NY Times - By KEVIN SACK
In their heart of hearts, few in the Obama administration would have predicted late last year that they would be this well positioned by June to achieve a major victory on health care. As the economy faltered, and attention focused on Wall Street and Detroit, it seemed unthinkable that Congress would be ready to devote the summer of 2009 to the costly proposition of providing health coverage for all, a goal that has eluded presidents since Theodore Roosevelt.
But five months after the inauguration, health care dominates the domestic agenda on both ends of Pennsylvania Avenue. Any package that emerges will preserve the country’s private insurance system, at least for now. It could nonetheless bring sweeping changes, requiring that everyone be insured, creating a government health plan to compete with commercial carriers and perhaps taxing employer-provided health benefits.
One Senate committee began the formal drafting of its overhaul plan in a contentious session this week, while a second — the influential Finance Committee — delayed the release of its proposal until after the Fourth of July because of emerging concerns about its cost. In the House, hearings on a draft proposal are scheduled for next week. Both chambers are striving to vote on bills before the August recess so that a conference committee can negotiate a compromise and send it to President Obama by October.
Mr. Obama now rarely lets a day pass without pushing the case for broad-based change. His cool-headed analysis is increasingly sprinkled with impassioned rhetoric. “If we do not fix our health care system,” he told the American Medical Association on Monday, “America may go the way of G.M.”
That politics and economics have converged to spark such momentum “is remarkable,” said Peter R. Orszag, the White House budget director. “You have industry groups that are cognizant of the need to make changes, members of Congress who have been preparing for this moment and a president quite committed to doing it. It is a rare alignment of forces.”
And yet, students of history in the White House and Congress realize they are only now entering the riskiest phase, when real details begin to generate real opposition. To date, a fragile coalition of stakeholders has been kept at the table by presidential leadership and fiscal realpolitik. But it may not take much for the guiding principle of “shared responsibility” to fracture into shards of self-interest.
On Monday, the American Hospital Association expressed deep disappointment in Mr. Obama’s weekend proposal to help pay for expanded coverage by cutting Medicare payments to hospitals. The next day, the United States Chamber of Commerce announced it would oppose a bill that included any one of three central elements: a new government insurance option, a requirement that businesses provide health coverage to workers or pay a fine, and the creation of a federal board to set insurance benefits. By midweek, the release of higher-than-expected cost estimates by the Congressional Budget Office had emboldened Republicans to step up their criticism, and forced the Senate Finance Committee back to the drawing board.
Kathleen Sebelius, the secretary of health and human services, said the administration was prepared for the undulations of the legislative process. “There will be a lot of times when it appears that everything is falling apart,” Ms. Sebelius said. “Anytime specific legislative language is crafted, there’s something to hate about it.”
But Ms. Sebelius said she had been impressed by the dedication of Congressional leaders, and by Mr. Obama’s “absolute focus on the fact that this is a moment — we’re not going to lose this moment.”
The moment arises from a confluence of factors: Democratic control of the White House and Congress; the exasperation of big business and consumers with uncontrollable health costs; heightened economic insecurity during the recession; the Massachusetts model for achieving near universal coverage; Mr. Obama’s determination that health care is central to economic recovery; the presence of health care enthusiasts at the helm of key Congressional committees; and even Senator Edward M. Kennedy’s battle against brain cancer.
Mr. Obama, among others, has observed that if a deal is not concluded this year, when his popularity is high and lawmakers are not running for re-election, it is not likely to happen at all.
What separates this year’s initiative from past health care expansions is that it would try to address the system’s shortcomings in cost, access and quality all at once. It would do so with intricately interlocking components intended to make health care affordable, end discriminatory insurance practices and redirect treatment toward prevention.
Whether any individual piece will produce its intended savings or improvements is impossible to tell; when judging how they might work in concert, the uncertainty is compounded.
Seeking broad popular support, the president and Congressional leaders have played between the 40-yard lines of the health policy spectrum. Those who favor a single-payer, government-run insurance system have been marginalized, along with those who would unleash the system to the free market.
Mr. Obama and the Democrats began by using the stimulus package to direct new money toward the computerization of health records and research on the effectiveness of medical procedures. In the legislation now being considered, there is broad Democratic consensus on mandating that almost all Americans have coverage, expanding eligibility for Medicaid, subsidizing insurance for the working poor, establishing an insurance marketing exchange and requiring insurers to cover those with pre-existing conditions.
But there are profound disagreements on other proposals, including the Medicare cuts, tax increases to pay for the subsidies, and the public-plan option, which insurers regard as a threat to their existence. The chairman of the Senate Finance Committee, Max Baucus, Democrat of Montana, has been searching for a compromise that might attract Republican support.
Although the Democrats may be able to pass bills without Republican votes, bipartisanship is important to Mr. Obama because it would set the tone for the rest of his term. The essential tension of the coming few weeks will revolve around whether the Democrats can maintain momentum while working to satisfy Republican concerns. Mr. Obama is leaving the details to Congress while pronouncing that he is “open to” particular compromises, like substituting member-owned insurance cooperatives for the public plan.
At a comparable stage of the Clinton health care push of 1993, “it seemed that health care reform was unstoppable,” former Senator Tom Daschle has written. The Clinton administration’s subsequent tactical failures have become the antimatter of Mr. Obama’s strategy, persuading him to move quickly, stay out of the weeds and share ownership with Congress.
In addressing the doctors this week, Mr. Obama argued that whatever the cost of revamping the system, “the cost of inaction is greater.” But he also made clear that he understood the most enduring lesson from past efforts.
“As clear as it is that our system badly needs reform,” he said, “reform is not inevitable.”
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