare, you may have won the battle, but will lose the war. The current health reform efforts, in the grand scheme of things, were very incremental in nature. Without it, the number of uninsured will rise, and health costs will continue to spiral upwards. That will eventually bring America's economy to its knees, and, as I said a few months ago, 'once that happens, more draconian measures will be forced upon us. Measures that assuredly will not be friendly to doctors.'"
Today's question: Do you agree with Kevin Pho that defeat of Obama's health care reform will lead to more draconian measures being forced upon physicians?
P.S. - The ACP Advocate Blog with Bob Doherty has been nominated for consideration in the Best Health Policy/Ethics category in the 2009 Medical Webblogs Award Program sponsored by epocrates. (It may not yet show up yet in the list of nominees, since it usually takes a day or so for the latest nominees to show up.) If you would like to support the nomination, you can do so by following the instructions "to place a nomination." The editors ask that when nominating, you indicate the blog's name and URL, as well as your thoughts why this particular blog deserves recognition.