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