A HAMSTRUNG HEALTHCARE AGENDA

Their hands are tied.

Giddy Democrats danced into control on Capitol Hill last week, with healthcare a headliner of their agenda. But seldom has there been less wiggle room for substantive action by a new majority party in Congress. A tissue-thin margin in the Senate, large budget deficits on the horizon (pay no heed to last week's White House disinformation campaign on that score), threatened vetoes and a lack of political will combine to make it a rather tepid changing of the guard.

OK, a couple of modest healthcare bills, notably reimportation of prescription drugs from Canada, might even become law. Other actions, such as expansion of embryonic stem-cell research and allowing HHS to negotiate drug prices in Medicare Part D, may attract a measure of bipartisan support, but a Bush veto will only serve to hand the Dems good campaign issues for 2008.

Even if one of these controversial ideas is slipped into larger bills that the president feels compelled to sign, they won't do much to address the central healthcare issues of the day: the rising tide of uninsured and the health cost crisis.

Dramatic responses to the coverage problem are highly unlikely. Sen. Ron Wyden (D-Ore.) recently announced an interesting plan for an individual health insurance mandate coupled with an end to employer-based coverage. Employers would give their portion of the premiums to their employees, who would buy private coverage but couldn't be turned down because of their health status or age. Subsidies would be offered to help people up to 400% of the poverty line pay their premiums.

We don't know what Wyden's bill would cost, but it would be a lot, and neither money nor will exist to see it through. We already are looking to a deficit that would be $286 billion without the $100 billion "emergency" funding for the wars in Iraq and Afghanistan, and fixes for the alternative minimum tax and the physician Medicare reimbursement program, both of which may cost in the hundreds of billions of dollars.

Turning back the president's tax cuts for the wealthy, no matter how fiscally sound such a move would be, appears to be untenable for the Democrats, who don't want to be labeled tax-and-spenders.

There is, however, one area of health coverage that presents an opportunity, even in these billion-dollar-pinching times. The State Children's Health Insurance Program must be reauthorized this spring. This program, because it includes state matching dollars, could be leveraged to cover several million adults for a relatively modest investment.

SCHIP, for those who don't follow it, gave states a total of $40 billion over 10 years to provide health coverage for children who lived in families that earned too much to qualify for Medicaid, but not enough to afford private insurance.

Even people like Mark McClellan, the former CMS chief under Bush, have come out in favor of expanding the scope of the program to target some of the most vulnerable of the uninsured. And because it involves children, a larger SCHIP is unlikely to be vetoed.

As to health costs, there simply does not appear to be much interest in the issue from the new majority. Already we have seen some disparaging remarks about pay-for-performance, quality measures and evidence-based medicine from some influential Democrats.

They should reconsider: It doesn't cost very much to use the federal government's financial leverage to push for preventive care, lifestyle changes such as smoking cessation and nutrition counseling, evidence-based clinical decisionmaking and disease management programs that have at least the promise of slowing health spending increases.

These are a handful of changes that could help the Democrats at least begin to fulfill their campaign promises, not just go begging for more ammunition for 2008.

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By Todd Sloane

CHANGE WILL BE INCREMENTAL

Democrats will push a healthcare agenda, but Bush still stands in the way

In the 110th Congress, new leadership will bring new priorities. However, we have to be realistic: President Bush will continue to occupy the White House for two more years.

Instead of working toward quality healthcare for everyone, President Bush wants to dismantle the parts of our healthcare system that work--Medicare, Medicaid and the coverage that most of us receive through our jobs. We can't expect too much from a president who ignores the overwhelming majority of Americans who support life-saving stem-cell therapy.

That doesn't mean Congress will be at a standstill on healthcare. On the contrary, we will be working to make much-needed improvements in our health system, helping to control rising costs and slow the loss of insurance coverage. But for the next two years, our efforts will be more incremental than some of us, me included, would prefer. (See related story, p. 28.)

Initially Congress will focus on Speaker Nancy Pelosi's (D-Calif.) "Six for '06" agenda, which includes two important healthcare items: fixing the Medicare prescription-drug program so that the HHS secretary negotiates drug discounts for Medicare beneficiaries and passing legislation to promote real stem-cell research. The House of Representatives will pass these two initiatives in January, setting the stage for meaningful action on healthcare in the months to come:

* Restoring Medicare's board of directors. Once we've completed the Six for '06 agenda, my focus will turn to oversight and management of Medicare. It is my intent to return the Ways and Means health subcommittee to its traditional role as, in effect, Medicare's "board of directors." For the past six years, Republicans in Congress have conducted almost no oversight of the administration's activities. Instead, they choreographed cheerleading sessions to compliment each other on the great work they were doing to bring "choice" to Medicare, all the while dismantling the traditional program through design and neglect.

Their focus has been to maximize the choices of private health insurance plans available to Medicare beneficiaries, rather than choice of physicians and hospitals--the choices that truly matter to patients. As a result, Republicans have placed Medicare on a path toward destruction. We need to reverse the march toward privatization and once again put Medicare on solid footing.

One way Republicans have made private plans in Medicare more attractive is by paying private plans 12% more than it pays fee-for-service. Equalizing payments between plans and fee-for-service would save upward of $50 billion over 10 years and would be a good place to begin.

Republicans also subjected Medicare to a bud get gimmick--called the 45% trigger--designed to indicate the sky is falling with regard to the program's financing and hasten its demise.

Further endangering Medicare, Republicans allowed a defective physician payment formula to be in effect far too long, forcing physicians and other providers to annually beg Congress to override the cuts the formula would have forced. Making providers angry at Medicare further aids Republican efforts to privatize it.

In addition to these topics, there are many other issues on which oversight is overdue--everything from ensuring that beneficiaries are receiving the benefits they are eligible for through the Medicare prescription-drug program to reviewing quality improvement programs to ensure that taxpayer resources are being carefully stewarded. We could fill the next two years in this arena alone. These efforts are necessary to guarantee that Medicare remains a high-quality program for generations to come.

A healthy, functioning Medicare program that pays adequately is an asset to healthcare providers working in a country where more and more people are uninsured--and from whom payment is not necessarily possible. Improving Medicare should be a bipartisan commitment. Again, I will work to restore that philosophy in the new Congress.

* Expanding coverage for kids: One major healthcare imperative in the 110th Congress is to reauthorize the State Children's Health Insurance Program. SCHIP is a combined federal and state program designed to provide coverage to uninsured children above Medicaid eligibility, but in families with incomes below 200% of poverty (higher in some states). Even with this program in place, we saw the number of uninsured children in America increase 5.1% to 8.3 million in 2005 from 7.9 million in 2004.

Reauthorizing this program provides the opportunity to improve it as well. Ideally, I would expand SCHIP to all children, and parents who provided coverage for their children from elsewhere could opt out.

Otherwise, anyone who takes a child as a deduction on their tax return would be assessed an annual SCHIP premium. Subsidies would be available for lower-income families on a sliding-scale basis. I don't know how much bipartisan support we could obtain for such a proposal, but I would happily dare the president to veto children's health insurance.

Bipartisanship is an important part of my game plan. While expanding government-funded healthcare might not be a bipartisan success, there are still plenty of opportunities for bipartisan cooperation. When I chaired the health subcommittee from 1985 to 1994, Bill Gradison of Ohio served as my Republican counterpart. Together, we wrote plenty of good Medicare legislation. In 10 years, my subcommittee never sent a bill to the House floor that was not co-sponsored by both Gradison and me. I intend to pursue a similarly bipartisan course this Congress.

All of these are important improvements to our healthcare system. If we can move forward in these arenas in the 110th Congress, we will enter the 2008 presidential election cycle, in which I expect healthcare to be a major issue. Then, we can turn to the pressing need to follow the rest of the world in guaranteeing that everyone in our nation has affordable healthcare.

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By Pete Stark