The tea leaves say President Barack Obama will do more than pay lip service to bipartisanship, but they don’t say whether others will follow his example. Health reformers typically genuflect at this altar, and have placed rich offerings on it in anticipation of impending deliberations. Comparative effectiveness research, health information technology (IT), and value-based purchasing are widely embraced on both sides of the congressional aisle and by payers, providers, and patient advocates alike.
“I sense a genuine interest in working together on the part of key Republicans in the Congress,” Senate Finance Committee chairman Max Baucus (D-MT) said this week. “They all want to be in on this. There’s a lot of excitement.” To be sure, differences over how to promote effectiveness research or IT will test the commitment of the pragmatic center. But, arguably, where there’s a will there’s a way.
That may not be the case, however, with another critical feature of the Democrats’ reform vision. Jeanne Lambrew, of the White House office of Health Reform, said this week that the administration eventually wants to beyond health-related initiatives in its economic stimulus package to create a structured market, or “exchange,” as it is called in the Massachusetts version of universal coverage, which streamlines disadvantaged buyers’ access to private insurance plans and also to a “public option.”
The subject of the public option came up frequently in the course of the Feb. 2-3 National Health Policy Conference, sponsored by Health Affairs and AcademyHealth. Whenever it did, old wounds seemed ready to reopen. A Business Roundtable representative asked if administrative costs of the public plan would be subsidized with taxpayer funds, giving it an unfair advantage over private plans. If the market power of the public plan enabled it to force lean reimbursement on providers, as the Medicare and Medicaid programs do, would providers shift costs onto private payers? The public plan idea makes the private sector nervous, said a participant in a workshop on employers’ perspectives on reform. “There’s a lot of concern.”
Medicare, of course, has been experimenting for 25 years with competing public and private options, although never on a very level playing field, and never in a way that either public or private participants seemed to find very satisfying. Last week, Democrats offered legislation that would resurrect the option of a publicly sponsored prescription drug plan for Medicare beneficiaries, as contemplated in the Medicare Modernization Act of 2003 but never realized in practice because of an unanticipated surfeit of private Part D drug plans. (A similar proposal appeared in Health Affairs in 2005.) The Pharmaceutical Research and Manufacturers of America (PhRMA) were not enthusiastic. “The competitive market approach of the Medicare drug benefit is working well,” PhRMA noted demurely.
Republican Hill staffers at the AcademyHealth conference also expressed deep reservations about the public plan option and the related idea of creating a National Health Board to oversee the national exchange and other health-system functions. Ryan Long, minority staffer on the House Energy and Commerce Committee, asked if the public option would mean that everyone in the exchange would end up on Medicaid. Dan Elling, from the House Ways and Means Committee, wondered if the Health Board would constitute “one big HMO.” But Democratic staffers insisted that the public plan option is a must for them.
Lambrew said that details of the administration’s plans aren’t likely to be available for weeks, because work on the stimulus package takes precedence. So the exact shape of this new animal is still somewhat obscure. But fear and loathing of public-sector solutions in health care remains powerful, as it has been for most of the past century. It may be the ultimate test of the new president’s dream of post-partisanship.