The

NEW ENGLA ND JOURNAL

of

MEDICINE

Perspective
A Vote for Health Care Reform
Jonathan Oberlander, Ph.D.

ealth care reform legislation has languished in political purgatory for the past 2 months, teetering between historic enactment and epic collapse. The House of Representatives and the Senate
both passed health care legislation at the end of 2009. After a year of tumultuous debate, agreement seemed near on a final compromise bill that would represent both a substantial advance in health care coverage and a major political triumph for the Obama administration. But the stunning victory of Republican Scott Brown in Massachusetts special Senate election in January sent health care reform into a tailspin. Democrats lost their 60-vote, filibuster-proof Senate majority and, briefly, their appetite for taking the final, difficult steps to enact health care legislation. Worries surfaced that the Massachusetts results signaled an erosion of public support for reform and an intensifying political backlash that could lead to significant losses for Democrats in the 2010 Congressional elections. Amazingly, health care reform legislation that had already passed Congress suddenly appeared in jeopardy of unraveling, as attention turned to the merits of more incremental reforms. Yet as the health care reform debate enters its final act, Democrats have regained their political nerve. In the House, Speaker Nancy Pelosi (D-CA) has been a persistent advocate of comprehensive reform that would substantially extend insurance coverage and regulate the insurance industry. In the Senate, support

among Democrats for using the budget-reconciliation process in which a simple majority of 51 senators is required to pass legislation has grown as the prospects for bipartisanship have faded. The Obama administration has also recommitted to passing comprehensive legislation, with the President making a strong final push to persuade wavering lawmakers and a weary public that reform cannot wait. The President, capitalizing on recent news stories highlighting staggering increases in health insurance premiums for some customers, is focusing his closing argument on the need to curb insurance-industry excesses. Thus, the political outlook for health care reform is improving, and Democrats are now close to securing enough votes to approve the legislation. Still, there is nothing simple about assembling a majority in the House to pass the

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reform bill approved by the Senate and also having both the House and the Senate pass a second bill through the reconciliation process to fix provisions in the original Senate legislation (Obama has proposed a package of such revisions, including elimination of the now-infamous provision giving Nebraska extra funding for Medicaid). Democrats have to grapple with procedural issues, including whether the House will alternatively vote on a package of reconciliation fixes without first directly voting for the Senate bill. After a year of worrying about securing 60 votes in the Senate to overcome a filibuster, the challenge is now greater in the House, where Pelosi must find a way to win over pro-life Democrats who oppose provisions in the Senate-approved bill on federal funding for abortion services that are less restrictive than those in the Housepassed bill. Pelosi must also persuade nervous House Democrats that their Senate colleagues will follow through on promised changes if the House passes the Senate bill. Democrats strategy of pushing ahead with comprehensive health care reform is risky. Most Americans wont see visible benefits for years, because the legislation is back-loaded, with implementation of the major policies that would expand insurance coverage delayed until 2014 to ensure that the programs price tag comes in under $1 trillion over the next decade. Although the bill will provide some immediate benefits, including a tax credit for small businesses that provide health insurance to employees and a rebate for Medicare beneficiaries who fall into the prescription-drug doughnut hole,
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4 years is a long time to wait to implement the balance of reform, given the controversy this legislation has generated and widespread fears of death panels, a government takeover of medicine, and other imaginary reform specters. Moreover, if health care reform passes, Republicans are sure to mount an immediate repeal campaign against a bill that has divided the public and catalyzed intense opposition. And if they pick up many House and Senate seats in the 2010 Congressional elections a likely event regardless of the outcome of the health care debate it could be seen, rightly or not, as a public repudiation of reform. However, pulling back from health care reform is perhaps even more risky, as Democrats learned in 1994 after the collapse of the Clinton health plan. Failure to pass health care legislation will disillusion party supporters and call into question Democrats ability to govern, while dealing a substantial blow to Obamas presidency. Midterm elections are about voter turnout, and the unraveling of health care reform could depress the Democratic base. Public support for reform could also rise if the legislation passes. The political calculus of health care reform is unclear. Yet the focus on the political implications and process-based issues surrounding reform legislation has obscured what should be the central question in this debate: Is this legislation worth passing? After all, any bill that passes this year will be the product of compromise, concessions, budgetary constraints, and an incremental approach that builds on our existing patchwork health care

system, with all its inequities, inefficiencies, and peculiarities. This is not reform as egalitarian or efficient as single-payer national health insurance. Nor is it as sweeping or bold as the proposal by Senators Ron Wyden (D-OR) and Robert Bennett (R-UT) that would move the United States away from employer-sponsored insurance. Neither of those plans, though, has a chance of becoming law in 2010. I wish that the health care legislation now before Congress insured more people. I wish it had stronger, more reliable cost controls, more generous subsidies and comprehensive benefits, and lower premiums. And I wish the implementation of its major provisions started before 2014. This legislation has real limits, and nobody should harbor the illusion that this bill will solve all the health care systems problems. But we should not lose sight of what health care reform would do. It would extend insurance coverage to more than 30 million Americans and provide hundreds of billions of dollars in subsidies to make health insurance more affordable for lowerincome people. It would modernize Medicaid by basing eligibility on income rather than demographic category. It would transform private insurance by prohibiting discrimination on the basis of preexisting conditions and by limiting medical underwriting, making insurance coverage more accessible for millions of Americans with serious illnesses. It would subject insurers to new regulations and outlaw the practice of rescission (whereby insurers retroactively cancel enrollees coverage once their care becomes too costly). It would establish health insurance

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exchanges that would in tandem with new tax credits enable small businesses and individuals without employer coverage to afford better coverage. It would make insurance more secure for Americans who already have it, and more available and affordable for those who do not. And it would improve Medicare by enhancing prescription-drug coverage and preventive benefits and by slowing the rate of growth in Medicare spending, which will reduce the financial burden on program beneficiaries. If a modified version of the Senate bill becomes law (reflecting Obamas proposed fixes and others backed by the House), it would represent the most important health care legislation since the 1965 creation of Medicare and Medicaid, and arguably the

most important since Congress first began considering national health care reform in 1943. But this legislation will do more than make history: it will make a real difference. It will help the uninsured and the insured. It will help young families and seniors. It will help small businesses and help to reduce the federal deficit. It will save thousands of lives by broadening access to medical services. Still, some critics will argue that because of its limitations, we should wait for something better for a law that insures all Americans or provides a firmer bulwark against rising health care costs. There is no reason, though, to believe that waiting will produce better health care reform. If reform fails now, having previously imploded during

the Clinton administration, what President or Congress will want to tackle this issue in a comprehensive way anytime soon? I believe that it is imperative to pass this bill now and then work to improve it, rather than start from scratch again and hope, against all odds, for a more favorable opportunity for change. This bill will lay the foundation for a fairer, more efficient health care system and move the United States closer to universal coverage. This is health care reform worth voting for.
Disclosure forms provided by the author are available with the full text of this article at NEJM.org. From the University of North Carolina, Chapel Hill. This article (10.1056/NEJMp1002878) was published on March 17, 2010, at NEJM.org.
Copyright 2010 Massachusetts Medical Society.

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