The Richard and Hinda Rosenthal Lecture 2008: Prospects for Health Reform in 2009 and Beyond: 20th Anniversary Lecture (2009)

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Keynote Presentation 

Julie Rovner ❧ National Public Radio Correspondent and Health Policy Expert Thank you. I actually hasten to add that the President Elect did not an- nounce that former Senator Daschle would be his HHS Secretary but it got leaked. Well thank you all very much for being here. I see some friendly faces in the audience, which is always nice. I have been asked to talk about the prospects for health reform and I am pleased to report that for the first time in many years there actually seem to be prospects for health reform. In fact, I’m going to go out on a limb and say that this seems to be a pretty good time to be a health policy reporter. It may even be a good time to be in health policy. On the other hand, it’s pretty risky out there. I was talking with one of my colleagues at National Public Radio last week and I mentioned one of the candidates for Health and Human Services Secretary—Tom Daschle, actually, and she said, gee, he’s such a nice guy, why don’t they give him something that achievable like Middle East peace? Seriously, in 1993 I traveled around the country and I made a lot of money talking about why health reform in 1994 was inevitable. Now I’m not allowed to take money, and I’ve pretty much stopped making predic- tions. But I will predict that we will see another effort in health reform in the next year and I’m going to give you several reasons why. First and foremost, President Elect Obama’s voters are expecting it. You know if you spend 80 percent of your advertising money on one issue, as candidate Obama did late in the campaign, by God the people who vote for you expect you to deliver on that promise. Now, health care was not the top issue in most of the exit polls—that  

 PROSPECTS FOR HEALTH REFORM IN 2009 AND BEYOND would have been the economy by a very wide margin. But of the voters that said that health was their top issue, they voted for Obama by very large margins and, more ominously, 60 percent of Obama’s voters said in a Harvard School of Public Health poll in late October that they expected that if he was elected it would make, “a great deal of difference on health care.” So economic woes notwithstanding, this is an issue that the new president can’t afford to put on the political backburner for very long. The second reason I think health care is likely to come up soon is Sena- tor Ted Kennedy’s last hoorah. Unless you’ve been living under a rock for the past 8 months, you certainly know that Senator Edward Kennedy, Chairman of the Senate Health, Education, Labor, and Pensions Commit- tee, is undergoing treatment for a malignant brain tumor. Senator Kennedy actually returned to Capitol Hill this week looking pretty good, all things considered, but it seems pretty clear that this next Congress is likely his last best chance to realize his career-long goal of achieving universal health insurance. Kennedy has been quietly laying the groundwork for another major health reform push, his fifth or sixth by my count—there may be someone in this audience who knows better than I—since he helped bro- ker the deal that produced Massachusetts’s landmark health reform plan in 2006. So Senator Kennedy has been pretty active on this the last couple of years. In fact, just yesterday he appointed Hillary Clinton to head a work- ing group of his committee on insurance coverage. I guess that’s assuming that she doesn’t become Secretary of State or, knowing Hillary Clinton, she might try to do both. Speaking of laying groundwork, the third reason I’m bullish on health reform is the proliferation of bipartisan and strange bedfellow alliances sprouting up around town. It seems just about everywhere you look people who don’t usually agree on health issues are working together. That strange little donkey-phant creature in the Divided We Fail ads rep- resenting AARP, the SEIU, the Business Round Table, and the National Federation of Independent Business—wow, who would have thought those groups would find common ground. It’s just the tip of the iceberg. On Capitol Hill, we’ve already got a substantial head of bipartisan steam building up behind Democratic Senator Ron Wyden’s Healthy Americans Act, including liberals like Debbie Stabenow and conservatives like Judd Gregg. They’re both co-sponsors of that bill. Downtown, there’s a group of former Senate majority leaders also working on health reform consensus, including Republicans Howard Bak- er and Bob Dole and Democrats George Mitchell and Tom Daschle—yes, that same Tom Daschle who’s about to be the Health and Human Services Secretary designate and White House health czar. Then there was the return of Harry and Louise this summer. Those were the actors who helped sink the Clinton plan. Yes, Harry and Louise 

JULIE ROVNER  were the names of the actors, not the characters. They were brought back calling for health reform, brought to you this time by former archrivals, the aforementioned NFIB, the National Federation of Independent Busi- ness, and Families USA, along with the American Hospital Association, the Catholic Health Association, and the American Cancer Society. Of course, seeing Harry and Louise back on TV isn’t the only way that it feels a little bit like 1993 out there. First of all, the state of the nation’s health care system is, to use a technical phrase, kind of sucky. I presume you wouldn’t be here if you didn’t already know most of the statistics so I won’t dwell on them: 46 million Americans without health insurance, 25 million more with inadequate coverage and the U.S. spends $2 trillion a year on health, about 16 percent of our GDP. The $6,700 we spend, on average, per person, is almost two and a half times the OECD average of $2,800 and half again as much as the next highest spending country, which is Switzerland. Now, I must say that I’ve just been to Switzerland earlier this year. They cover everyone through mandated private insurance. They don’t seem to skimp on care for the substantially less they pay but I digress. You only have to look up at Capitol Hill to see the big three automak- ers begging lawmakers for a bailout to see what health care costs are doing to our manufacturing base—what there is left of it. Okay, the woes of the auto industry are about more than just health care cost but they’ve played much more than a minor role. Still, while there are lots of ways you could say this is like 1993 but worse, there’s one big difference: attitude. Back then health reform seemed, well, inevitable. It wasn’t a matter of whether but what form it would take. Now, with many key players on Capitol Hill (likely about to populate the new Obama administration) still sporting scars from the aftermath of that spectacular Clinton failure, I’m going to coin this effort the new era of pragmatism. To listen to people, legislators, lobbyists, and stakeholders alike, they might as well all be wearing the same t-shirt already emblazoned with these words—and I’ll give you the G-rated version—let’s not mess it up this time. Just today the members of the Senate Finance and Senate Health, Education, Labor, and Pensions Committee met to talk about jurisdic- tion. That’s always a touchy discussion. Yet, Republicans and Democrats emerged from the meeting to profess just how optimistic they are at their chances to get legislation not just passed, but passed early next year. They’re talking January, not for passage but for getting a bill. I must say I am surprised at how willing to compromise everyone seems to be, at least for now. After all, there’s nothing quite like the first blush of everything seeming possible. But there’s reason why every effort at health reform since Teddy Roosevelt has failed. A big one is the power 

 PROSPECTS FOR HEALTH REFORM IN 2009 AND BEYOND of the status quo. That $2 trillion we spend on health care every year, every penny of that is someone’s income and the dirtiest word in health reform, it’s not rationing, although that’s a close second, is redistribution. Every time you take one of those dollars and give it to someone else the donor is going to yelp and hire a lobbyist. A second problem is that the devil is always in the details. It is so much easier to get agreement on a broad outline or a set of principles, than it is to write actual legislation or to remake a system that accounts for a seventh of the nation’s economy—or is it a sixth by now? Then there’s money. Yes, the $700 billion Wall Street bailout finally made health reform look cheap. It’s about time something did but there’s still going to be sticker shock and there’s going to have to be the difficult discussion of who’s going to pay and how much? The next biggest obstacle is what I call the demagogue’s delight. Let’s face it; the public doesn’t understand health reform because the public doesn’t understand the health system as it exists today. Most seniors would have been far better off under the ill-fated 1988 Medicare Catastro- phe Recoverage Act—and I know there are people in the room here who know this. It was specifically designed to create far more winners than losers but because, like virtually all health legislation, it was complicated to explain and easy to mis-explain, demagogues were able to churn up enough opposition to make Congress repeal it. Another unanswered question is what the loyal opposition will do. As I already mentioned, Republicans, for the moment, seem to be all aboard the health reform express. They read polls and run for reelection too. But those who were around at this point in 1992 might remember that Repub- licans were also professing support for health reform. In fact, Republican opposition to the entire effort didn’t really begin in earnest until late in 1993, after President Clinton sent his bill up to Capitol Hill. With minori- ties in both the House and Senate, the only real power Republicans will have over the next 2 years is the power to say no. We’ll have to see if they end up using it. Finally, there is what we in health policy circles know as Altman’s law. It’s named for Brandeis University health policy professor and long- time Washington policy maven, Stewart Altman. It holds that every stake holder’s second choice for health reform is the status quo. In other words, when no one can agree on a change, nothing changes, which is pretty much where we’ve been in health care since the passage of Medicare and Medicaid—at least in terms of large-scale changes. So where does that leave us? Well, I’m pretty confident there’s going to be a health care debate in the relatively near future. The outcome? Your guess is as good as mine but I’m guessing it’s going to be a pretty fun ride. Thank you for listening and I’ll be happy to answer a few questions.