For the first time since the first two years of the Clinton administration, Democrats are going to dominate the House, Senate, and occupy the White House, giving Capitol Hill a decidedly blue tint. There’s lots on the agenda, but three factors weigh against much in the way of health reform in the next Congress.

First, there’s little money to spread around.
Second, there are big problems that demand immediate attention – the collapsing economy, rising unemployment, Iraq and Afghanistan. Russian President Medvedev’s sabre-rattling yesterday is another signal that international issues will require significant attention from the executive branch. These meet the definitions of both ‘important’ and ‘urgent’ and will likely dominate the agenda for the next few months.
Third, the Democrats will not have a veto-proof majority in the Senate.
Despite the presence of these rather large obstacles, I’d bet we do see meaningful steps towards health reform in the next Congress. First, something has to be done to show progress on key issues. Second, several policy initiatives can be enacted that don’t ‘cost’ anything, and other measures can be funded with cuts in current programs. Third, I’m not so sure the Dems will need 60 votes from Democrats to pass health reform. Susan Collins and Olympia Snowe from Maine are generally well-disposed towards health reform, and the independents will likely vote with the Democrats as well.
And most importantly, Pres-elect Obama’s newly designated Chief of Staff, Rahm Emanuel, is a hard-nosed centrist who knows how to get votes for his boss. Emanuel was instrumental in getting welfare reform passed for Clinton; that success coupled with his experience in the House and high level of respect he commands in both the House and Senate stack the deck in favor of reform.
Let’s not forget Sen Kennedy’s ongoing efforts as well; his standing and longevity in the Senate make him a very powerful force.
Here’s what I’d expect we’ll see in 2009 – 2010 from Congress and the new President.
SCHIP will be first out of the blocks. The expansion of coverage for kids is a central piece of Obama’s platform on health reform, and with a Democratic Congress the chances of meaningful expansion of this program are pretty good. And it won’t just be Democrats voting ‘aye’. After the back and forth battles, marked by confusion and consternation from Republicans who felt Pres. Bush threw them under the bus by vetoing a bi-partisan bill to extend SCHIP earlier this year, enough Republicans are likely to cross the aisle to support funding of a somewhat-expanded program.
The fall will be highlighted by a debate over Medicare physician compensation. With docs scheduled to see their reimbursement drop by around 20% in 2010, the caterwauling will be heard loud and clear inside the Beltway. Don’t look for a major policy change, but rather something to satisfy the physician community and build a little equity for the future. Where will the money come from?
Do not be surprised if CMS is expressly ordered to negotiate prices with big pharma in the near future. The Part D program is a budget buster, big pharma has few political allies (despite big contributions) and reducing the cost of drugs will save CMS budget dollars that can be spent on physicians.
Also on the table will be reduced funding for Medicare Advantage, a program that has long struck Democrats as a giveaway to big healthplans. Foolishly. the insurance industry worked hard, and effectively, to block reductions in MA this year. As Bob Laszewski notes, with Congress and the White House changing hands, the bill they stopped this year will look great compared to what they’ll get next. Expect MA subsidies to be slashed, in what could, and should, be seen as a shot across the bow of the insurance industry.
What does this mean for you?
Politics is the art of the possible. And even now, meaningful health reform is, indeed, possible.

Today was another day of ‘dropping lit’ – this time myself and an attorney from Manhattan were tasked with hanging signs on doorknobs in a typical spread-out suburban community in Bucks County PA. The signs were specific to the polling place for each address, and also listed what voters needed to bring and polling hours. The signs, 146 to be exact, and the combination of big lawns, a highly targeted list of addresses, and a desire to not walk on lawns made for about seven miles of trudging around cul de sacs and wyndy roades (that’s how they spell in parts of Bucks). Spoke to several potential voters, including one irate McCain supporter who was apparently incensed at the idea that people would actually walk thru his neighborhood in an effort to encourage his neighbors to vote.
Truth be told, there were also two Obama supporters who seemed to have had just about enough of door-to-door canvassers…
Spent several hours this evening (thankfully sitting down) getting trained to be a poll observer. I’ll be working to help voters figure out where to stand in line, how to make sure each vote counts, and watching for any attempts at voter suppression. I can honestly saw I know way way more about the Danaher voting machine now then I thought needed knowing.
It is not exactly a triumph of technology – the machine uses a printed piece of paper that overlays rows of buttons which the erstwhile voter has to press – through the paper – to indicate his/her choices, and then confirm the vote by pressing another button.
like this…

There are counters, and accumulators, and figures that have to be cross checked against each other. And it seems these triumphs of American ingenuity break down fairly regularly, which then results in voters filing out paper ballots. Unfortunately, through the wisdom of the election officials in Bucks, each polling place will only have fifty (50) paper ballots on hand. Not to worry, they have another fifty for each polling place secured in an undisclosed location, which they will transport to any affected polling place pdq. This in a county where turnout is expected to top 75% of eligible voters, a county that is also deemed to be one of the key counties in the nation.
Tell me again, how is it that we have the gall to send people to oversee other countries’ elections to make sure they are fair?
I learned a lot of other interesting stuff about subtle means of voter suppression, how vote tabulation works, appellate court rulings on voter identification, and what defines ‘electioneering’ and why you can’t do it within ten feet of a polling place (definition of where that ten feet is measured from to be determined arbitrarily by the boss of each polling place.)
For now, I’m just thankful this only comes every four years. And after fourteen hours at my assigned polling place tomorrow, I’ll likely be even more thankful.

Today, tomorrow and Tuesday I’m in Bucks County, PA, volunteering for the Obama campaign. No, its not glamorous, I won’t be appearing on NPR or the Nightly Business Report. I will be being doing whatever the caffeine- and cheesesteak-fueled twenty-somethings running the local Obama campaign GOTV (get out the vote) team choose to delegate to me.
Got to the office (one of many in Bucks County, which is north of Philly) I was assigned to early this morning, and was immediately put to work doing menial clerical work by local boss John, who looked like he’d been awake for quite a while (as in days, not hours). About ten am, a bus arrived and disgorged about 60 New Yorkers. The seating capacity of the bus was 53, so seven stood all the way here from NYC (about 90 minutes). And they each paid $30 for the privilege of spending their Sunday working for Obama. And a couple dozen volunteers were left curbside in Manhattan as there was no more room on the bus.
They paired up those with cars (e.g. me) with those without (two recent Barnard graduates and a retired cellist), handed us a detailed, coded, yet simple map and materials and directions and sent us out to place literature on doorknobs of previously identified likely Obama supporters.
These people are organized. I mean, really, really organized. Organized like big businesses are supposed to be, but rarely are. There were over 120 of us there this morning, and all of us were trained, out, and canvassing within a half-hour, with computerized lists coded with directions, separated by odd and even house numbers so we could work both sides of the street most efficiently. They are also frugal – no one offered to pay for gas or tolls or lunch, there were no piles of buttons and swag laying around for the taking.
Yesterday (Saturday) was door knocking and contact day, when canvassers tried to engage those still undecided voters. Obama canvassers knocked on 69,000 doors yesterday. That’s not a typo – 69,000 doors in one day. In one county (Bucks), in one state, albeit a critical swing state (PA). Today and tomorrow are reminder days – voting times, polling place locations, specifics on what you do and don’t need to bring to vote. Tuesday is an 8-8 shift, making sure all potential Obama supporters get to the polls. And rest assured they’ll know precisely who makes it to vote and who doesn’t, and for those is the ‘doesn’t’ camp, some smiling Obama volunteer will be on their doorstep offering to drive them to the polls by early Tuesday evening.
Pennsylvania is supposed to be tightening up. The GOP’s vaunted 72-hour program has delivered in the past, and McCain is going all in in PA. The Senator from Arizona has to win Pensylvania to have any realistic chance of beating Obama.
From what I can tell, I don’t think McCain has a chance.
Admittedly I’m only seeing one tiny part of one candidate’s campaign, and I’m certainly no expert in these things. I do know Obama’s Get Out The Vote effort is extremely well run, efficient, and very focused. Obama also benefits from his volunteers’ weird combination of enthusiasm, paranoia, and sense of self-responsibility. To a person, everyone I spoke with or heard in passing believed it was their responsibility to do everything they could to get Obama elected. That includes the mom from Weston CT with two kids in boarding school, the high-school kids from the neighborhood, the retired veteran, the pipefitter, the farmer from rural western Massachusetts and two residents taking a day off from medical training.
This wasn’t a lark, it was a personal responsibility.
I’m going to be reporting from/commenting on the experience – be forewarned, MCM likely won’t have much to do with managed care until Wednesday. For those incensed/outraged/angry as my keystrokes meander away from the mainstream of managed care, I’ll be glad to send you a full refund.

For several months rumors have been floating around Capitol Hill about efforts by Sen Ted Kennedy to get legislation to the floor of both houses early in the new year. With the Senator’s recent move back to his DC home from his residence on Cape Cod, the talk is the discussions are accelerating in anticipation of a big win for his party (that would be the Democratic party) next week.
To date, meetings have included the usual suspects – AARP, the AMA, Consumers Union, Families USA, and the NFIB. Notably, some ‘unusual’ suspects have also been in attendance, an occurrence that may bode well for chances of something actually happening. According to the Boston Globe and other sources, meetings have included staffers from both parties, including staff from Mike Enzi’s office (R WY). This bipartisan participation, along with ‘pre-meeting meetings’ with staff from the two key Senate committees (Kennedy’s Health, Education, Labor and Pensions, and Max Baucus’s (D MT) Finance) reflects Kennedy’s desire to not repeat the mistakes of the past.
The Clinton efforts were partially undone by intraparty infighting, a situation Kennedy et al are working hard to prevent at the outset. His efforts will likely build on the heavy lifting already done by Wyden and Bob Bennett on behalf of the Healthy Americans Act, a bipartisan initiative that has gotten positive reviews by a number of analysts, including me. HAA has been in the works for almost two years, and in that time the two originators have been able to garner support from equal number of GOP and Democratic Senators, an amazing accomplishment when one considers the partisan rancor that has smothered DC for the past six years.
Kennedy was one of Sen Obama’s early endorsers, a move that may well help push health reform to the front of the list in the next Congressional session.
What the sausage will look like after it comes out of the factory is impossible to know, but here’s a couple of predictions.
First, there will be some form of Medicare opt-in for individuals who want to buy into the program instead of dealing with individual insurers (sign me up!).
Second, expect a minimum set of benefits to ensure health plans don’t ‘underwrite’ via benefit design.
Third, don’t expect to see medical underwriting continue much longer.
Beyond that, it depends on who gets to throw the last ingredients into the sausage grinder.
That is, of course, if Kennedy et al are successful and health reform actually becomes law. While my gut tells me there’s just no money, my other organs are thinking ‘hell, if we can afford to give AIG an eighth of a trillion dollars, we can definitely afford big-time health reform’.
What does this mean?
Don’t think this as the last gasp of an aging, sick man. It may well be the final roar of the Lion of the Senate.