Health Politics

When Bill Frist was Senate Majority Leader, he did not advance the cause of comprehensive, bipartisan health reform and will be remembered for his role in the Schiavo case (although he did take heat for working with Democrats to expand federally-funded stem cell research). Mostly he pushed for malpractice reform (in a very partisan model) and for small business purchasing pools (also from a GOP perspective).  If there were compromises to be had under his watch, he didn't have them.

Better late than never.

We've watched Frist over the past few months. As we've noted, he has backed a fairly expansive approach to prevention and population health, and recently endorsed the individual mandate (which was a centrist Republican idea before it became a Democratic idea). Now he tells Karen Tumulty of TIME that he'd vote for the Democratic health care reform bill in Congress -- even if there's a lot in it he isn't crazy about. (He later told ABC News Radio that he doesn't like the Baucus bill as currently drafted, according to the Politico.) 

The Republican stance on Medicare has Paul Krugman tearing his hair out. Or maybe he wants to tear their hair out. In a column titled "The Politics of Spite," he writes:

At this point, the guiding principle of one of our nation's two great political parties is spite pure and simple. If Republicans think something might be good for the president, they're against it -- whether or not it's good for America.

Now, it's understandable that many Republicans oppose Democratic plans to extend insurance coverage -- just as most Democrats opposed President Bush's attempt to convert Social Security into a sort of giant 401(k). The two parties do, after all, have different philosophies about the appropriate role of government.

But he argues that when Democrats opposed President Bush's plan to privatize Social Security, they did it in an ideologically consistent way. Not so the Republican assault on health reform. 

Two short anecdotes from this weekend in Washington:

1) Seen on Washington's Massachusetts Avenue -- a vanity license place  that said B INSURD

2) Listening to "Marketplace" in the car Friday afternoon with my not-quite-nine year old, (born and bred, for better or worse, inside the Beltway) as two commentators debated whether health reform or revamping financial regulation should be the top congressional priority. This confused my son, who asked my [predictable] opinion and then formed his own. "You know, we really need to do health care first, because if the economists don't have health care, they could get sick and die and then no one would be left to fix the stock market." 

From his mouth to the Senate's ears...

2 a.m. on C-SPAN is usually reserved for coverage of the Smithsonian Institution Board of Regents' annual meeting or a panel discussion of Lost and Stolen Art.

Last night was different.

After seven days of hearings with a total of 564 amendments offered, the Senate Finance Committee finished working on its portion of the health reform legislation. Pending a preliminary CBO score of the amended legislation, the committee will reconvene next Tuesday to make any final changes before reporting it out of committee.

This was the longest mark-up in over 15 years for the Senate Finance Committee. It produced what the Washington Post describes as "a political consensus large enough to carry the plan to final passage..." The conclusion of the Finance hearing clears the way for health reform legislation to reach the floors of House and Senate -- as early as mid-October.

The public plan option, in the Senate at least, is beginning to remind us of one of those really really convoluted word problems back in sixth grade math.

"If there are 60 Democratic senators, and 50-something (maybe) back the public plan and none really want to kill health care reform but 15 want to make the playing field more level and four want to leave it to the states, and two are named Nelson and twenty are up for re-election and 9 come from red states... and one is named Reid" how many cookies did Johnny eat?

And would Johnny have eaten all those cookies if he had better primary care?

Every slide comes to an end, and the latest Kaiser Health Tracking Poll finds that public support for health reform increased from August to September.

As with previous polls, a majority of American's continue to support health reform, with 57 percent of respondents saying it is more important than ever to address the issue -- a 4 point increase from August's survey. The percentage who said their family will be better off also increased six points (42 percent vs. 36 percent in August), as did the share of those who think the country will be better off if health reform passes (up eight points from up eight from 45 percent in August to 53 percent).

Democratic support for reform remains steadily high (77 percent favor tackling reform now), and the shift in polling reflects a softening in opposition from Republicans and independents. The percent of respondents who felt they would be worse off if reform past fell by 12 points from August to September for Republicans and by 10 points among independents.

Last time I ran into Bill Frist, he was sounding distinctly nonpartisan on a panel discussion about preventive care and social determinants of health. We then talked about comparative effectiveness research at Vanderbilt, where he is affiliated, and he was so enthusiastic that he took my notebook out of my hands and began sketching diagrams of DNA molecules (at least I think that's what they were.) I asked him why he didn't write on op-ed about this, given that the research has been so controversial among his fellow Republicans. As far as I know, he hasn't written that an op-ed -- but he just penned an endorsement of an individual mandate to purchase health insurance.

The mandate is a lynch pin of effective insurance market reform and it's coming under increasing Republican attack. Some state legislators are even talking about amending their constitutions -- a largely symbolic conversation among conservatives -- to ban such a requirement.

In his guest column for U.S. News and World Report, Frist called for an individual mandate. He wants to begin smaller than the bills currently being considered in Congress, recommending a mandate for catastrophic coverage as "an appropriate place to start." But he defined catastrophic coverage as good enough to protect people from bankruptcy from medical bills, and made clear that he favors expanding coverage as the economy improves.

With the Senate Finance Committee still to debate how (or if) to include a choice of public health insurance plan or co-op in the new insurance marketplace, it is a good time to clarify the implications of a public plan that takes effect when competition is lacking or prices are too high, the so-called "trigger" option. Senator Snowe (R-ME) is expected to introduce a version of this idea in an amendment to provide a "safety net fallback plan to ensure access to affordable coverage."

The amendment (Snowe Amendment # 1 - Coverage, p. 207) would establish a non-profit government corporation to offer a competing plan in any state where 5 percent or more of its residents do not have access to "affordable" coverage (with affordable defined consistently with the original Chairman's Mark on a sliding scale between three percent and 13 percent of income for individuals between 133 percent and 300 percent of the federal poverty level (FPL). Chairman Baucus has since modified his mark, moving the sliding scale affordability test to between two percent and 12 percent of FPL. More than likely, Senator Snowe will modify her amendment accordingly. 

Some have argued that a "trigger is an excuse for not doing anything." This assertion is simply wrong. It should not get in the way of serious consideration of this viable option.

During mark ups of the America's Healthy Future Act in the Senate Finance Committee yesterday afternoon, Senator Chuck Grassley asked Chairman Baucus if he should book a plane ticket home or if they would be their all weekend.

It looks like the ranking Republican from Iowa got his wish, as the Senate Finance Committee adjourned at 12 pm Friday. The Committee will resume markups next Tuesday, when, as Politico reports, they are expected to take up amendments related to the public health insurance option.

So while we wait patiently for what may be the most closely watched debate in C-Span 3's history, here's rundown of some of the major changes to the chairman's mark, as well as some outstanding issues going forward:

Polls have been all over the place about what the public thinks -- or what the public thinks it thinks because the confusion is evident -- about health reform, although overall the trend seems to be more positive since late summer and President Obama's speech to Congress. And as the FiveThirtyEight blog pointed out a few weeks ago, even the pollsters sometimes seem confused about what it is they are asking about. But here are a few highlights from the latest  New York Times/CBS News poll.

• Confusion reins. Thirty percent mostly support the president's health reform agenda, 23 oppose it and  46 say they don't know enough about it.
• Notwithstanding the confusion, Americans found Obama far more trustworthy than the Republicans on health policy, and 76 percent said Republicans had no clear health plan.
• Despite all the Baucus-bashing, the Finance Committee chairman's painfully prolonged attempts to reach out to Republicans and the president's support for bipartisanship seems to have had political dividends."By "a lopsided margin" those surveyed said Obama had tried to reach out to Republicans, and that Republicans had not reciprocated.