There Will Not Be Health Care Reform in 2009…

…without Republican leadership.

I will suggest that there is an opportunity for the Republicans to
score a huge political and policy win. It can be done in a bipartisan
way and it can be done in a way that does not sell out the core
principles that either Republicans or Democrats believe in.It would require a new effort—a clean sheet—this time initiated by the Republicans.The
Republicans have won August. No doubt about it. But they have “won,”
not because they actually did anything to deserve the win—they pretty
much sat back and let political gravity do all of the work.Now what? Do Republicans really think they can sit back and do nothing for three or four more months and come out “winners?”At this rate, this health care debate is headed for a stalemate that will not do the country, nor either party, any good.

I don’t know any leading Republicans who don’t think this health care
system is in crisis, that we have to bring our costs under control, and
every responsible American should have health insurance.

Democrats could just be on their way to a health care reform
“Waterloo”—again. Letting them implode on their own—with a little bit
of help from the far right—is a tantalizing proposition. But it is not
a terribly patriotic one.I will also suggest that the American
people are smart enough to know the difference between a Republican
Party that reaches out to take a constructive role in turning this
around as opposed to the party of “No” that backs themselves into an
accidental “win.”For Republicans who think they can again
convert the Democrats’ health care problems into a big election victory
in 2010, there is one huge difference between this battle and 1994. In
1994 the Congressional Republicans hadn’t been in power for
decades—they had new and intriguing ideas. After the American voters’
verdict in the 2006 and 2008 elections, it is clear the American people
don’t exactly see Republicans as a new and intriguing brand.It’s
pretty clear that the Republicans have as great a need to prove
something to voters, as do the Democrats. Republican leaders just
sitting there letting the talkmeisters do their work for them isn’t
going to turn around voters’ perceptions of the Republican Party.I
will also suggest there is a pathway Republicans can be enthusiastic
about suggesting to Democrats, that there already is precedence for,
and about which Democrats should be able to become enthusiastic.I would suggest four ideas for the Republicans:1. Propose Bulletproof Health Care Security
– Lots of Americans, especially those with health insurance, are
worried health reform will hurt them. Republicans have a chance to put
those fears to bed. They can propose that the President, the Congress,
and all federal political appointees should have to get their health
care from that same health insurance exchange regular citizens would
use in the community in which their families live. Insurance
underwriting reform would be part of it.That guy we saw in a
town hall this month screaming at his Senator could be a lot more
comfortable knowing he would get exactly the same health insurance
choices his Senator—and his President—got.This approach would
send a message that everyone could be confident about because their
elected officials would be in the same boat.It is also clear
that most Democrats and Republicans can agree on leaving the
employer-based system of health insurance alone—including ERISA. This
would give individuals the right to keep the employer plan they now
have or join their elected officials in the insurance exchange. It is
the citizens’ choice—whatever leaves them wealthier and happier.With
this approach, Republicans can combine the kind of insurance networks
the conservative Heritage Foundation has argued on behalf of for years
with the kind of health insurance Ted Kennedy called for in his recent Newsweek essay.2. Medical Malpractice Reform
– None of the Democratic bills that have made it through committee even
mention it. There won’t be any compromise between Democrats and
Republicans over the old arguments about whether or not we need to cap
damages. But the thinking over malpractice has evolved greatly in
recent years—health courts, for example, designed to quickly resolve medical injury claims and promote medical error reporting toward improved quality.In
candidate Obama’s health care plan document he called for “promot[ing]
new models for addressing physician errors that improve patient
safety.” Sounds like health courts to me. Republicans should call him
out on it by putting it in their offer!3. Paying for It
– It is gratifying that both Republicans and Democrats see the need to
give families not covered by employer plans the subsidies they need to
buy health insurance. Of course, that is by far the greatest cost in
any bill.I was struck by a recent Washington Post op-ed
written by the co-sponsors of the Wyden-Bennett Healthy Americans
Act—six Democrats and one independent plus five Republicans. In it,
they said:

“The Democrats among us accepted an end
to the tax-free treatment of employer-sponsored health insurance;
instead, everyone—not just those who currently get insurance through
their employer—would get a generous standard deduction that they would
use to buy insurance—and keep the excess if they buy a less expensive
policy.“The Republicans agreed to require all individuals to
have coverage and to provide subsidies where necessary to ensure that
everyone can afford it. Most have agreed to require employers to
contribute to the system and to pay workers wages equal to the amount
the employer now contributes for health care.”

Let me
suggest that Republican Senators Bennett, Gregg, Crapo, Graham, and
Alexander are showing the way. Republicans don’t need to sign-on to the
entire Wyden-Bennett bill so much as recognize that these bipartisan
Senators have found a way to reorganize and modernize existing health
care tax incentives toward raising revenue and making the system more
efficient in a way that appeals to both parties.

And, it is
notable that these Republicans and Democrats have also compromised on
ways to reform the medical malpractice system with some unique ideas.

is a model that covers everyone and is deficit neutral in the second
year after it is enacted—and begins to bend costs down in the third

4. Tough Cost Containment – Liberals tend to believe that the best way to control costs is with the public option. I disagree with that
just like Republicans do—I see it as a means to artificially suppress
provider payments but not get at the waste in the volume of care that
is really at the crux of the cost issue.

But what I have been
gratified by are all of the liberals who say passing a health care bill
would not be health care reform—more that it would be a wasteful
exercise—without cost containment. I doubt there are any conservatives
who would disagree with that statement!

August has proven that the public plan option is not tenable—as a cost containment device or anything else.So how could both parties agree on containing costs?

I have suggested something I call the Affordability Model.
Simply, we set and phase-in affordability goals for health care a
number of years down the line. Insurance companies, doctors, hospitals,
drug makers, and everyone else in the system gets to do business in the
way they believe will improve cost and quality. Patients get to choose
any health plan available in their market—a completely free market.
Republicans ought to like that.

The networks of insurers,
doctors, hospitals, and drug companies that are right in their choices
and meet the cost containment goals would get to continue to offer
their services and products through networks as tax deductible health
plans for employers and consumers. The networks that don’t control
their costs or maintain their quality will not be attractive to
patients and employers. They will also not be tax deductible any
longer—a meaningful government enforcement mechanism. More, if there
were not any affordable networks available at the end of the period, a
government plan would be made available. Democrats ought to like the
enforceability of it all.


There are a number of other
health care proposals both Republicans and Democrats can agree on such
as greater use of health information technology, prevention, wellness,
and comparative effectiveness research.

One can see a pathway to a very meaningful reform of America’s health care system that both sides could agree to.

with the politics of health care now so polarized who is in the best
position to extend the “olive branch” and break the impasse? I believe
it is the Republicans who hold the keys to a breakthrough. A
breakthrough that would be bipartisan and therefore one the American
people could have confidence in. A Republican led bipartisan
breakthrough on health care also wouldn’t hurt anyone’s confidence in
the American political system.

Which course will most likely lead to a Republican return to power?

Sitting on their hands watching somebody else’s “Waterloo”—or demonstrating real leadership?

Robert Laszweski has been a fixture in Washington health policy
circles for the better part of three decades. He currently serves as
the president of Health Policy and Strategy Associates of Alexandria,
Virginia. Before forming HPSA in 1992, Robert served as the COO, Group
Markets, for the Liberty Mutual Insurance Company. You can read more of
his thoughtful analysis of healthcare industry trends at The Health
Policy and Marketplace Blog
, where this post first appeared.