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Previous Volume 361:e25 October 1, 2009 Number 14 Next

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In a rare address to Congress, designed to consolidate support among Democrats behind one health care reform plan, reassure people with insurance that they would benefit from reform, and offer conciliatory gestures to skeptical Republicans, President Barack Obama sought to rebuild momentum among legislators for pursuing reform. By emphasizing in his prime-time address on September 9 that "now is the season for action," Obama signaled that he was taking command of his primary domestic initiative after months of urging Congress to craft a reform proposal. Obama set out three basic goals for reform: increasing security and stability for people with insurance, providing coverage for the uninsured, and slowing the growth of health care costs. Although the President indicated that he intends to incorporate ideas from Democratic and Republican legislators in a reform plan, the early reaction from most GOP legislators suggested that he had made little headway in persuading them to support his initiative.

The scheduling of the speech during prime time 2 days after legislators returned from their August break applied pressure to the Senate Finance Committee to move forward with a reform bill despite its inability to strike a bipartisan agreement among its 23 members. Only hours before Obama's address, Finance Committee chairman Max Baucus (D-MT) announced plans to begin marking up a reform bill on September 21, whether or not Republicans cosponsor it. At the time of his announcement, the draft bill, developed through prolonged discussions among three Democratic and three Republican committee members, still lacked any support from GOP senators.

Early in his address, Obama underscored his commitment to enabling "the hundreds of millions of Americans who already have health insurance" to maintain that coverage if that is their preference. He continued, "nothing in this plan will require you or your employer to change the coverage or the doctor you have."

Obama also emphasized that his plan would place restrictions on some of the current unpopular practices of private insurers, including denying applicants coverage because of preexisting conditions, dropping or reducing coverage when an enrollee becomes ill, and arbitrarily capping annual or lifetime coverage. In addition, he said, "we will place a limit on how much you can be charged for out-of-pocket expenses, because in the United States of America, no one should go broke because they get sick. And insurance companies will be required to cover, with no extra charge, routine checkups and preventive care, like mammograms and colonoscopies — because there's no reason we shouldn't be catching diseases like breast cancer and colon cancer before they get worse."

Next, Obama stressed that for Americans who are currently uninsured, the plan will offer "quality, affordable choices." Through a new insurance exchange — a marketplace offering the choice of many plans — individuals and small businesses could purchase affordable coverage. Individuals who bought coverage in this way would form one large group, thus wielding greater leverage to bargain with insurers for better prices and higher-quality care. For small businesses and individuals who could not afford the lower-priced insurance available through an exchange, the government would provide tax credits, the size of which would be based on income and need.

The exchange would become operational in 4 years, "which will give us time to do it right," Obama said. Among the coverage choices Obama proposes to include in the exchange is a new publicly sponsored insurance option that eligible individuals without access to employer-based coverage would be free to select. Republicans, some conservative Democrats, and the insurance industry all oppose the creation of a new public option, believing that it would put private carriers out of business because many people would switch their coverage. Straddling the contentious issue, Obama countered that "a strong majority of Americans still favor a public insurance option of the sort I've proposed tonight. But its impact should not be exaggerated. . . . It is only one part of my plan. . . . And to my Republican friends, I say that rather than making wild claims about a government takeover of health care, we should work together to address any legitimate concerns you may have."

Emphasizing "shared responsibility," Obama said that all individuals would be required to carry basic health insurance, and "businesses will be required to either offer their workers health care or chip in to help cover the cost of their workers" — though there would be hardship waivers for people who still could not afford coverage and exemptions for most small businesses.

Obama offered few specifics about the financing for his reform plan, the cost of which he estimated at $900 billion over 10 years, although he said, "I will not sign a plan that adds one dime to our deficits — either now or in the future. Period. And to prove that I'm serious, there will be a provision in this plan that requires us to come forward with more spending cuts if the savings we promised don't materialize." Obama maintained that most of his plan could be paid for by eliminating waste, fraud, and abuse; reducing payments to Medicare Advantage plans that contract with Medicare; and imposing fees on "the very same drug and insurance companies that stand to benefit from tens of millions of new customers." In addition, he proposed the creation of "an independent commission of doctors and medical experts charged with identifying more waste in the years ahead." Members of both political parties have long talked up the elimination of waste, fraud, and abuse, but resources adequate for accomplishing that task have not been provided.¹

In several instances, Obama sought to demonstrate his interest in bipartisanship — or perhaps deflect criticism that he never sought it — by embracing ideas favored by Republicans. For example, he noted that under his plan, the government would "immediately offer low-cost coverage" for people who had been denied insurance because of preexisting conditions, so they would be protected "against financial ruin" if they became seriously ill. Obama remarked, "This was a good idea when Senator John McCain proposed it in the campaign, it's a good idea now, and we should embrace it."

Obama also noted that GOP legislators have long maintained that reforming medical malpractice laws could help to reduce the cost of health care. "I don't believe malpractice reform is a silver bullet," he cautioned, "but I have talked to enough doctors to know that defensive medicine may be contributing to unnecessary costs. So I am proposing that we move forward on a range of ideas about how to put patient safety first and let doctors focus on practicing medicine." Citing a Bush administration proposal to authorize state-based demonstration projects testing various approaches to malpractice reform,² Obama said he had directed the secretary of health and human services to launch such an initiative now. But though the administration will award grants to states for such projects, it is not proposing to shift responsibility for these matters to the federal government.

After Obama pledged that the administration would pursue remedies for the malpractice system, Senator Kent Conrad (D-ND), a senior member of the Senate Finance Committee, said the committee would consider addressing malpractice in its reform bill. Although the committee does not have jurisdiction over professional liability issues, Conrad said he saw no reason why the panel could not make suggestions such as creating "safe harbors" for physicians who adhere to evidence-based practices and special health courts that would focus on these matters.

Though Obama covered a lot of ground in setting out his vision of reform, his clear political aim was to persuade moderates in both parties to support his cause. Among these legislators are Republican Senators Susan Collins and Olympia Snowe of Maine and Senator Ben Nelson, a Democrat from Nebraska who is undecided about proposed reforms. In a statement following the address, Snowe praised Obama for proposing "additional spending cuts if projected savings aren't realized — as it is vital we maintain budget neutrality as fundamental to any final package." Nelson said he was pleased that Obama released specifics of his plan and added, "I remain committed to working with the President and my colleagues for a bipartisan bill." By contrast, prospects have dimmed that Senator Charles Grassley of Iowa, the ranking Republican on the Senate Finance Committee, will end up supporting the measure introduced by Baucus. Grassley has said repeatedly that he will not support a Democratic reform proposal unless he would be joined by enough Republicans to result in a 70-to-80-vote majority.

There are many miles to go before reform is achieved, and it may once again slip from the grasp of policymakers. In the coming weeks, all eyes will be on the Senate Finance Committee, because whatever bill emerges from that panel is likely to come closer than any other bill to the middle ground between Democrats and the few Republicans who may be persuaded to support reform. And as far as I can surmise, Obama would be delighted to sign a measure that reflects such a compromise.

Source Information

Mr. Iglehart is a national correspondent for the Journal.

This article (10.1056/NEJMp0908476) was published on September 14, 2009, at NEJM.org.

References

1. Iglehart JK. Finding money for health care reform -- rooting out waste, fraud, and abuse. N Engl J Med 2009;361:229-231. [Free Full Text]
2. Mello MM, Brennan TA. The role of medical liability reform in federal health care reform. N Engl J Med 2009;361:1-3. [Free Full Text]

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