The health reform debate has had its share of key players. Many of them have been elevated to star status (Snowe, Baucus, Stupak), although the meaning of “star” would depend on whom you asked. Perhaps a more apt term would be a “highly influential” player, or a “significant game changer”. All of these monikers could also apply to a collection of individuals who, over the course of the debate’s more interesting and contentious moments (think House debate), seem to be setting the fiscal parameters on which the key Senate debate is being issued — the Congressional Budget Office.

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Less than a couple hours after Senate Majority Leader Harry Reid (D-NV) publicly made the current definition of the health reform bill on the senate side an official one, the WH has issued a perfunctory measure of support for its language, which includes an “opt out” mechanism for states.

The President congratulates Senator Reid and Chairmen Baucus and Dodd for their hard work on health insurance reform. Thanks to their efforts, we’re closer than we’ve ever been to solving this decades-old problem. [...] the President is pleased that at the progress that Congress has made. He’s also pleased that the Senate has decided to include a public option for health coverage, in this case with an allowance for states to opt out. [...] he supports the public option because it has the potential to play an essential role in holding insurance companies accountable through choice and competition…

Perhaps even more unexpected is the level of apparent support Max Baucus [D-MT] (long a vehement PO detractor) has for the majority leader’s version of the merged product.

It is time to make our system work better for patients and providers, for small business owners and for our economy. It is time for health care reform. [...] Success should be our threshold and I am going to fight hard for the 60 votes we need to meet that goal this year.

Is this a watershed in the entire reform movement (at least by standards on the Hill)? Will progressives warm to the notion of a public option in which many, if not most states, choose to participate? Or will they grow to loathe a position which ultimately favors Insurance and its practically assured regulation of any individual public product placed into the healthcare marketplace? | LINK

Yesterday, while this blog took some time off, healthcare’s political power players took to the Sunday talk shows. And while they did not explicitly say so, Obama’s push for a public option appears to be turning into something less demonstrative. Top Obama aides are framing his push for a public option provision as an insistence now. This all sounds plausible to some degree — except, he has been doing that all along, hasn’t he?

President Obama isn’t demanding that health care legislation include a government-run insurance option even though he believes it would best meet his reform goals, White House advisers said yesterday.

The White House and lawmakers are trying to blend five House and Senate committee versions of health care legislation into a bill that will pass both houses, where near unanimous GOP opposition was expected.

Senior adviser Valerie Jarrett said Obama believes the public plan is still the “best possible choice,’’ but she said he’s not demanding it.

White House chief of staff Rahm Emanuel, who is deeply involved with Democrats in trying to merge the various committee proposals, also appeared to set aside the public option.

“It’s not the defining piece of health care. It’s whether we achieve both cost control, coverage, as well as the choice,’’ Emanuel said…

Where’s the choice without a public option? This was the platform upon which Obama’s #1 domestic priority was placed. One possible interpretation for Obama’s newfound reticence: a “laying low” strategy. Realizing the House’s version of the bill includes a public option provision and that the Senate’s version is anything but, he could be waiting for subsequent committee placement of it back into the bill if the Senate’s final version passes without the provision; that would require sixty Republican votes.

Democrats who wish to have any semblance of a political future in 2010 should be clamoring for a public option. If CBO estimates are to be believed^[1], when voters realize that they will have to wait a few years for the Max Baucus Senate-backed law to be implemented and show any potential savings for care delivery in general, there could be a backlash for healthcare consumers led to believe that public option alternatives in healthcare marketplace competition would be immediate and healthy (insurance co-ops, for example). | LINK

1. The Congressional Budget Office finds that the country would get the most savings on health-care costs from a public option tied to Medicare rates. This version, found in two of the House bills, would save $110 billion over 10 years. [↩]

By now healthcare policy watchers everywhere know that the Baucus Senate Finance bill passed and that Olympia Snowe’s (R-ME) moderate voice was the lone Republican modicum of support. Next up — no more than two weeks (according to Harry Reid [D-NV] — majority leader) of debate before the final floor bill. Besides keeping busy with the pending debate, possible reconciliation, and floor vote; senate Dems are busying themselves with another cause. The deer in the health reform headlights is none other than Insurance itself.  Whatever the reason, the eleventh hour report the industry’s lead lobby — the AHIP — rapidly rolled out on the eve of the Baucus bill vote has complicated matters for themselves. If the AHIP thought that this move would help their cause by drawing a line in the sand, it’s done nothing but inflame all three (four?) sides of the healthcare debate: the Republicans, Democrats, Obama & the WH, and the healthcare beneficiary.

It’s the latter demo that the other three have to contend with over the next crucial 14 days before the most sweeping changes in 65+ years in healthcare delivery occur. Vitriolic townhalls may be a thing of the recent past, but the public’s ire over what is now seen as insurance reform (as opposed to true grassroots healthcare reform) is sure to grow over the next few days – in part due to the latest stirrings by the AHIP. Obama’s spearheading of the reform debate up to this point has generally been heralded as positive, if not mildly successful. But that victory may be a pyrrhic one if many see this detour on the road toward reform as beholden in some part to Insurance.

As the blending of the House and Senate versions of the reform bill coalesce for a vote on its passage, Democrats (who, let’s not forget, own the majority in both houses) must continue to frame the debate on reform as one of guaranteed access that won’t bankrupt the “system” by skewing risk pools, as the AHIP’s report suggests.^[1] Sound fiscal arguments persuasive enough to woo and keep moderate Republican interests like Sen. Snowe are the Dems’ best shots at melding a bill that will please many at the expense of a dilute public option.

1. The AHIP says that young healthy ‘invinvibles’ will not gravitate toward coverage and spread the risk pool, causing an incentive for the sickest, oldest, and neediest to clamor for it — driving up costs. [↩]

This morning’s vote on the health reform bill is as anticlimactic as it is divisive. After weeks and months of speculation, townhall harangues, and political incivility, the Baucus bill^[1] and its more liberal cousin^[2] will merge and go the floor. It’s a foregone conclusion that the bill will be more notable for what it does not contain than for what it does — mainly a so-called public option provision that is enough to satisfy Obama’s more politically Left base.

Fueling the the events today was the release of a report on Sunday (which the White House denounces as a political ploy at influence peddling) from the AHIP lobby detailing the rapid increase in premiums [PDF] if Baucus’s plan saw the light of day. No matter, according to Baucus — as he has the votes to pass his version. Responses are coming out of the woodwork on the heels of today’s vote. A few:

• A leading hospital lobby seems to be backtracking on recent total support of the Baucus plan. The hospitals, which agreed to contribute $155 billion in savings over 10 years toward an overhaul effort, have said that not enough new people would be covered by the finance committee’s final version.
• Some physicians who practice in highly technological subspecialties feel unfairly targeted — as they have complained about provisions in the legislation, including a measure that would penalize physicians in the top 10 percent of spenders. Additionally, some medical device makers oppose a tax provision in the Senate Finance bill that would require them to pay $40 billion annually.
• The AHIP (the organization at the center of the current Hill firestorm) considers the Finance committee’s measure to be one it generally supports but still retains concerns over the ability for insurance companies to reach “higher coverage targets”.

Although there are key differences the White House says Insurance completely ignores, like the utilization of healthcare exchanges to ensure future cost savings; there is generally broad bipartisan agreement on issues of the abolition of preexisting condition provisions, preventive care initiatives, and EHR implementation. The road to complete agreement on how to spend dollars to achieve these goals is a different matter altogether, however.

1. so named as its chief architect is also the Finance Cmte. chair [↩]
2. courtesy the Health Employment Labor and Pension Committee [↩]

It’s just something that makes healthcare policy observers want to ask, “how public is this public option going to be after the merger of House and Senate versions of the reform bill occurs”? Now that the Baucus bill has been released and is being met favorably by fiscally conservative Democrats (as expected) and the more progressive wing of the party (somewhat surprising), criticisms are beginning to emerge in advance of Baucus’s committee’s vote on it next week. Most notably, a current report by the RWJ finds that older Americans under the Senate Finance Cmte. version will be paying more in premiums than much younger adults; this would only apply to those patients finding coverage on the open healthcare market or are uninsured.

This pits the actions of two groups of observers/lobbyists, the AARP and the AHIP, as a potential source of political friction once the Senate Finance version passes. Insurance plans would stand to gain in a plan in which the government would have to subsidize the inclusion of younger patients in a given pool of beneficiaries to offset the high risks incurred by covering, say, those over 65 who lack affordable insurance coverage. The AARP, needless to say, will be watching the merging process very closely in the run up to the final reform bill. They obviously have much to gain if uninsured seniors are not forced to pay premiums which may be as much as 5 times higher than what a younger adult under the Baucus-led bill would pay. | LINK

It’s the liberal wing of the Democratic party vs. the moderates. The issue is government’s reach in the delivery of healthcare — in particular, the issue of the public option. Liberals know that any sort of government plan — even a modicum more expansive than the rudiments of a public option — is essentially off the table. That’s why they’ve launched an ad campaign targeted at their Public Enemy #1, Senate Finance Chair Max Baucus. Although Baucus’s staff say that he is not intolerant of the public option, he supports the competition with Big Insurance at the hands of non-profit co-ops — something Insurance wants no part in.

Sens. Schumer (D-NY) and Rockefeller (D-WV) support government involvement in the form of a payment negotiating body and Medicare model for coverage, respectively.

And those moderates? They could be looking to Olympia Snowe (R-ME) who supports the use of a public option only as a threat — a stipulation for insertion into the healthcare marketplace only for non-compliant insurance companies which don’t keep their premiums “in check”, whatever that means.

Lawmakers get back to work today. | LINK

UPDATE: It appears as though those same liberals failed to get a public option in the Senate Finance version of the reform bill. | LINK

The concept of so-called “Cadillac” health plans for consumers has been briefly introduced on this blog. Just as its title implies, higher than average premiums guarantee a certain level of care for the policyholder. The types of plans covered vary, and the coverage may apply to individuals or pooled, risk-stratified groups. Of course, premiums imposed by the latter are completely dependent on the health of that risk pool.

Among other things, the bill introduced by Dem Senator Max Baucus includes provisions for imposing a tax on premiums above a certain threshold for individuals and families. And although the “Cadillac” name may imply coverage for high wage earners, not everyone paying these premiums is especially well off financially. The tax on premiums is meant to affect the insurance companies; but many fear that the tax will be passed on to the healthcare consumer since the cost of healthcare delivery almost always rises faster than inflation. | LINK

So, Sen. Max Baucus has introduced his healthcare reform bill to the world. It was met with a resounding yawn. What’s next? Well, outside of the fact that Republican support is practically dead (save for some pleas to Republican moderates who may give it a second chance), the bill’s failure to gain traction puts the reform debate at the eleventh hour into the wider national spotlight and out of the Gang of Six’s lawmaking closed quarters.

Senate Democrats are now more renewed than ever to the fact that there needs to be some public “plan” at final passage. Interesting how this is referenced on the Senate side, as Speaker Pelosi is still holding fast to a public option provision in the House. Although Baucus may have lost the battle, his ideas may not have lost him the war. In the Senate, the goal now — even for the more liberal cognoscenti — is the search for government involvement at a level that will not invoke cries of socialism, but for alternatives that will benefit insurance coverage purchasing while appeasing insurance companies fretful of government competition. Obama seems to be echoing this, and will continue to tour on its premise.

Is this the new Democratic strategy for health reform in the homestretch? | LINK

UPDATE: In an effort to gain greater leverage among go-it-alone Democrats wary of his plan’s original language, Baucus is reportedly tweaking the bill’s affordability parameters.

The changes could add $28 billion to the 10-year cost of his bill, which was originally estimated at $774 billion by the Congressional Budget Office. The revised bill, though, could still meet President Obama’s stipulation that health care legislation not add to the federal budget deficit.

An interesting move which buys the Finance chair some time and, perhaps, some support. | LINK

Today, Senate Finance Cmte. Chair Max Baucus, the Montana Democrat who has had his share of criticisms regarding Big Insurance cronyism, unveiled his hotly anticipated health reform plan — notable for two things: the lack of a public option (in contrast to Obama’s goals) and the inclusion of provisions for private nonprofit co-ops in the healthcare marketplace. Although the plan is not endorsed or backed in any way by Republicans, it certainly has the imprint of the GOP all over it — specifically calling for the use of tax credits to help low- and middle income consumers purchase insurance.

The Baucus plan in many ways looks like a Republican-lite version of reform measures aimed at minimizing taxpayer cost and maximizing boilerplate issues usually reserved at maintaining GOP star profiles. But Baucus seems to have has own vision in promoting reform. It’s just difficult to distinguish between the plan’s reform goals and his. | LINK

UPDATE: The Baucus bill appears dead in the water, as the effort needs a full 60 votes. The most it can possibly muster is 59. Apparently, good news for the progressive wing of the healthcare reform movement. | LINK

Previously on Doctor Pundit: Obama Delivers Key Reform Speech to a Weary and Wary Nation

The so-called ‘Gang of 6′. Yep, you know who they are. Its most high-profile member, Sen. Max Baucus (D-MT), has threatened to put forth his own healthcare proposal if Obama’s new definition of healthcare reform does not yield bipartisan momentum to get a more slender bill — one that would take effect more slowly and would probably consider some sort of public insurance plan with the stipulation of lower rates offered by private insurers. This, of course, isn’t sitting well with liberal Democrats (with Speaker Pelosi in tow) who is on the record as saying she wants a “vigorous” public option pursued.

With the act of reconciliation looking more and more likely as a way of passing any bill with a label of health reform, Republicans are making sure to draw lines in the sand to prevent future funding problems that are almost certain with such a mechanism for a bill’s passage (as opposed to simple filibuster). With the president’s speech on the issue of “coming together” and the internal dissention among partisan factions in Congress becoming more of a barrier, the path to a reform bill’s passage will be just about as entertaining as the analysis of the final package itself. | LINK

UPDATE: The NYT has more on the last-minute Senate Finance Cmte. machinations, and the result isn’t really what Barack Obama needs to hear concerning his biggest domestic priority.

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So whom do we believe? House Speaker Nancy Pelosi goes on record as saying her constituents are on schedule to submit a final version of the reform bill “whenever”, and the Senate is still in limbo mode, now essentially including a provision for insurance cooperatives to compete with private plans — a scenario orginially introduced by Kent Conrad [D-ND] and discounted. But is the Senate really eschewing “bipartisanship” for expediency?

After weeks of secretive talks, a bipartisan group in the Senate edged closer Monday to a health care compromise that omits a requirement for businesses to offer coverage to their workers and lacks a government insurance option that President Barack Obama favors, according to numerous officials. … Like bills drafted by Democrats, the proposal under discussion by six members on the Senate Finance Committee would bar insurance companies from denying coverage to any applicant. Nor could insurers charge higher premiums on the basis of pre-existing medical conditions.

And also, what about the role of small business in all of this? If the Senate throws Obama’s original plans for reform under the bus, how will public funds pay for any type of guaranteed care to employees of non-participants? Easy. They’ll be the one’s reimbursing the government for the choices of their employees going elsewhere for coverage.

[ME Sen.  Olympia] Snowe said the idea is to discourage employers from dropping coverage because under the plan their workers could get government assistance to pay premiums. “We don’t want to undermine (employer coverage) or create a perverse incentive where employers potentially drop coverage because their employees can get subsidies,” she said.

Snowe is just one of the Senate Finance Cmte. members taking part on the highest profile committee structuring the Senate version. The committee convened Monday by Max Baucus [D-MT], who still thinks that his definition of bipartisanship will create an acceptable Senate version. The drama plays on. | LINK

Is the original Obama healthcare reform plan dead in the water? If you believe the last-minute motives of the Senate in altering the public-option component considerably at the pleasure of private interests, then you can probably form your own opinions at this point. According to the Washington Post today,

As his committee has taken center stage in the battle over health-care reform, Chairman Baucus (D-Mont.) has emerged as a leading recipient of Senate campaign contributions from the hospitals, insurers and other medical interest groups hoping to shape the legislation to their advantage. Health-related companies and their employees gave Baucus’s political committees nearly $1.5 million in 2007 and 2008, when he began holding hearings and making preparations for this year’s reform debate.

Reality comes full circle. Although overwhelming support among Americans in the original Obama plan and its public option provision provided the impetus behind the downplaying of the role of Insurance, Pharma, and Health Plans in drafting the ostensible language of the reform package; acknowledgment of the special intrerest minority by Baucus and other Democrats (and Republicans)  seems to be influencing things now. | LINK