Is Congress ready for universal health care coverage?

Congressional staffers and health policy experts who participated in an Alliance for Health Reform presentation on the Commonwealth Fund’s proposal for a consensus framework to provide coverage for the uninsured see value in discussing the issue but are far from united about the proposal.

David Nexon, health policy director for the Democrats on the Senate Labor and Human Resources Committee, said it is "positive that this issue of universal coverage is back on the national agenda. The fact that we’re having this [program] at all is indicative of a change. I don’t know that we would have had it a year or two years ago."

Mr. Nexon said there has been a problem with covering the uninsured since President Theodore Roosevelt proposed universal health insurance at the beginning of the 20th century and expressed the hope that the time is coming when something will be done about it. He urged that those who are working on the problem keep three things in mind: 1) any expansion of coverage is going to be expensive in terms of the public expenditure and while it is not an insurmountable amount, the problem won’t be solved without a substantial increase in federal resources; 2) there is a special role for employers because the U.S. system has been built on employment-based coverage; and 3) for a program to be credible and to meet the needs of the American people, it has to have an element of reducing costs or reducing the rate of inflation in health care.

"There are major opportunities to reduce cost by improving quality of care and by moving health care really into the 20th, not just the 21st,
century, in terms of information technology," he said. "We have immense administrative costs in health care, estimated at as much as 40 cents of every health care dollar. And a large part of those could be reduced or eliminated by moving to a more advanced information technology system in health care. But it’s not going to happen without a substantial public investment."

Mr. Nexon outlined a proposal made by his boss, Sen. Edward M. Kennedy (D-MA). Mr. Kennedy would provide universal coverage by requiring all employers to offer quality coverage to their employees and contribute to the cost of that coverage. Mr. Nexon said the time is overdue to insist that every good job should come with health insurance coverage and declared that it’s appropriate that every employer fulfill social responsibility that the vast majority of employers already provide. The second element in Mr. Kennedy’s proposal provides for special assistance to vulnerable small businesses, recognizing that they have special problems in providing health insurance coverage to their employees. Mr. Kennedy also has a concept similar to the Congressional Health Plan outlined in the Commonwealth Fund framework.

Mr. Nexon also referred to an approach put forth by Sen. John Breaux (D-LA) based on an individual mandate with tax credits. He said the two senators have been having talks about whether they could come together with a proposal that would unite the two approaches.

From the majority Republican side of the Senate, Finance Commit-tee majority health policy advisor and counsel Colin Roskey said his boss, Sen. Chuck Grassley (R-IA), "subscribes to the view that incrementalism is not dead, although some have come to him and said that it was. I think consensus is obviously the key word in a Senate that is as divided as it is over here and certainly Senator Grassley’s view is that to get anything done around this place you need to get not just 50, not just 60, probably something like 70 or 80 [votes in the Senate] or a real breadth of support for a proposal that’s even as small as $50 billion. Unfortunately, I don’t think the Commonwealth Fund proposal cuts and does consensus very well." Mr. Roskey said last year’s experience in approving a bipartisan Trade Promotion Authority bill is instructive in the approach that needs to be taken for health coverage. He said Republicans have concerns about the lack of a nongroup market option in the Commonwealth Fund plan and are concerned that access to unrestricted individual insurance is severely limited. He also questioned the wisdom of expanding Medicare and Medicaid.

Another senator, Ron Wyden (D-OR), has a plan explained at the presentation by his senior health policy advisor, Stephanie Kennan. She described key elements in Mr. Wyden’s bill, Health Care That Works for All Americans Act, a bipartisan effort accomplished with Sen. Orrin Hatch (R-UT). She said the central point in the bill is "public input and political accountability. Essentially, our bill is a process to develop a road map so that we can get to an endgame. It doesn’t support one solution over another, but rather is about getting input and then holding Congress accountable to do something." Ms. Kennan said the bill would establish a 26-member citizens’ work group that report to the American people on what it means to have 41 million people uninsured. The group would hold community hearings around the country to help people understand issues and trade-offs involved in potential solutions. The work group would send to Congress, in narrative form or legislative language, the preferences of the American people. The bill would specify that if the work-group recommendations don’t come out of committee within six months, any member of Congress could go to the House or Senate and eventually call up a bill that it based on the work-group recommendations and force consideration through what is known as a discharge vote.

Neil Trautwein, director of employment policy for the National Association of Manufacturers, said he sees encouraging signs, although his association does not back the Commonwealth Fund plan. He added that employers care about the uninsured and about the impact of cost shifting and uncompensated care. "But we do not care enough to embrace the wrong kinds of health care proposals." Mr. Trautwein said employer-based coverage has worked because it has been voluntary and has evolved over time. "Today’s economy is too fragile, and we simply cannot afford a 5% of payroll mandate and simply can’t afford to be locked into coverage. The consumer-driven market is getting a lot of attention. There’s a surprising degree of interest in individual mandates and the idea that every American should have coverage. I don’t see any softening whatsoever in the traditional opposition to employer mandates or mandated participation. . . . we really prefer an incremental approach building off the employer system."