It might seem hard to fathom after a summer of rancor but there are issues in the health care debate that still evoke widespread agreement.
As Congress returns from a fractious recess during which lawmakers were confronted about the public health insurance option and other contentious elements in Democratic bills political strategists and policy experts already are identifying a subset of less controversial proposals that could attract support from moderate Democrats and even some Republicans.
None of these would immediately solve the questions of how to cover the estimated 45 million uninsured Americans or contain long-term health spending. But identifying a patch of common ground would at the very least inject some momentum into a debate that has virtually gridlocked Congress and confused many Americans.
Should lawmakers prove unable to craft a grand compromise by the middle of October its likely they will try to enact a series of scaled-back bills to save face.
Its hard to get everything on your wish list passed in one fell swoop" said Ken Thorpe chair of the department of health policy at Emory University and a senior official in the Clinton administration during its unsuccessful push for a health care overhaul in the early 1990s. They could decide to pass something then come back later and try to improve on it."
However Anne Kim economic program director at the think tank Third Way said breaking a bill into too many pieces makes it more difficult for Democrats to secure Obamas legacy and show how they are making a difference in middle-class Americans lives.
There is a political imperative that has to be satisfied. The average American is asking the question Whats in it for me? " Kim said. The further away you get from fundamental reforms and the more you deal with abstract payment issues the less people will understand what is being achieved."
Obama will allude to the areas of agreement during this Wednesdays prime time address to a joint session of Congress by noting there is a roughly 80 percent overlap among the leading health care proposals circulating in Congress and that the bills hew to the broad principles he laid out for an overhaul early this year according to a set of talking points the White House distributed to Democratic members last week.
Here are three areas experts say congressional negotiators are likely to focus on in the coming weeks as they begin looking for a compromise:
Bending the Cost Curve
Obama and administration officials have repeatedly spoken about the necessity of bending the curve" and slowing a trend that has seen U.S. health care spending more than triple since 1990. For good reason. Health care spending constitutes 16.2 percent of the gross domestic product and is projected to rise to 25 percent in 2025 and 49 percent by 2082.
Policymakers have so far largely focused on quick fixes that can deliver quantifiable savings over 10 years as measured by the Congressional Budget Office. The administration and its allies are pressing to change aspects of the health delivery system by cutting Medicare payments for potentially preventable hospital readmissions tying payments to productivity improvements and by eliminating so-called overpayments to Medicare Advantage plans in which private insurers provide seniors their Medicare benefits in place of the government.
Many of these cost controls have been portrayed as Medicare cuts by Obamas foes. But the bigger problem say experts may be that the belt-tightening needs to be accompanied by fundamental changes in patient care that cant necessarily be quantified. For example hospital readmissions can only be reduced if providers spend more money hiring nurse-practitioners and following patients after they are discharged to make sure they are taking medications and following instructions.
The administration needs quick money savings that can be scored but many of the changes wont do so. There is a tension there" said Gail Wilensky senior fellow at the think tank Project Hope and a Medicare administrator in the early 1990s in the first Bush administration.
Wilensky and others believe a health care bill should provide more resources for comparative effectiveness research to determine which drugs devices or procedures work best. Many in Congress still dont agree on who should conduct the research or how cost-effectiveness should be factored in. Conservatives in particular have warned the programs could evolve into rationing policies that are more far-reaching and controlling than they are described. However a majority in Congress saw enough merit in the idea to include $1.1 billion to fund an accelerated comparative effectiveness program in the economic stimulus package (PL 111-5).
Disease Prevention
To many involved in the health care debate disease prevention is a key to reducing long-term costs. The Centers for Disease Control and Prevention estimates that 133 million Americans live with one or more chronic diseases such as hypertension diabetes or asthma and that chronic conditions account for more than 75 percent of health care spending.
This year the nation is expected to incur $129 billion in costs treating diabetes and hypertension alone a figure that rises to $430 billion when related costs of stroke heart disease and kidney failure are added.
Congress has considered steps such as providing tax incentives for employers to offer wellness programs that encourage healthier lifestyles. However the Congressional Budget Office and many experts contend prevention efforts are expensive not well-targeted and unlikely to be cost-effective. In a June analysis CBO Director Douglas Elmendorf noted that the cost of implementing wellness programs for a large population would exceed the likely savings for the relative few who would avoid a disease as a result. In addition any decision by the federal government to subsidize preventive care might shift some costs to the government that would otherwise be borne by the private sector.
The House health bill (HR 3200) would seek to improve disease prevention by covering only those services deemed effective by Medicare and Medicaid. Lawmakers also are pondering other ideas such as funding medical homes" a variety of primary care facility where doctors are paid to monitor and manage chronic diseases.
Experts like Emorys Thorpe believe its time for the government to take the long view and revise the way it scores" the economic benefits of disease prevention. While CBO typically provides Congress with economic forecasts covering a 10-year period disease progression usually goes well beyond a decade and can last a lifetime.
Universal Coverage
No one in the Obama administration or Congress believes that even the most comprehensive overhaul would cover all of the uninsured. But the arguments for not trying are ominous because of the way health care inflation is projected to ripple through society in the coming decades.
A recent Urban Institute analysis projects the uninsured population could swell as high as 57.7 million by 2014 and 65.7 million by 2019 if health costs continue to outpace wage growth. The biggest increase would be among middle-income individuals and families who wont be able to cover out-of-pocket expenses or those who are dropped from employer plans. Businesses that still can afford to cover workers would be hit with steep premium increases forcing many to lower wages. Taxpayers will shoulder an added burden as government expands public safety-net programs like Medicaid and the Childrens Health Insurance Program.
Compounding matters is the fact that any health overhaul will increase spending in the short run as more initiatives are launched. Given this reality if the public insurance plan promoted by liberals is deemed politically unacceptable and if there is an unwillingness to shift safety-net funds the government will have to raise new sources of revenue.
That is why moderates are considering an idea that has been around since the tax debates of the 1980s: limiting an exclusion in tax law that allows workers to receive unlimited untaxed compensation in the form of health benefits. The move would force middle-class workers to pay more taxes it could raise more than $418 billion in additional revenues according to an early estimate and help the administration get closer to its goal.
Democratic leaders also are likely to use an overhaul to establish an insurance exchange or purchasing pool in which private insurers compete to sell coverage to the uninsured in a highly regulated market. This marketplace was an essential part of a closely watched 2006 health care overhaul in Massachusetts that dramatically reduced the ranks of the commonwealths uninsured.
But lawmakers will have to decide whether to require individuals to purchase subsidized coverage or face a penalty. And the Massachusetts experience has shown certain groups can fall through the cracks. A Kaiser Family Foundation report on overhaul found many low-income Massachusetts workers are still struggling to pay their medical bills because subsidized coverage isnt available to workers who still get insurance through their employers.
It might seem hard to fathom after a summer of rancor but there are issues in the health care debate that still evoke widespread agreement.
As Congress returns from a fractious recess during which lawmakers were confronted about the public health insurance option and other contentious elements in Democratic bills political strategists and policy experts already are identifying a subset of less controversial proposals that could attract support from moderate Democrats and even some Republicans.
None of these would immediately solve the questions of how to cover the estimated 45 million uninsured Americans or contain long-term health spending. But identifying a patch of common ground would at the very least inject some momentum into a debate that has virtually gridlocked Congress and confused many Americans.
Should lawmakers prove unable to craft a grand compromise by the middle of October its likely they will try to enact a series of scaled-back bills to save face.
Its hard to get everything on your wish list passed in one fell swoop" said Ken Thorpe chair of the department of health policy at Emory University and a senior official in the Clinton administration during its unsuccessful push for a health care overhaul in the early 1990s. They could decide to pass something then come back later and try to improve on it."
However Anne Kim economic program director at the think tank Third Way said breaking a bill into too many pieces makes it more difficult for Democrats to secure Obamas legacy and show how they are making a difference in middle-class Americans lives.
There is a political imperative that has to be satisfied. The average American is asking the question Whats in it for me? " Kim said. The further away you get from fundamental reforms and the more you deal with abstract payment issues the less people will understand what is being achieved."
Obama will allude to the areas of agreement during this Wednesdays prime time address to a joint session of Congress by noting there is a roughly 80 percent overlap among the leading health care proposals circulating in Congress and that the bills hew to the broad principles he laid out for an overhaul early this year according to a set of talking points the White House distributed to Democratic members last week.
Here are three areas experts say congressional negotiators are likely to focus on in the coming weeks as they begin looking for a compromise:
Bending the Cost Curve
Obama and administration officials have repeatedly spoken about the necessity of bending the curve" and slowing a trend that has seen U.S. health care spending more than triple since 1990. For good reason. Health care spending constitutes 16.2 percent of the gross domestic product and is projected to rise to 25 percent in 2025 and 49 percent by 2082.
Policymakers have so far largely focused on quick fixes that can deliver quantifiable savings over 10 years as measured by the Congressional Budget Office. The administration and its allies are pressing to change aspects of the health delivery system by cutting Medicare payments for potentially preventable hospital readmissions tying payments to productivity improvements and by eliminating so-called overpayments to Medicare Advantage plans in which private insurers provide seniors their Medicare benefits in place of the government.
Many of these cost controls have been portrayed as Medicare cuts by Obamas foes. But the bigger problem say experts may be that the belt-tightening needs to be accompanied by fundamental changes in patient care that cant necessarily be quantified. For example hospital readmissions can only be reduced if providers spend more money hiring nurse-practitioners and following patients after they are discharged to make sure they are taking medications and following instructions.
The administration needs quick money savings that can be scored but many of the changes wont do so. There is a tension there" said Gail Wilensky senior fellow at the think tank Project Hope and a Medicare administrator in the early 1990s in the first Bush administration.
Wilensky and others believe a health care bill should provide more resources for comparative effectiveness research to determine which drugs devices or procedures work best. Many in Congress still dont agree on who should conduct the research or how cost-effectiveness should be factored in. Conservatives in particular have warned the programs could evolve into rationing policies that are more far-reaching and controlling than they are described. However a majority in Congress saw enough merit in the idea to include $1.1 billion to fund an accelerated comparative effectiveness program in the economic stimulus package (PL 111-5).
Disease Prevention
To many involved in the health care debate disease prevention is a key to reducing long-term costs. The Centers for Disease Control and Prevention estimates that 133 million Americans live with one or more chronic diseases such as hypertension diabetes or asthma and that chronic conditions account for more than 75 percent of health care spending.
This year the nation is expected to incur $129 billion in costs treating diabetes and hypertension alone a figure that rises to $430 billion when related costs of stroke heart disease and kidney failure are added.
Congress has considered steps such as providing tax incentives for employers to offer wellness programs that encourage healthier lifestyles. However the Congressional Budget Office and many experts contend prevention efforts are expensive not well-targeted and unlikely to be cost-effective. In a June analysis CBO Director Douglas Elmendorf noted that the cost of implementing wellness programs for a large population would exceed the likely savings for the relative few who would avoid a disease as a result. In addition any decision by the federal government to subsidize preventive care might shift some costs to the government that would otherwise be borne by the private sector.
The House health bill (HR 3200) would seek to improve disease prevention by covering only those services deemed effective by Medicare and Medicaid. Lawmakers also are pondering other ideas such as funding medical homes" a variety of primary care facility where doctors are paid to monitor and manage chronic diseases.
Experts like Emorys Thorpe believe its time for the government to take the long view and revise the way it scores" the economic benefits of disease prevention. While CBO typically provides Congress with economic forecasts covering a 10-year period disease progression usually goes well beyond a decade and can last a lifetime.
Universal Coverage
No one in the Obama administration or Congress believes that even the most comprehensive overhaul would cover all of the uninsured. But the arguments for not trying are ominous because of the way health care inflation is projected to ripple through society in the coming decades.
A recent Urban Institute analysis projects the uninsured population could swell as high as 57.7 million by 2014 and 65.7 million by 2019 if health costs continue to outpace wage growth. The biggest increase would be among middle-income individuals and families who wont be able to cover out-of-pocket expenses or those who are dropped from employer plans. Businesses that still can afford to cover workers would be hit with steep premium increases forcing many to lower wages. Taxpayers will shoulder an added burden as government expands public safety-net programs like Medicaid and the Childrens Health Insurance Program.
Compounding matters is the fact that any health overhaul will increase spending in the short run as more initiatives are launched. Given this reality if the public insurance plan promoted by liberals is deemed politically unacceptable and if there is an unwillingness to shift safety-net funds the government will have to raise new sources of revenue.
That is why moderates are considering an idea that has been around since the tax debates of the 1980s: limiting an exclusion in tax law that allows workers to receive unlimited untaxed compensation in the form of health benefits. The move would force middle-class workers to pay more taxes it could raise more than $418 billion in additional revenues according to an early estimate and help the administration get closer to its goal.
Democratic leaders also are likely to use an overhaul to establish an insurance exchange or purchasing pool in which private insurers compete to sell coverage to the uninsured in a highly regulated market. This marketplace was an essential part of a closely watched 2006 health care overhaul in Massachusetts that dramatically reduced the ranks of the commonwealths uninsured.
But lawmakers will have to decide whether to require individuals to purchase subsidized coverage or face a penalty. And the Massachusetts experience has shown certain groups can fall through the cracks. A Kaiser Family Foundation report on overhaul found many low-income Massachusetts workers are still struggling to pay their medical bills because subsidized coverage isnt available to workers who still get insurance through their employers.
