The tone on Capitol Hill during Tuesday's debate was more civil, the partisan rhetoric less harsh than previous exchanges on the House floor. But there's little doubt that the Republican-led House will vote later today to repeal President Obama's signature health care reform law.
That largely symbolic vote – there's almost no likelihood the Democratic Senate will follow, nor would the president sign the bill – signals the start of a two-year campaign by newly empowered Republicans in the House to undermine the new law. Proponents of "repeal and replace" will next turn to eliminating the most unpopular elements of the law—including the individual mandate – and to cutting off funding for implementation.
But the administration won a powerful set of centrist allies on Tuesday as it scrambled to set in motion reforms that it believes will be popular with the American people once its key provisions go into effect. The new law, signed by Obama last March, is designed to provide about 32 million previously-uninsured Americans with coverage either through Medicaid or subsidized private insurance sold through state-based insurance exchanges. The total cost of the program of about $900 billion will be paid for by a combination of tax increases and slower growth in Medicare spending. The law also places consumer-friendly restrictions on insurance carriers, funds Medicare pilot models in alternative care delivery, and creates a government-run long-term care insurance program.
Republicans contend that the law is overly intrusive and that it will drive up the deficit and destroy jobs. But a bipartisan group of former senators and high-level health political operatives launched a new program to help states organize viable health insurance exchanges, the centerpieces of the effort to provide coverage for the uninsured and small businesses under the law.
While the state-based exchanges won't begin operating until late 2014, efforts to get them up and running are already underway in many states, including several whose attorneys general have challenged the law in court. To help them iron out problems encountered along the way, the Bipartisan Policy Center recruited two former Senate majority leaders, Democrat Tom Daschle and Republican Bill Frist.
The center's Health Project also corralled Sheila Burke, Republican Sen. Bob Dole's former chief of staff, and Chris Jennings, who was former President Bill Clinton's top health care aide, to help coordinate and staff the effort. The two have decades of experience on Capitol Hill, and are considered among the most knowledgeable health policy experts on either side of the aisle.
In announcing his support for the project, Frist, a physician, said efforts to repeal the law rather than fix its shortcomings were shortsighted. "It's not the bill that I would have drafted, but it is the law of the land," he said at a news conference. "It is the platform, the fundamental platform, upon which all future efforts to make this system better for that patient, for that family, for that community, will be based."
Republicans may succeed in slowing down the process by going after funding for the Health and Human Services Department that is charged with implementing the law. But it won't be stopped, Frist predicted. "The appropriations will be a vehicle by which the implementation is titrated," he said. But there will be countervailing pressures from within the Republican Party. "When I talk to governors in the states, they want the grants to flow even quicker," he said.
Daschle, for his part, signaled a new flexibility on the part of Democrats to allow greater experimentation in the states. Most of those states have Republican governors and legislatures following last November's election. The administration has already granted a number of waivers to firms that provide insurance policies that don't meet minimum coverage rules or have excessive administrative costs. The rules for the minimum benefit packages that will be sold on the exchanges are being written now. The administration's regulations should "allow states significant breathing room and ample opportunity to adopt the health care reform law to their own needs," Daschle said.
The recession-induced financial crisis faced by most states has dramatically altered the landscape on which reform will play out. Of the 32 million or so Americans slated to gain coverage under the new law by 2019, about half would find themselves in expanded Medicaid programs – a program that is going broke in most states.
Former Ohio Gov. Ted Strickland, who was recruited to the Health Project after losing his bid for re-election in November, predicted that hard-pressed states in the short-run will continue to make sharp cutbacks in Medicaid programs to help balance their budgets. In one of his last acts in office, he eliminated dental coverage for Medicaid recipients, even though medical research shows that the short-run savings from the cuts will wind up increasing long-term health care costs since untreated cavities often lead to serious infections, oral surgeries and systemic infections.
"What voters want from us now is to deliver pragmatic and practical solutions to the many financing and delivery system problems that we will face in implementing health care reform," he said. But what voters want and what takes place on Capitol Hill can be two very different things. The weeklong rhetorical hiatus after the attempted assassination of Rep. Gabriel Giffords, D-Ariz., and the tragic killing of six bystanders in Tucson gave way Tuesday to the usual partisan hyperbole.
For instance, the administration began gearing up its own propaganda machine to counter Republican claims that health care reform is "job-killing," the name given to the repeal resolution. But rather than focus on whether the bill will dissuade small business from creating jobs – something that's largely unknowable for legislation that is still more than three years away from implementation – the Democrats highlighted the benefits already enacted under the law.
HHS Secretary Kathleen Sebelius released a report that claimed "between 50 and 129 million non-elderly Americans have at least one pre-existing condition that would threaten their access to health care and health insurance without the protections of the Affordable Care Act."
The larger number counts every American who takes a pill for hypertension or elevated cholesterol. While that is, by medical definitions, a pre-existing condition, it's not very likely that many Americans have been denied insurance coverage because they take drugs to manage these warning signs of heart disease.
In fact, some insurance companies are starting to waive co-pays for such drugs. They believe that paying more now to foster better compliance with medication schedules will reduce the incidence of much more costly heart attacks and strokes down the road.