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Will President-elect Obama achieve true health care reform?

From the January ACP Internist, copyright 2009 by the American College of Physicians

By Robert B. Doherty

Health care reform is the holy grail of Democratic presidents. Truman, Johnson, Carter and Clinton all set out to find consensus to provide every American with health insurance coverage, only to end up empty-handed. Some already are predicting that President-elect Obama also will fail after spending so much of his political capital on other priorities, such as the U.S. economy, energy independence, global warming and the Middle East.

There are at least four good reasons why President-elect Obama may succeed.

He thinks the time is right

Just four days before he was elected, Sen. Obama listed health care reform as his third priority, behind fixing the financial mess and creating jobs, but said, “I think the time is right.”

He continues to believe the time is right. One of the most important signals was the nomination of former Senate Majority Leader Tom Daschle as Secretary of Health and Human Services. Mr. Daschle has been described as being passionate about health care reform, having served on the Mayo Clinic board after leaving the Senate. He has the political acumen and respect needed to help President Obama get the votes he needs.

Congress wants it

Leading congressional Democrats are committed to comprehensive health care reform (with some influential Republicans likely to join them). Sen. Ted Kennedy (D-MA), suffering from a brain tumor that likely will cut short the time he can continue to serve in the Senate, has charged his staff with introducing health care reform legislation by mid-January. ACP is one of three physician organizations (along with the American Medical Association and National Medical Association) that Kennedy reached out to in drafting his proposal.

In November, Sen. Max Baucus (D-MT), chair of the Senate Finance Committee, released a white paper that presented his vision for comprehensive health care reform, including affordable coverage for every American and comprehensive reforms to support primary care, which he calls the keystone of a high-performing health care system. ACP congratulated him for views that were remarkably consistent with our policies.

Rep. Charles Rangel (D-NY) chair of the Ways and Means Committee, has said that health care reform is a top priority. Rep. Henry Waxman (D-CA), a long-time advocate of universal coverage, will assume chairmanship of the powerful Energy and Commerce Committee, which has jurisdiction of Medicaid and shares jurisdiction over Medicare with Ways and Means.

Plus, the Democrats are close to having the filibuster-proof majority of 60 votes in the Senate, and have a very large majority in the House of Representatives, having picked up more than 50 seats in the last two election cycles.

Voters want it

When the Commonwealth Fund surveyed voters two months before the election, more than 80% said health care needs “fundamental reform” or should be “completely rebuilt.” This finding was consistent across all income brackets and regions of the country.

The May/June issue of Health Affairs published the perspectives of several nationally recognized polling experts on Americans' views of health care. Celinda Lake, a Democratic pollster, reported that an overwhelming majority of Americans view health care as a right and that peace of mind is their overriding goal. Bill McInturf, the McCain campaign's pollster, wrote that Americans want health reform more than any other major public policy issue, with “the percent of people saying that they want ‘radical change’ to the health care system at one of its highest levels since 1992.”

He has to

Perhaps the most important reason that President-elect Obama might succeed is the health financing system is unsustainable.

Economist Peter Orzag will soon join the Obama White House as its budget director. As Director of the Congressional Budget Office, he called rising health care costs the greatest single fiscal challenge facing the U.S. He has told Congress that because of rising health care costs, the country will be unable to fulfill its obligations to Medicare beneficiaries.

Princeton economist Ewe Reinhardt noted that a person with a gross wage today of $60,000 might see wages increase by 3% per year, reaching $86,000 by the end of the decade, but the same person's out-of-pocket costs for health care might increase by 8% annually to $33,700, or more than 40% of gross wages. He concludes that health care expenses cannot be supported by wages.

There are many reasons why President-elect Obama and Congress could still fail to reform health care. Voters and stakeholders may balk at the trade-offs required to control costs. The deficit may be too large. Too many other urgent needs may compete for limited dollars, time and attention. But I believe that President-elect Obama and the new Congress have the greatest opportunity in generations to bring home the holy grail of health care reform. To let the system crash and burn is far less acceptable.

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