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How The Opposition Might Emerge
In Health Care Debate

Jun 05, 2009

It’s almost crunch time: Influential senators involved in drafting health care legislation say they will begin unveiling bills within days. That means the real debate is about to begin. The big question: Where will the opposition come from and how intense will it be? We consulted policy and political experts to find out what they think will happen next.

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Top Row (L-R): Feder, Butler, Burgess, Garin
Bottom Row (L-R): Helms, Altman, Turner, Goodman


Geoff Garin
President, Peter D. Hart Research Associates
Democratic pollster and strategist

“I think the attacks will be led primarily by Republican politicians, and ideological allies. I don't think it will be led to the same degree by business groups and health care interests…The Republicans have built up a brand over the last few months of being the party of "no" and kind of a pro-status quo party .... My guess is that a lot of this will be done by the Republican leadership itself. I'm sure we'll hear from (former House Speaker Newt) Gingrich, (talk show hosts) Rush Limbaugh and Sean Hannity.

“The Republicans wrote their talking points before the Democrats wrote their plan and we already know they're going to make the same attack they made against health care, health reform in '93 or '94, even though we’re not talking about a plan that looks like '93 or '94. So it's all going to be about 'government-run health care.' … They're going to be making a 16-year-old-argument against something that is very different from the plan of 16 years ago … And at the end of the day, (if it's) a debate between Barack Obama and (Senate Minority Leader Mitch) McConnell, Obama is a better and more credible communicator.”


Rep. Michael Burgess, M.D., R-Texas
Advisor to Sen. John McCain during 2008 presidential campaign


“(Sen. Edward Kennedy is) pretty far left of center – I don't think anyone would dispute that – and the programs he's putting forward are pretty (far) left. From my standpoint as someone who's right of center, perhaps it's good to have the more explosive proposal being talked about first. Maybe that's what it takes to get people fired up.

“If (the bill) is in line with the principles that were talked about last week, the immediate casualty is Sen. (Max) Baucus, D-Mont., and the bipartisan work that he's been so careful to do. He's the one most immediately at risk.

“Government-run insurance is a big concern. Mandates are a big concern, whether (on) individuals or businesses. The (May unemployment report)…that's not going to look good, and a new tax in the form of a mandate is the absolute worst thing for that.


Stuart Butler
Vice President, Domestic and Economic Policy Studies, The Heritage Foundation

“I think (the public plan) could easily kill the legislation because the coalition that’s both inside and outside the Congress that actually wants to get an agreed, bipartisan solution will come apart. The Business Roundtable and the employers are utterly opposed to it because they feel… it will have low rates and the higher cost will be shifted to them. People in the medical profession and the health industry see it as a sort of Trojan horse for a single payer system. A public plan in any proposal is a death sentence to the health insurance industry…. So, they will not go along with it.

“If I were Sen. (Max) Baucus, the nightmare scenario would be that you feel you have to incorporate a public plan, so that means then that Sen. (Charles) Grassley and everyone to his right declines to support it and actively opposes it, then in order to get enough votes to get reconciliation you have to incorporate other things that people on the left want in a much more vigorous and clear way. Then public support for the proposal falls apart as vehement opponents from the business community, insurers and the health care industry convince ordinary Americans that this is a travesty of what they were promised in November.

“There are several others that are potentially contentious. The idea of a mandate, which I think can essentially be finessed, I think is going to be a potential problem. President Obama’s letter yesterday to the Hill talked about a hardship waiver for people who feel cost is a problem. I think that’s got some potential ... I think pay or play is going to be a problem, certainly for smaller firms. I think the idea of taxing benefits above a certain point is going to be controversial. But I hope it will be included and I think it can be done in a way that reduces potential opposition by having it adjusted for high cost areas of the country or older workers and so on.”


Judy Feder
Senior Fellow, Center for American Progress

“The more freedom a public plan has, the more assertive it is able to be, the more it will be able to constrain costs. One purpose of the public plan is to put some more competition in the marketplace. The insurers are concerned that there is going to be some really strong competition. (But) I think it's reasonable to expect them to deliver on what they have long claimed to be able to deliver on…The industry leaders have said they can save some money, and they might see some policies pushing them in that direction, but we should hold them to their promise.

“Anybody who says that this is taking away choice is ignoring the premise of this legislation, as I see it, to expand choice and bring an end to a situation in which too many people have no choice, and their coverage is dictated by an insurance company.”


John Goodman
President, National Center for Policy Analysis


“If health care reform is stopped, it will be stopped in the hinterland. At one point, it looked like (the Clinton health reform) plan would just sail through. What stopped Hillary's plan was the negative reaction by voters all across the country. The same thing's going to happen again. All these interest groups are going to be ready to sign on, but there's going to be a negative reaction by the voters.

“I'm really surprised Obama is backing the public plan because all the interest groups are willing to sign on to this, but the public plan could make the doctors and insurers bolt. All these groups are saying they want to be part of the solution… But it's hard for me to imagine AHIP (America's Health Insurance Plans) supporting a plan that would destroy the insurance business. It's a significant deal killer for members of the group that are negotiating all this. It's a deal breaker for both sides. (Liberal economist) Paul Krugman said if there's not a public plan in this, he's not signing on.

“The small employers aren't even at the table… In general, small business doesn't have the lobbying clout that large business does. There's a huge amount at stake because the small business sector is the job-creating sector, and what we're talking about is a huge tax on labor.”


Drew Altman
President and CEO, Kaiser Family Foundation


“The real debate on health reform will begin afresh once there is legislation on the table with details about how health reform will work, and especially details about how it will be financed. That's when we will find out whether health care's legendary interest groups -- who have been on the train -- will stay on the train.

“In order to put together a financing package to pay for the plan, (Congress is) going to have to include some reductions in future payments to hospitals and doctors under Medicare. The hospitals and doctors have been strongly supportive of health reform so far -- will they remain supportive?

“(Congress) is going to have to raise some revenues in order to pay for the plan, and they're looking hard at the tax preference for employer-based health insurance and whether it should be capped. Labor is strongly opposed to that. And if they do, how hard does labor fight? Labor is caught in the middle; it very much wants health reform, but it does not want the tax preference cap because it feels that it fought for that benefit in lieu of higher wages in the past.

“Small business is a group to watch very, very closely because there's little doubt that an employer mandate (to buy insurance for employees) will be a part of this. Small business has opposed employer mandates in the past, even when the tiniest firms have been exempted. If small business is supportive of the legislation with an employer mandate, then that really will signal that we're no longer seeing the kind of interest group opposition to legislation that we've seen in the past. That really is a kind of bellwether to watch.

“AHIP (America’s Health Insurance Plans) and the insurance industry have been at the table and even making their own proposals ... Unless the Congress goes further than it has gone so far, it might very well be that the insurance industry stays at the table to one degree or another and just fights on details, such as eliminating medical underwriting or placing limits on what insurance companies can charge for administration and profits, which I do expect to be a fight…They're very worried about their image as an industry and want to try and remain positive and at the table overall.


Grace-Marie Turner
President, The Galen Institute


“I have said for a long time that there is something I call an 80-20 rule in this health reform debate and that addresses the issue that most of the people who have been around the table talking about health reform with the president, with the leadership in Congress and others can go along with about 80% of the reform agenda… but there is 20% that is going to really make their business model very difficult. For example, the health insurance companies, they're fine with an employer mandate and certainly even an endorsement of an individual mandate, but they really are going to fight tooth and nail over a public plan because they see that this is going to put them out of business.

“The AMA has said for a long time that they're not going to talk about this until they actually see a plan. And even I hear doctors very concerned that if they have a significantly larger number of their patients paying at Medicare or Medicaid rates that they are really worried about whether or not they can keep their doors open.”


Robert B. Helms
Resident Scholar at American Enterprise Institute for Public Policy Research

“I’ve had a number of Democratic friends say (reform) is just inevitable. They’re going to pass something this year. They’re going to ram it through. I think the Democrats have to have something at this point but it doesn’t mean it’s going to be smooth sailing ... There are lots of things I see a lot of people not agreeing on. In a certain fundamental sense, I think everyone I know, no matter where they stand on this thing, is in agreement that we need to do something.

“There just doesn’t seem to be any strong opposition to this at the moment, effective political opposition. Now, what’s going to happen with the small business community and so on if they get some sort of employer mandate? And I would imagine there’s going to be a lot of people who will rise up about this individual mandate. Right now, it’s hard to see if there’s going to be any sort of organized resistance to this despite what a few of us think tankers say… (The lightning rod issues) will be the public plan, you know, this notion of Medicare for all, and the employer mandate will probably be more of an issue for the business sector than the individual mandate. But, still, both of those have the potential. And, then there is just the broader economic issue of how to fund this and what it does to the debt.” 


Jennifer Evans, Jenny Gold, Jessica Marcy, Jaclyn Schiff, Stephanie Stapleton, Andrew Villegas, Christopher Weaver contributed to this story.

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