Making hard choices in health policy
By Howard B. Shapiro, PhD
Advocacy in health policy requires difficult choices. How those choices are made is an expression of an organization's reputation and effectiveness.
A case in point is provided by the current legislation on insurance reform, known commonly as the Kassebaum-Kennedy bill after its chief Senate sponsors, Edward Kennedy (D-Mass.) and Nancy Kassebaum (R-Kan.). The bill's primary purpose is to make health insurance more portable by limiting exclusions based on pre-existing conditions when individuals move from one group plan to another or from group to individual coverage. These provisions could help up to 25 million people maintain their health insurance despite changes in job status. The American Academy of Actuaries has estimated that these requirements would raise premiums only 2% to 3%.
Although representatives of both parties once favored health reform packages that went well beyond this provision, this approach is a practical first step and, importantly, the only bill that can be enacted this year. At press time, the bipartisan coalition backing the bill was fragile and in danger of breaking down if other components were added to the legislation. Supporters of the bill from both parties, therefore, have urged their colleagues not to offer amendments, although, at press time, that was exactly what was beginning to happen:
Liability reform and more. On March 28, the House, by a vote of 267-151, passed a version of the insurance reform bill that included medical liability reform provisions, including a $250,000 cap on non-economic damages, a limit on punitive damages and options for creating tax-sheltered medical savings accounts. These items were part of last year's debates on the balanced budget package, and a number of them and others made it into the final legislation that the president vetoed. Even though the House voted for these items last month, attempts to add them in the Senate would lead to filibuster and defeat of the core insurance reform legislation. Moreover, President Clinton has indicated he will only sign an insurance reform bill without amendments.
Lifetime caps. Sen. Jim M. Jeffords (R-Vt.) backs an amendment that would eliminate lifetime dollar caps on benefits. While the College supports the idea, it also is committed to passing limits on pre-existing conditions. Because the insurance industry opposes the lifetime caps so strongly, adding the provision would likely lead to the bill's defeat. Consequently, ACP has opposed adding this amendment. The Senate was expected to vote on insurance reform this month.
With the opportunity to enact any reform bill in jeopardy, ACP's message in meetings with members of Congress on Leadership Day on Capitol Hill (see "Leadership Day focuses on modest reform") was to pass a "clean" Kassebaum-Kennedy bill. Rep. Marge Roukema (R-N.J.), sponsor of the House companion bill, confirmed that this was the only achievable objective this year. Unfortunately, House leaders rejected her approach and threw their support behind the version with liability and other provisions.
Our physician leaders accepted the political reality of setting aside cherished goals for a time, such as malpractice reform, to pass legislation that would take a step in the direction of universal coverage--one of the College's core principles. More than one member of Congress commented that day how impressive it was that physicians were saying, "Don't jeopardize this bill that will increase security of health coverage for millions by adding provisions that are not politically feasible this year. Pass a bill that the president will sign."
What is the gain from the ACP approach? First, it increases the chances that, for the first time, a health system reform bill will be signed into law. Second, a successful step in this Congress could lead to another step in the next Congress, moving the nation closer to universal coverage.
Third, this strategy enhances the College's reputation as a politically realistic organization that expends its energies for achievable objectives. Finally, we gain credibility as an organization of physicians that puts the interests of patients front and center.
We have little to lose. The other issues remain priorities of the College, but are simply not viable this year at the federal level. We will be ready to promote them in more promising environments.
Howard B. Shapiro is Director of Public Policy at the ACP Washington, D.C. office.
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