Published 12/1/2009
Nick Piatek

Balance of power precarious in healthcare reform debate

Significant hurdles remain as a final bill takes shape

Current healthcare reform legislation has reached a milestone that previous attempts at reform have been unable to achieve. In early November, the House of Representatives passed HR 3962, the Affordable Health Care for America Act, by a 220-215 vote. Although this was only two votes above a majority, the fact that the bill passed at all is significant.

Prior to the vote, 69 Democratic members of the House publicly expressed doubts and concerns about the bill, but, ultimately, only 39 Democrats voted against it. Some were concerned that the public option did not go far enough; others were worried about the long-term financial implications of the costly overhaul.

The concerns of many of the “Blue Dog Democrats,” a fiscally conservative faction of the House Democrats, were mollified when Speaker Nancy Pelosi (D-Calif.) agreed to allow an amendment that prohibits the use of federal money for abortion services. Yet, doubts remain about whether the final bill will contain the various provisions included to enable House passage.

As this issue of AAOS Now went to press, the Senate had taken one procedural vote on HR 3590, the “Patient Protection and Affordable Care Act of 2009.” The 60–39 procedural vote along party lines clears the way for debate on the measure to begin when the Senate returns from its Thanksgiving recess. Substantial hurdles remain, however, for both lawmakers and the Obama administration before a bill can be developed and considered by both the House and Senate and subsequently sent to the president for his signature.

A complicated process
Healthcare reform has morphed in extraordinary ways since early January. As with any bill, healthcare reform has faced committee hearings, committee votes, backroom rewrites, mark-ups, amendments, and floor votes. By the time healthcare reform becomes a reality, legislation will have passed three House committees, two Senate committees, the full House, the full Senate, the conference committee, and another round of full House and Senate votes.

With each successive step in the legislative process, special interest groups, political factions, and the American public weigh in, making the debate over healthcare reform a twisted, ambiguous maze of conflicting political realities and maneuvering.

As the 2010 election cycle nears, many representatives are looking closely at how their votes will affect their re-election chances. Of the 39 Democratic representatives who voted against HR 3962, 32 represent districts that voted Republican in the 2008 Presidential election. Of the seven districts that voted Democratic in 2008, four voted Republican in the 2000 and 2004 Presidential elections.

The 2006 and 2008 congressional elections swelled the ranks of moderate House Democrats. Although the Democrats won the majority and subsequently built on it, they have also broadened their political make-up to include many members who may perceive political risks in voting for comprehensive healthcare reform. These representatives cite constituent concerns over the projections of high costs and the perceived detrimental effects on the ability to access care.

The Senate challenge
The difficulties faced by the House in passing HR 3962 reflect the dynamics of the political and ideological make-up of that legislative body. Many analysts perceive an even greater challenge for the Democratic majority in the Senate.

Although the initial vote to allow debate on HR 3590 was supported by all 60 members of the Democratic caucus, there is no guarantee that the final vote will have similar support. In particular, Sens. Mary Landrieu (D-La.) and Blanche Lincoln (D-Ark.) noted that their votes to permit debate did not signal their support of the entire bill.

The concerns of many senators mirror those of their colleagues in the House who opposed HR 3962. While the fact that only 31 senators are up for re-election in 2010 might appear to lessen election anxiety, the need for 60 votes can focus the outcome of the bill on a single senator, making the Senate healthcare reform negotiations intense and fragile.

As a result, most analysts are focusing on the impact that the Congressional Budget Office (CBO) could have. On Nov. 20, 2009, the CBO estimated that HR 3962, the House bill, would yield a net reduction in deficits of $138 billion over the 10-year period 2010–2019. The CBO estimates that HR 3590, the Senate bill, would yield a net reduction in federal deficits of $130 billion during the same period. Those figures, and the political realities of these key lawmakers’ districts, will eventually determine the fate of a final healthcare reform bill. They may also affect the number of concessions that leaders will be willing to make.

What about the providers?
Throughout the healthcare debate, the American Association of Orthopaedic Surgeons (AAOS) office of government relations, AAOS fellows, and others in the surgical and specialty medicine communities have engaged in direct discussions with key members of both the House and Senate. AAOS efforts have centered on educating lawmakers about the essential services provided by orthopaedic surgeons and the need for patients to have access to needed specialty care.

Although the AAOS has not taken a position on the House bill (HR 3962), it does oppose the Senate bill (HR 3590). According to AAOS President Joseph D. Zuckerman, MD, “This bill will significantly interfere with the ability of orthopaedic surgeons to serve the best interests of our patients. It would further bureaucratize the Medicare system with a new 15-person advisory board that would not be accountable to anyone. In addition, it would prematurely institute a mandatory and punitive physician quality reporting program, decrease funding for patient access to specialty care, and impose onerous restrictions on physician-owned hospitals.

“The Senate attempt at reform is also flawed by its omissions,” said Dr. Zuckerman in his Advocacy Now Health Care Update (Nov. 20, 2009). “Serious reform should include medical liability reform, a complete fix to the sustainable growth rate (SGR) formula, and a cost-effective way to provide access in addition to coverage. In addition, the bill does not adequately address workforce shortages in specialty care.”

The AAOS is currently working with several coalitions to craft the most effective strategy for formally opposing the Senate bill.

“The Senate must still debate and offer amendments to the legislation, and it is our intention to continue to work with the Senate to produce legislation that is consistent with the AAOS principles of healthcare reform,” said Dr. Zuckerman. “In addition, the House will continue to negotiate its legislation. There is still time for the Senate and the House to do the right thing. We remain completely committed to working toward legislation that serves the needs of our patients.”

Nick Piatek is the communications specialist in the AAOS office of government relations. He can be reached at piatek@aaos.org