A new Congress may patch up a few problems, but don't expect a cure
Last Wednesday morning, the clouds scudding over Lake Monona in Madison, Wis., did little to obscure Tammy Baldwin's bright view of the future. "I think we have the chance to make some real changes to healthcare," said the Democratic representative, who had celebrated her return to the U.S. House for a fifth term the night before on a terrace by the lake. The liberal Baldwin is cosponsor of a bill, with conservative Republican Tom Price of Georgia, to allow states to experiment with different ways to expand coverage and access. Not only does the bill enjoy broad bipartisan support, "but with the Democratic takeover of the House, we can move on the bigger issues. Democrats recognize healthcare is an immediate crisis," Baldwin says.
Indeed, crisis is a word being used more and more often to describe the U.S. healthcare system. Medicare is going to cost a staggering $30 trillion over the next 75 years, "and no one has any idea how we are going to pay for this," says Robert Moffit, head of health policy studies for the conservative Heritage Foundation. Plus we're not getting enough for the money: A 2003 study in the New England Journal of Medicine showed that only about half of all adults get the medical care recommended in established guidelines. And no one is doing anything about the more than 46 million Americans who are uninsured. "Congress has, in many ways, been asleep at the wheel," says Jeanne Lambrew, a health-policy expert at George Washington University.
Lawmakers are unlikely to wake up and enact major overhauls during the next two years, despite Baldwin's optimism. Big fixes will remain stuck in ideological gridlock, though small changes-such as allowing Americans to buy drugs from abroad or expanding state insurance coverage for low-income children-are possible, say a broad spectrum of policy analysts and congressional strategists. But larger reforms, such as incoming House Speaker Nancy Pelosi's proposal to let Medicare negotiate prices directly with drug companies, are likely to hit a wall in the Senate, where Republicans are still strong enough to hold up legislation and have genuine antipathy to expanding government programs. "Changing the drug benefit is not going to happen," says a high-ranking Senate aide.
The problem is that there are deep, genuine divisions in how to fix healthcare. It's not just playing politics, says Price, an orthopedic surgeon who just won his second term: "Representative Pelosi and Tammy Baldwin may believe that a single-payer system is the answer. I think it would be a complete disaster for medicine." Letting Medicare negotiate drug prices, many conservative analysts think, would simply reduce the supply"That's what price controls do," says Moffitnot contain costs. Baldwin, on the other hand, points to countries like Canada "that buy in bulk for lower prices and don't have shortfalls."
States' rights. The beauty of the bill that she and Price put together, Baldwin adds, is that it gets away from theoretical debates: "We give states the ability to experiment with different systems. We'll actually get to see what works and what doesn't." States would propose plans for children's health insurance, elder care, or drug subsidies to a bipartisan congressional commission. It would pick a slate of proposals, and Congress would vote yes or no on the slate. States would then get money to try these things out for five years. A similar bill in the Senate, cosponsored by Ohio Republican George Voinovich and New Mexico Democrat Jeff Bingaman, is also on the table. "This is the first thing we're going to act on," says Voinovich spokesman Chris Paulitz. "We think it's important, and we think we can get it passed."
States, in fact, are becoming laboratories for health reform, says Mark McClellan, former head of the Centers for Medicare and Medicaid Services. "Massachusetts passed a way to expand insurance, and other states, like New Mexico, are considering it, too. I think states are where the action is now, and their experiments may eventually start some national movements."
Federally, there are some other opportunities for action come January. Funding for the State Children's Health Insurance Program has to be renewed, and that gives Congress the chance to broaden eligibility or shift funds for more preventive care. Drug reimportation is already beginning to garner bipartisan support. But anything more extensive, even if it moves through Congress, "is probably going to run into President Bush's veto pen," says Henry Aaron, a health policy analyst at the Brookings Institution. "And that pen may get quite a workout."
This story appears in the November 20, 2006 print edition of U.S. News & World Report.