NewsCMAJ

You could say United StatesPresident Barack Obama isliving up to the title of his

book as his fight to reshape US healthcare enters its most crucial days. Talkabout The Audacity of Hope.

He’s taken on this colossus in themidst of economic calamity, two wars, aheaving national debt, tepid popularityand partisan sniping that makes evenincremental change a tough sell in Wash-ington. He’s done so despite a leadershipstyle more deliberative than daring, andwith keen knowledge of the perilous his-tory of diving into health care politics.

Congress is engaged in intensifyingdebate, pushed by Democratic leaderswho are racing to get legislationthrough the Senate by Christmas afterhaving prevailed in the House of Rep-resentatives in the fall.

If it goes well, Obama could have atranscendent domestic achievement totrumpet in his next State of the Unionspeech, one that eluded towering fig-ures of the past.

At the moment, though, that union isin a state of bewilderment about thewhole messy thing.

“There’s been a slow, gatheringconsensus since the collapse of ‘Clin-ton care’ (15 years ago) that this is aproblem whose solution is overdue,”says Will Marshall, founder and presi-dent of the Progressive Policy Institute,an influential centrist Democraticthink-tank. “What’s really driving thatis out-of-control costs. What’s beenfascinating is to watch public doubtsrise. What was overwhelming publicsupport for action has now become amuch more ambivalent picture.”

Republicans have spared no effort togive people the willies about what thepresident wants to do, even raising theghoulish specter of federal “death pan-els” arising from “Obamacare.” Democ-rats are seeing internal fractures and

putting their congressional majority onthe line in 2010 elections. Special inter-ests are in roiling motion.

Although Obama’s legacy will belargely set by the outcome of thisstruggle, he seems to be the only calmfigure around. He’s practically Zen-like that way.

“We’re closer to that significantreform than at any time in recent his-tory,” he has repeatedly said. “Thatdoesn’t make it easy. It’s hard.”

Americans tend to badmouth theirhealth insurance system until someonetries to change it. Then they fear legis-lators will throw out the good with thebad, saddling taxpayers with expen-sive new entitlements and overbearinggovernment. The lobbyists weigh in,conservative activism is ignited and astatus quo that leaves some 40 millionwithout health insurance lives on.

This time, it just might be different.By any measure, the US is closer to

a reinvention of health insurance thanit’s been for generations. Not sinceLyndon Johnson won Medicare andMedicaid health coverage for theelderly and poor in 1965 has the coun-try proposed such sweeping healthchange.

The House and Senate bills, differ-ing in their reach, share bottom-lineprinciples in seeking to bring millionsmore into the system and prohibitinginsurers from denying people coverage.

They would require nearly all Ameri-cans to carry health insurance, with sub-sidies to make plans affordable to morepeople and businesses. New marketswould help workers in small companiesand the self-employed obtain coveragenow beyond their means. Billions innew fees (such as various new levies on

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Obama taps new allies and tackles age-old divisions innudging health care reformPublished at www.cmaj.ca on Dec. 10, 2009

United States President Barack Obama's proposed health care reforms promptedimpassioned debate. Here, a health care reform supporter blocks a sign held by a Lyn-don LaRouche supporter during a health care prayer rally last summer in Hollywood,California.

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drug makers, health insurers, medicaldevice manufacturers and clinical labo-ratories), higher taxes on the rich andMedicare cuts would help pay the cost,roughly US$1 trillion over 10 years.

None of this is Canadian-stylehealth care — not even close.

Advocates of a single-payer systemlike Canada’s were brushed aside in awave of polemic (CMAJ 2009; DOI:10.1503/cmaj.109-3027). For that mat-ter, so were critics who warned that ail-ments of the Canadian system wouldinfect the US if Washington went downthe road of more federal intervention.

“I don’t find Canadians particularlyscary,” Obama cracked at one point,“but I guess some of the opponents ofreform think that they make a goodboogeyman.”

Still, he said of the two countries,“We’ve evolved differently.” The USmust “develop a uniquely Americanapproach to this problem.”

The legislative horse-trading isfierce. Ten days into the Senate debate,Democrats agreed to jettison their pro-posal for a government insurance planto compete with private insurers, set-tling instead for limited nonprofit plansthat would be overseen by Washington.This major concession to conservativesbrightened chances the Senate bill willpass but opened conflicts with theHouse legislation, which has a govern-ment plan firmly embedded.

Then a different point of divisionarose as a few senators pushed to amendtheir bill to ease imports of cheaper drugs,mainly from Canada. The Obama admin-istration pushed back, clearly reluctant toalienate US drug makers who havebecome key allies in the broader reforms.

Uninsured Americans have alwayslacked the political clout to achieve thereforms necessary to bring them intothe system. Now, every Democraticplea to cast a safety net to the uninsuredis paired with an appeal to middle-classself-interest.

It’s not just about getting sick withoutcoverage, says Senator Harry Reid ofNevada, the Senate Democratic leader,but about rising bankruptcies, lost jobsand squeezed budgets afflicting thosewho pay staggering insurance costs.

Premiums for plans provided in theworkplace — the way most Americans

get coverage — have doubled since2000. The government estimates it willcost employers and workers an averageUS$19 000 a year by 2016 for a planfor a family of four.

That drag on the economy hashelped bring some powerful lobbies on-board, in part to ensure the outcomedoesn’t stomp on their interests.

In a striking turnaround, the Ameri-can Medical Association (AMA) issupporting the initiative. One of UShistory’s leading voices against “social-ized medicine,” the AMA battledMedicare in the 1960s using futurepresident Ronald Reagan to make arecording that warned: “The doctorbegins to lose freedom. It’s like tellinga lie and one leads to another. One daywe will awake to find that we havesocialism.”

The AMA swung behind the Housebill in the summer, though, declaring“we’ve decided on a course that isdecent and civilized,” and recentlyfended off dissidents’ attempts toreverse that support.

“So, the AMA is at a crossroad,” itspresident, Dr. J. James Rohack, toldmembers. “In a crisis, true character isrevealed. Times change, situationschange, technology changes, the land-scape may be altered, but basic valuesmust not.”

Those values? “Universal access, pluralism, free-

dom of choice and freedom of physi-cian practice.”

Self-interest is, of course, part of theequation: Doctors want to keep theirseat at the table as they fight to rollback substantial cuts scheduled for pay-ments they receive under Medicare.

Other health care lobbies, also for-mer foes of reform, have helped theObama administration even whilefighting aspects of the bills. Drug mak-ers and hospitals, for example, agreedto absorb more than $200 billion incosts over the next decade to ease thegovernment’s expense.

What gives?“The simple answer is that they’ve

been promised a deal,” Marshall says.“There are going to be more customerscoming in. By and large, they arehealthy and younger folks whose med-ical bills aren’t as big as others. So

they’ve seen a way they can do well inthe universe of expanded coverage.”

A year of economic distress has alsohelped to empower the will to take onhealth care, opening an opportunity forbroad changes. As Obama’s hard-driving chief of staff Rahm Emanuelput it: “You never want a serious crisisto go to waste.”

So, close, yes. But failure is still apossibility.

Democrats are struggling to keeptheir ranks together, for they can’tafford to lose a single vote. So far, theydon’t have that unity and it’s a mysteryhow they’ll get it.

One problem is that Democrats arehaving a rare dispute over abortion.Some say the Senate bill does not doenough to block federal tax dollarsfrom being used for abortion coverage.

Under Senate rules, Democrats needthe votes of all 60 in their caucus —not just a simple majority of 51 — tostop Republicans from delaying legisla-tion to death.

Should the initiative emerge fromthe Senate, both houses of Congresswill need to reconcile their two ver-sions, which could be markedly differ-ent after Senate amendments. Theythen must both pass the final “recon-ciled” legislation before Obama cansign it into law.

But at least a measure of civilityappears to have now been introducedinto the debate, after a summer of pop-ulist discontent during which, as Kath-leen Hall Jamieson, director of theAnnenberg Public Policy Center at theUniversity of Pennsylvania, describesit, “crazed viral fantasies” took rootonline.

“The unengaged ad hominem of thetown halls in August existed in anotherworld,” she says.

Away from the political extremes,what do average Americans want?

Polls have been so nuanced thatboth sides can claim the findings vali-date their views and neither side canprove it.

“People admit that it makes themnervous,” says public opinion analystAndrew Kohut, president of the PewResearch Center. “There’s been a greatdeal of interest in health care reform.Though, when the question gets raised

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more specifically, the anxiety that itprovokes begins to challenge the desireto see things change.”

Even so, Kohut adds, Obama hasassembled a broad coalition and seizeda ripe moment. After Democrats sunkthe attempt by former US presidentBill Clinton and his wife Hillary toachieve an overhaul of health care in

1994, no serious Democratic con-tender for national office even daredpropose universal coverage again for adecade. The Clintons had labouredlargely in secret, producing a complex,micromanaged package that Congresssnubbed.

But Obama, the “yes we can” man,let the legislators work up the legisla-

tion. He seemed so pliable on detailsthat people wondered at times what,exactly, he stood for. The process ismore open this time. More measured,flexible, respectful of Congress. Andstill one audacious roll of the dice. —Cal Woodward, Washington, DC

DOI:10.1503/cmaj.109-3132

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US health reform Q&A

Some questions and answers about the health care legisla-tion making its way through the United States Congress:

Q: Did Washington study Canada’s experience?A: Admirers and critics of Canadian health care testified toCongress but their impact was minimal because the US isnot following Canada’s path.

Q: Why not follow Canada’s path?A: Democrats decided the only way to go was to build onthe employer-based system, expand existing governmentofferings, make insurance more affordable and set newcontrols on private insurers.

Democrats have their passionate single-payer advocates.But that possibility ran aground on the broadly held viewthat government delivery of services is inefficient. As WillMarshall, founder of the Progressive Policy Institute, a cen-trist Democratic think-tank, notes: “The United States isexceptional in the sense it doesn’t have a real socialist orsocial democratic tradition. There’s a deep strain of anti-statism that cuts across the usual political categories. Forbetter or worse, that’s the American ethic. That’s why it’sno accident that it’s taken us so long to get to even a patch-work plan that covers almost everybody. There’s a deep-seated feeling that government ought not to help those whocan help themselves.”

Q: So after all of this, some Americans still won’t becovered?A: Right. About 95% of legal residents under 65 will havecoverage if the legislation’s goals are achieved. That’s upfrom 83% now. Older people already have coverage fromgovernment, as do the poorest Americans. The millions ofillegal immigrants will not be helped.

Q: What will prompt more people to get insurance?A: The law, for starters. Insurance will become mandatoryand people will be penalized in their taxes or fined if theydon’t get it from their employer, from a government plan oron their own. The only exception will be for people whoobtain hardship waivers after demonstrating that they can’tafford the financial blow despite subsidies.

In return, the government will set up new insurance

markets and provide subsidies to make coverage affordableto more Americans.

Q: Will insurance become cheaper?A: Subsidies should lower costs for many, but not all. TheKaiser Family Foundation estimates a family of four mak-ing US$44 000 a year will pay US$200 a month and a fam-ily making US$66 000 will pay US$550 a month, if provi-sions of the House bill become law. That’s down frommore than US$1000 a month now.

Higher income people will get less help and might seelittle difference. The wealthiest Americans will pay highertaxes.

Young people could pay more. Insurers will face limitsin their ability to set premiums based on age. That’s boundto make insurance more expensive for young people andcheaper for older people.

Q: What are key differences between the House andSenate bills that will have to be reconciled before healthreform becomes law?A: The House bill proposes setting up a government insur-ance plan to compete in the private market, a key provisionfor many Democrats. The Senate has moved away fromthat “public option.” To appease more conservative legisla-tors, senators are proposing the creation of private, non-profit insurance plans that would be overseen by the federalgovernment. This boosts chances of health reform passingin the Senate but opens up potential fissures with theHouse. In addition, the House legislation puts more pres-sure on medium and large businesses to offer health insur-ance to workers.

Q: What impact will the changes have on the US healthcare system?A: The US system will come under tremendous pressure todeliver higher quality care for more people and with muchless waste if this overhaul takes effect. Electronic recordkeeping, comparative effectiveness research and manyother promising and speculative efficiencies will be accel-erated and put to the test as millions more people come intothe insurance system and policy-makers struggle to pay forit all.