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June 23, 2009

America's Agenda: Health Care For All - Conversation with Dick Gephardt on bipartisan business-labor-payor coalition prodding policymakers into action

I had the opportunity to speak with Dick Gephardt and Mark Blum yesterday, courtesy of America's Agenda: Health Care For All.  Mark is the organization's Executive Director.  Dick Gephardt is a board member and is also . . . Dick Gephardt.  The organization has been engaged in some bipartisan efforts to promote health care reform at the state level (e.g., Vermont), and is now trying its hand at the national stage, having sponsored a series of "summit conversations" over the past few months.  This is one of a new breed of political action committee, which strives to bridge gaps between Democrats and Republicans (Tommy Thompson is also a board member), Big Labor and Big Business and Big Healthcare (members range from SEIU to IBM to PhRMA to Catholic Healthcare West), and promote health care reform.  As is true of many proposals on the table these days, the group's consensus document on national health reform takes the mom-and-apple-pie approach, endorsing a federal disease prevention initiative, a national strategy to improve efficiency and coordination of chronic disease care, strengthening comprehensive primary care, improving evidence for practice guidelines and quality standards, aligning incentives to promote best practices, promoting HIT to reduce waste and enable care coordination, and guaranteed access to care.  The $2.4 trillion question remains: How do we pay for all this health care goodness?

Gephardt was in a leadership position in Congress during the "HillaryCare" campaign in 1993-94.  In his view, comprehensive reform stands a better chance now because the Obama Administration has set out basic goals to be achieved that are straightforward and positive, and has turned it over to Congress to work out the details -- in contrast to the HillaryCare plan drafted in private by a panel of experts and dumped on legislators' desks.  "In the end, the only thing that matters is votes in the House and Senate," Gephardt said, and the only way to secure those votes is to engage Senators and Representatives in the development and drafting of the bills, which was not done in the Clinton era.  His other observations: Stakeholders in the process have remained engaged this time around; in the '90s, many big stakeholders opted out early and just attacked the process.  In order to succeed, a health reform plan needs to offer tangible benefits to the 85% or so of the population who already have health insurance (e.g., savings or efficiencies); otherwise there can’t be a successful political outcome.  "We can't just talk about who do we tax to cover the uninsured; we need to talk about savings for everyone."

I asked Gephardt whether and how the spirit of bipartisanship that we see these days among many prominent former government officials "reaching across the aisle" could be instilled into current political leaders.  His observation: it's hard, given the degree to which the parties have become polarized, yet some Republicans, notably Senators Grassley and Enzi (ranking minority members on key committees), are able to engage in policy discourse.  Gephardt noted that given the range of views within the Democratic Party, there needs to be as much attention paid to keeping the conservative and progressive wings of the party engaged as there is to keeping lines of communication open across the aisle.  Gephardt and Blum both said that there seems to be more common ground this time around because business, labor and provider communities are all feeling pain and recognize that reform is needed.  However, it seems to me that shared pain does not guarantee shared views on the right prescription to ease that pain.  The prescription involves a lot of money, and the stakeholders under various plans floating around Congress these days are weighing in, making swift passage seem less likely as time goes on.  See, e.g., the letter from AHIP to Sen. Kennedy, as reported in the Wall Street Journal.

Blum pointed to the organization's success in helping garner support for the Vermont health care reform plan enacted a couple of years ago.  After the plan was initially vetoed by the governor, and his approval ratings didn't budge, America's Agenda came to town and recommended taking a different tack, based on polling data showing that the key issue for Vermonters (most of whom were already insured and were unmoved by the rhetoric about universal coverage) was concern about being able to continue to pay for one's own health care in the future.  Focusing on that angle led to passage of the bill and its signing by the governor, Blum said.  A more recent model for success is the West Virginia five-year plan, enacted within the past month.  Again, local conditions dictated strategy and tactics.  And again, it will be very interesting to see whether and how the broad promise enacted will ultimately be funded and implemented.

Translating this success to the national stage requires identifying the health care delivery system reforms that can drive down costs, according to both Blum and Gephardt.  If everyone's covered, they say, we can spread costs over more premium payors and manage chronic conditions more effectively and efficiently.  I pushed on this point, given the evidence demonstrating that preventive care doesn't necessarily save money in the long run, because (a) preventive care for all is more expensive than treating the small numbers of cases of any illness or injury that could have been prevented and (b) the people who benefit from such care tend to live longer and eventually suffer from costly illnesses.  Blum insisted that employers such as IBM have found that given a long enough time horizon (10-15 years), the savings are there, and preventive care pays off (4:1).  I am not convinced; I think that given an even longer time horizon -- e.g., into retirement -- the costs will spike, but then that's no longer IBM's problem . . . it's everyone's problem.  Now, I'm not opposed to primary and preventive care; I would just prefer that the trade-offs and consideration of all costs and benefits be explicit.  This is a big social policy issue, not just a health care issue, given the amount of money that's at stake and the potential for rationing engendered by the price tag.

Other topics touched on included the question of whether for-profit insurance companies should be permitted to reap the financial benefit of health care expenditure savings (Gephardt pointed to legislative language calling for community rating, limitation of pre-existing condition exclusions and, in the House Tri-Committee health care reform bill released as a discussion draft within the past week, regulation of medical loss ratios so as to prevent windfalls to commercial insurers; this last provision seems destined for the dustbin of history sooner rather than later).  In addition, I asked whether contributors to America's Agenda's campaigns are skewing their focus (Blum said the $12 million contributed by PhRMA to the SCHIP fight was firewalled away from the current campaign regarding health care reform).

Bottom line: America's Agenda has done a good job of bringing the policy debate out of the back rooms and onto the internet, and has also made important contributions to enabling state-level reforms.  It remains to be seen whether this new stripe of activism will gain significant traction in Washington, or whether the business-labor-payor alliance will simply break down as we get closer to the massive financial issues at stake in the debate.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting


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