Ed. Note – This report was prepared on July 31, 2009. Details pertaining to the status of the health care reform process were accurate at that time. However, we acknowledge that developments may occur before the report is released. Please contact John McGlew at (202) 756-2227 or [email protected] for up-to-date information or further discussion.

When President Barack Obama announced his ambitious timetable for health care reform and challenged the Democratic-controlled House and Senate to send legislation to his desk before the August recess, eyebrows were raised throughout Washington, DC, and the country as a whole.

Of course, the President’s high approval ratings and success in steering the controversial and costly economic stimulus packages through Congress allowed him a degree of confidence. Yet, to most observers, this schedule seemed unrealistic.

Obama had good reason for setting this aggressive schedule. Despite solid majorities in both chambers, there remains a great deal of skepticism even among Democrats about the design and cost of the competing proposals. Republicans are united in almost universal opposition to the legislation based on ideological grounds and concerns about the cost of the proposal as well as in protest to perceived heavy-handed tactics by Democratic congressional leadership.

The administration anticipated these challenges and believed that its best chance for success lay in swift action – building on early momentum and enthusiasm. Of importance, the administration targeted the August recess to have legislation in place before members of Congress returned to their states and districts to hear local constituent opposition to the proposal and organized, national campaigns fighting the plan.

As it stands, Congress will adjourn for August and return home without passing health reform legislation. Although this is undoubtedly a blow to the administration and its allies on this issue, it is premature to announce the issue dead or to suggest that this missed deadline represents a fundamental setback.

Despite widespread evidence to the contrary, policy-makers in Washington strive to pass effective, popular legislation that achieves the outcomes targeted. Debate on health care has moved so swiftly that even reform proponents are concerned about the lack of critical analysis regarding legislation that will cost trillions of dollars and account for more than 15% of the entire economy.

Assuming that the August recess represents a break (rather than a breakdown) in discussion on the Hill, the recess also provides an opportunity to review the discussions to date and highlight where lawmakers have found common ground and which issues are proving most divisive.

Progress So Far

Falling short of the stated goal of a bill on the President’s desk by the August recess should not be interpreted as a legislative failure. Given the controversy surrounding this issue and the extent to which health care and the economy are intrinsically linked, the progress made in the first 6 months of the 111th Congress is remarkable.

Legislatively, the health reform process is complicated because the issue itself is cross-jurisdictional. Two committees in the U.S. Senate – the Health, Education, Labor and Pensions (HELP) Committee and the Finance Committee – have oversight of portions of the reform process and have each drafted legislative language. In the House, three committees – Energy and Commerce, Ways and Means, and Education and Labor – share responsibility.

Committee Report

• At presstime, the Senate HELP Committee, House Ways and Means Committee, House Energy and Commerce Committee, and House Education and Labor Committee had each approved separate pieces of legislation that will eventually be considered on the floor of the appropriate chamber.
• The hugely influential Senate Finance Committee, which controls all health programs under the Social Security Act and health programs financed by a specific tax or trust fund, was an early leader in releasing discussion documents and legislative talking points; however, it has reached an impasse in negotiations and has not held hearings on the issue since May, when the committee attempted to “mark up” legislation.

What Is Being Discussed and What it Means for Clinical Pharmacy

Many ACCP members are aware that the College’s number one legislative priority has been to secure coverage for clinical pharmacy services under Part B of the Medicare program. As the 111th Congress got under way, it became increasingly clear that the old model of fee-for-service payments in Medicare had grown out of favor.

In addition, the proposed expansion of the public role in providing health care beyond the existing Medicare and Medicaid programs meant it was important to broaden and simplify the College’s proposal to ensure the inclusion of pharmacists’ services in whatever new health delivery models were developed during this process.

Of all the legislation in circulation, the Senate HELP legislation would provide the most comprehensive coverage for pharmacists’ services:

• Section 212 of the HELP bill would provide grants to establish community-based, multidisciplinary, interprofessional teams, including pharmacists (referred as health teams) to support primary care practices within the hospital service areas served by the eligible entities. This approach is popularly known as the “medical home model.”
• Section 213 of the HELP bill would establish grant programs to expand opportunities for pharmacists to deliver medication therapy management (MTM) services through local community-based, multidisciplinary health teams to patients who suffer from chronic diseases such as heart disease, cancer, and diabetes.

These two sections were also included in the final legislation of the House Energy and Commerce Committee after Rep. Butterfield (D-NC) introduced an amendment late in the final mark-up process that ensured the inclusion.

Fifteen national pharmacy organizations formally endorsed this language and applauded the recognition of the value of MTM services delivered by pharmacists and the inclusion of clinical pharmacists in the medical home model.

A formal press release was issued by the pharmacy community expressing its support for these sections, and letters were sent to leaders on the HELP Committee, thanking them for their leadership on this issue.

Legislation passed by the House Ways and Means and Education and Labor Committees includes coverage for MTM services and discussion around the medical home model, but it stops short of specifically referencing pharmacists.

Political Landscape

Given the controversial nature of this issue and the real potential for the entire effort to derail and ultimately collapse in the face of opposition or dispute among opponents and stakeholders alike, ACCP chose to tread carefully in its negotiations.

The sheer scale of the health care reform process should not be underestimated. Each of the various pieces of legislation circulating around the Hill is at least 1000 pages long, with a price tag approaching $1 trillion. There are fundamental ideological differences among policy-makers over the role of government in administering health care delivery and the role of society in paying for it; however, that these bills are even being debated in committee speaks to the gargantuan effort by the administration, congressional leadership, and stakeholders from across the health care spectrum to move this issue forward.

In discussions with staff on Capitol Hill, it was clear that Congress and the administration were working to keep all stakeholders engaged and that the input of the pharmacy profession was sought and valued by those in decision-making positions.

However, staff warned that no one would get exactly what he/she asked for from the legislation. The purpose of this effort is to reform the health care system, attempt to curb the rate of growth in health spending, address the issue of the uninsured in America, and improve quality and outcomes to ensure that the College receives value for money for the investment it makes in health care.

The reform process is not intended to provide a wish list for all health care stakeholders or an opportunity for interest groups (including ACCP) to flex their political muscles. The message received from the hill was clear – “we want to work with you – but you have to work with us.”

To that end, the goals of the College were to provide support and insight to policy-makers to help them craft effective legislation and to bring the pharmacy profession together as much as possible to respond with a single voice and provide a clear and concise vision for the role of pharmacy in a reformed health care system.

What Are the Controversial Issues?

As is often the case in Washington, the real battles come down to the cost of the proposal. No one is seriously arguing that the U.S. health system does not require some sort of reform, but the cost of administering this reform is dividing many policy-makers.

Linked to cost, and perhaps driving cost, is the question of a “public plan option” – a public, government-sponsored insurance option for middle-income Americans.

The more liberal wings of the House and Senate believe that meaningful reform can only be achieved by establishing a public health insurance plan that Americans could opt-in to if they chose to do so. The public plan would provide a coverage option for the currently uninsured or underinsured population of Americans.

This federal foray into the administration of health coverage is unprecedented (other than the Medicare, Medicaid, and Veterans Affairs programs). It is also of great concern to those who value the competitiveness of the U.S. system and believe that consumer choice and the availability of many options in health care outweigh the simplicity and universality of the European or Canadian systems.

Some Americans argue that the establishment of a public plan is merely the first step to a universal, government-run system. Private insurers would find it hard to compete on price with a federally subsidized plan, and the fear is that this public plan would “crowd out” private payers and ultimately drive all Americans into the public option.

In response, proponents of a public plan argue that this approach increases, rather than decreases, consumer choice. The Obama administration makes regular reference to an “insurance exchange” in which consumers could choose among health insurance plans, including the public option. The administration also reiterated that low-income people should not have to buy insurance they cannot afford and that small businesses should be exempt from any mandate requiring employers to offer health benefits or pay a tax to finance government subsidies.

Americans have historically resisted “government-run health care,” however, so this remains an important issue to resolve as the process continues.

Advocacy Outlook for Clinical Pharmacy

Assuming the overall health reform effort proceeds as planned and is not derailed by partisan or ideological stalemate, the outlook for clinical pharmacy can be described as cautiously optimistic.

The provisions endorsed by ACCP represent just a fraction of the overall bill and, compared with many of the controversial aspects of this debate, would be considered logical and appropriate by most casual observers. The provisions do not carry a significant price tag – in fact, some indicators suggest they would be budget-neutral because the MTM grant programs could pay for themselves through savings.

In addition, ACCP has been actively working with various coalitions and provider groups to gain support for the inclusion of pharmacists as part of an integrated, interdisciplinary team and for their participation in efforts to manage health care through the concept known as the medical home model. Although the College is a long way from declaring victory in this endeavor, its advocacy efforts are gaining traction, and the feedback from other provider groups and stakeholders has been positive.

Next Steps – Fall Strategy

Until now, the political strategy of the College has focused on cautious, behind-the-scenes negotiation. Friends and allies on the Hill welcomed ACCP’s input but warned of the importance of compromise and understanding to avoid overplaying its hand at this early stage and upsetting the fragile coalition of support.

As the effort moves out of committee and onto the floors of the respective chambers and, ultimately, into the reconciliation process, active, informed grassroots support will be imperative.

Put simply, until now, Congress has focused on the big-picture items – cost, access, and the role of government in health care. As the process moves forward, however, discussion will shift to the specific details of the bill; at this point, ACCP members will be required to show their support for the inclusion of pharmacists in the medical home model and recognition of the need to adequately manage medication therapy in a reformed health delivery system.

With Congress in recess during August, ACCP members should consider inviting their elected representatives to tour their practice sites and learn firsthand the value of clinical pharmacy services.

ACCP members should also consider attending in-state town hall meetings or other forums where they can meet with their elected officials and remind them of the importance of including the services of clinical pharmacists in the health care reform package.

ACCP members should watch for additional updates from ACCP as the College moves forward in providing input into the final legislative product. In addition, ACCP members should prepare to engage their own congressional officials and their staff as Congress reconvenes after the August recess.

For more information on grassroots advocacy, contact John McGlew at (202) 756-2227 or [email protected].

Conclusion

At this stage of the health care reform debate, with so much of the bill still unfinalized and with passage of the package as a whole uncertain, it is premature to draw any sweeping conclusions.

In general, despite making health care reform a centerpiece of his campaign, Obama has kept his distance from congressional leadership and adopted a hands-off approach. It is widely assumed that he learned from the mistakes of the Clinton administration’s failed attempt to reform the health care system. In the early 1990s, then–First Lady Hillary Clinton was appointed chair of the administration’s task force on reforming the system and was charged with maneuvering the issue through Congress.

Recognizing the mistakes made in the past and the prominence of congressional leaders such as Finance Committee Chairman Max Baucus (D-MT) and HELP Committee Chairman Ted Kennedy (D-MA) – represented in many discussions by New England colleague Chris Dodd (D-CT) – Obama initially chose to take advantage of the Democrats’ strong congressional majorities and defer to the legislative branch.

In recent weeks, in the face of widely reported in-fighting within the Democratic Party, Obama has taken a more prominent role in the debate, but for the most part, the White House has deferred to the legislative branch.

Obama is also noted for his willingness to engage major stakeholders in the process, particularly his likely opponents. Although the health insurance lobby famously derailed the Clinton reform process with its “Harry and Louise” TV commercials, this time around, representatives from the health insurance industry, pharmaceutical manufacturers, and hospitals identified up to $300 billion in savings that could help offset the cost of the reform proposal.¹

Wal-Mart, the world’s largest retailer, joined forces with an unlikely ally in the Service Employees International Union in supporting, at least in concept, the health care reform effort.² Some might see this as a cynical move by Wal-Mart to rehabilitate its image as an employer; however, that these historical opponents are both in favor of the initiative suggests a level of momentum around this issue never seen before.

Although there is much to admire about the health care reform process so far with respect to engaging stakeholders and building coalitions across the spectrum of the health care delivery system, congressional leaders and the Obama administration can also be criticized for failing to address key concerns within the current system:

• Failure to Address Medical Malpractice – The overall price of what columnist Charles Krauthammer called the “insane cost and arbitrary rewards of our malpractice system”³ contributes greatly to the rising cost of health care. Between the spiraling cost of medical malpractice insurance and the practice of defensive medicine – tests and procedures that health care providers order simply to protect themselves from lawsuits – reforming the system of medical malpractice could generate significant savings to offset the cost of the health reform proposal. Yet Democrats in Congress and the Obama administration have largely ignored this issue.
• No Clear Plan for Paying for Reform – During the campaign, Obama suggested in general and often vague terms that savings to the system would pay for the reform initiatives over time, rendering his proposal budget neutral. Economists from the Congressional Budget Office quickly quashed this idea, forcing the President to reevaluate the economic side of his proposal. A series of ideas were subsequently floated to varying degrees of success – revenues generated from the “cap and trade” energy policy, a tax on Americans earning more than $250,000, or the elimination of the preferential tax status of employer-sponsored health insurance. Overall, the lack of a clear economic plan has provided fuel for opponents and left many supporters, including economically conservative Blue Dog Democrats in the House, very nervous about the entire effort, especially during a recession and unprecedented government spending.
• Failure to Adequately Engage Congressional Republicans – Although the minority party in Congress inevitably complains about being excluded from policy negotiations, Republicans have been particularly vocal in their concerns about the lack of access and transparency throughout this process. Democrats claim the process is so intricate and delicate that legislative proposals are often only finalized at the last minute. However, given the cost of the proposal and the extent of its impact on the health and lives of all Americans, most would prefer a process that took into consideration the perspectives of all elected officials, not just those in the majority.

The fate of this attempt at a comprehensive overhaul of the health care delivery system will ultimately be decided when Congress returns to Washington in September. During the August recess, members of Congress will hear from local and national opponents and proponents of the effort. Ideological differences over the cost of the proposal and the potential impact of a public health insurance plan continue to divide Congress, but few would argue that the current system of paying for and delivering health care is sustainable over the long term.

The provisions included in the Senate HELP and Energy and Commerce Committee bills represent a historic opportunity to significantly advance the practice of clinical pharmacy and to target health care spending on ensuring value for money through improved quality and outcomes. ACCP is a nonpartisan organization and does not take a position on areas such as the funding mechanisms or the role of the federal government in administering health care. However, the College will endorse legislation that expands patient access to the clinical services of pharmacists, and it will continue to work to ensure that this principle is reflected in the final health care reform package.

References
¹ - The Washington Post. Hospitals reach deal with administration. Available at http://www.washingtonpost.com/wp-dyn/content/article/2009/07/06/AR2009070604053.html?hpid=topnews. Accessed July 31, 2009.
² - The Wall Street Journal. SEIU health-care push aided by Wal-Mart. Available at http://online.wsj.com/article/SB124865337393682517.html. Accessed July 31, 2009
³ - The Washington Post. Why Obamacare is sinking. Available at http://www.washingtonpost.com/wp-dyn/content/article/2009/07/23/AR2009072302723.html. Accessed July 31, 2009.