When the Senate finally adjourned for the Christmas recess, the passage of controversial health care reform legislation looked increasingly likely.

Back in November 2009, the House of Representatives passed its own reform legislation, but the Senate continued to struggle with lightning-rod issues such as abortion, the “public option” question, and proposed funding mechanisms.

However, on Christmas Eve, by a 60-39 party-line vote, the Senate approved the $1 trillion health care overhaul, and Congress appeared on course to meet the Obama administration’s informal deadline to pass legislation in time for the first State of the Union address.

Every member of the Democratic Senate caucus backed the legislation, and every Republican opposed it. Republican Senator Jim Bunning (Ky.), a staunch opponent of the bill, was the only senator to miss the vote.

Even though acknowledging this partisan divide and the considerable procedural hurdles that remained – both chambers still had to pass identical legislation for the president to sign into law – health care proponents on Capitol Hill were confident that a compromise could be reached.

That both the House and Senate, separately, were able to pass health care reform legislation was indicative of the momentum behind the effort, despite partisan sniping and growing unease among the electorate around its cost and the potential role of the federal government in health care.

But that was before the special Senate election in Massachusetts.

The Massachusetts Effect

That the single greatest obstacle to meaningful health care reform in the United States arose from the legacy of Ted Kennedy, the senior Senator from Massachusetts, is ironic. Despite Kennedy’s 40-year fight for this very cause, his death in August 2009 proved pivotal in a manner few would have predicted.

Massachusetts, widely considered the “bluest of blue” Democratic states, had even implemented its own state-level health care reform that many saw as the precursor to the national effort. Yet on January 20, 2010, voters in the Massachusetts elected Republican State Senator Scott Brown over Democratic Attorney General Martha Coakley.

Of course, this outcome can be attributed to the electorate’s concerns about the economy and unemployment, as well as a badly run Democratic campaign; however, there is no denying the impact of the health care issue on this race and the effect this outcome had on the health care reform process in Washington.

The Democrats not only lost their filibuster-proof supermajority of 60 votes, but also, many members of their party, especially those up for reelection in 2010, found themselves questioning the public appetite for health care reform and its impact on their own chances for reelection.

Suddenly, Democrats were struggling to regroup and calling for a “breather” to allow the dust to settle and Congress to focus on a jobs package. Senator Mary Landrieu (D-La.) described health care reform as being on “life support,” whereas Senate Majority Whip Dick Durbin (D-Ill.) said: “We are thinking about it and how to move on it. Jobs are our current high priority, and that’s what we’re going to work on for now.”¹

Where Did the Democrats Go Wrong?

No single issue or event – whether it is abortion, the public option, or the effect of the Senate election in Massachusetts – can fully explain this dramatic turnaround for the Democrats.

Barack Obama’s Campaign Promise

Back when he was Candidate Obama, the future president told the nation [Obama, Aug. 15]: [I]f you like your health care plan, you keep your health care plan. Nobody is going to force you to leave your health care plan. If you like your doctor, you keep seeing your doctor. I don’t want government bureaucrats meddling in your health care. But the point is, I don’t want insurance company bureaucrats meddling in your health care either.”²

The intention of this campaign promise was to help broaden Obama’s centrist appeal and avoid the mistakes made in the early 1990s Hillary-care effort. However, in practice, it would be very difficult, if not impossible, to deliver a comprehensive overhaul to the financing and delivery of the entire U.S. health care system without meaningfully changing current coverage structures.

This predicament strained the president’s relations with his congressional Democrats pushing for a public option and agitated his opponents, who cried foul over Medicare cuts. Focus shifted to the debate over the public option rather than broader questions regarding coverage, access, and cost. Proponents argued that health care reform was meaningless without a public option. Opponents said it was tantamount to socialized medicine. Whichever side of the fence you stood on, the debate was vicious and charged, doing little to rally the nation around the far-reaching health care reform process.

Smoke-Filled Rooms and Secret Deals

The days of deals actually being made in smoke-filled rooms might be a thing of the past after House Speaker Pelosi banned smoking in the Speaker’s Lobby, but the lack of transparency around the handling of health care reform made many Americans very uneasy about the process as a whole.

A widely known deal struck between major insurance companies, the pharmaceutical industry, and the White House would provide substantial revenues to help pay for the reform package, in exchange for concessions by the White House such as dropping efforts to directly negotiate Medicare drug prices with manufacturers or legalize the reimportation of drugs.³ This perceived cozy relationship between the White House and the Washington lobbyists against whom those in the White House had campaigned did not sit well with the American public.

Then, Nebraska Senator Ben Nelson (D) struck a deal that would have secured his support for the bill in exchange for a carve-out that would bring $100 million annually⁴ in Medicaid assistance for Nebraska, while other states would be required to self-fund the Medicaid expansion. This questionable arrangement prompted outrage from state governors and was seen as epitomizing a murky deal-making process.

It can be argued that any effort to reform a sector that constitutes 15% of the GDP will inevitably involve this sort of quid quo pro negotiation. Nevertheless, a perception of “business-as-usual” politics, in which well-funded special interests are protected, reflected poorly on the president, especially in light of his unfulfilled campaign promise to broadcast all negotiations to the public on C-SPAN.⁵

Whatever truth lies beneath allegations of secret deal-making and backroom politics, the enduring image of these hushed negotiations contributed to diminished public support for the effort.

Media Overload

The public may have lacked facts and details about the proposed package, but there was no shortage of speculation and rhetoric. From congressional leaders holding slick press conferences to talk-radio hosts and bloggers arguing their position, a sense of hysteria began to surround the process.

The health care reform debate became synonymous with angry town hall meetings, “tea bag” protests, and fears over “death panels.” With an issue as personal, emotional, and charged as health care, it is hardly surprising that Americans became confused and disillusioned by the accusations hurled by both sides.

Outlook for Health Care Reform

The Democrats’ inability to build bipartisan support around their legislation in the Senate came back to haunt them with the loss of the 60-vote supermajority. Momentum around the issue has evaporated as policy-makers shift their focus to jobs and the economy in the run-up to the November congressional elections.

Yet even though the administration and congressional leaders have toned down their rhetoric, all remain firmly committed to seeing through the passage of health care reform legislation.

The White House

President Obama reiterated his desire for Congress to create a bill – in his State of the Union address, he called on Congress to finish the job. “Don’t walk away from reform. Not now. Not when we are so close. Let us find a way to come together and finish the job for the American people. Let’s get it done. Let’s get it done.”⁶

The president also acknowledged the many problems he had encountered throughout this process and invited Republican leaders to a health care reform summit at the White House. Republican calls to scrap the entire bill and begin work all over again – a move that Democrats are reluctant to make given their investment in this process – once again underscores the extent of the ideological divide between Republicans and Democrats on this issue.

Congress

In the House of Representatives, Speaker Nancy Pelosi could not have been more emphatic about her determination to pass health care reform: “We need to get this done. Process, I don’t care about. But we need to get this done, one way or another.”⁷

The process she was referring to, known as “budget reconciliation,” would allow the House to pass an amended version of the Senate bill, meaning the Senate would not need to begin this process from scratch, but only without their 60-vote majority. Under budget reconciliation rules, a simple 51-vote majority is required, rather than the 60 votes needed to break a filibuster.

This approach is risky. Forcing this package through using strong-arm procedural tactics could turn public opinion against the effort altogether – an important factor for House and Senate Democrats up for reelection in November. In addition, it would require the Senate to agree to some of the more controversial House provisions that the upper chamber earlier rejected. Pelosi has also discussed passing certain provisions as separate, stand-alone bills while still pushing forward with more comprehensive reform.

Pelosi’s dilemma is this: Although 81% of Americans are fairly or very satisfied with their health care, 87% want some type of health reform.⁸ Do the Democrats push for reform and risk alienating the 81% who are happy with their coverage, or do they step back and appear weak and directionless in the eyes of the 87% who want some type of reform?

On the Senate side, Majority Leader Harry Reid and Finance Committee Chairman Max Baucus both indicated their willingness to take a break from the issue to concentrate on the economy. Reid commented, “This is not a one-year Congress, this is a two-year Congress and we have had a number of extensive meetings of trying to come up with a path forward, we are going to move forward on health care. We’re going to do health care reform this year.”⁹

With Reid considered vulnerable in his bid for reelection in Nevada this year, he has strong motivation to use the coming months to deliver on some of the promises made by his party since they retook control of Congress in 2006.

Legislative Options for ACCP

Should the effort to pass the legislation as it currently stands prove unsuccessful, ACCP and our pharmacy stakeholder colleagues in Washington, D.C., are considering alternative strategies for moving forward independently with the clinical pharmacy provisions in the health care reform bill.

We are exploring the possibility of introducing stand-alone legislation or having our provisions folded into one of a series of “mini-bills,” and we have held preliminary discussions with members of the Appropriations Committee focused on the process of authorizing and funding medication therapy management (MTM) grant programs directly.

The inclusion of these important pharmacy provisions in the reform package represented an important step forward in our advocacy efforts; however, the potential collapse of the overall health reform process need not represent a correspondingly importunate setback.

Securing these provisions acknowledges MTM as a vital component of any health care reform initiative and recognizes pharmacists as the experts to deliver these services. This is the result of an ongoing, profession-wide effort to educate lawmakers and advocate for expanded access to pharmacists’ services, and it provides a platform from which we can continue to move the issue forward.

How You Can Get Involved

ACCP’s Legislative Action Center contains a wealth of information about your elected officials and allows you to communicate with your members of Congress.

For your convenience, we have prepared letters you can send directly to Congress, urging passage of legislation (with the clinical pharmacy provisions intact) or inviting your elected officials to learn more about the practice of clinical pharmacy.

Remember, to maximize your impact, you are encouraged to edit and personalize the letter, providing background on your practice and professional experience.

In addition, you are strongly encouraged to make the following requests in your letter:

• Ask for a list of the dates that your members of Congress will be available for meetings in their district or state.
• Ask about any town hall meetings your members of Congress have scheduled, particularly those focused on health issues.
• Request an in-person meeting with your members of Congress and/or staff while they are home for the recess.
• Invite your members of Congress and/or staff to tour your clinical pharmacy practice site. (Click here for more information on hosting your members of Congress.)

If you are planning to contact your member of Congress, let ACCP help you. Contact John McGlew at (202) 621-1820 or [email protected] to discuss how to conduct a successful meeting with a lawmaker and how to maximize your political impact with that lawmaker.

References

1. Roll Call. Democrats hope a breather helps health care bill. Available at http://www.newsweek.com/id/212588. Accessed February 11, 2010.
2. Huffington Post Article: “Obama Reneges on Health Care Transparency.” Available at: http://www.huffingtonpost.com/2009/08/13/internal-memo-confirms-bi_n_258285.html. Accessed February 17, 2010
3. The Hill Article: “CBO pegs Nelson''''''''''''''''s Nebraska Medicaid deal cost at $100 million.” Available at: http://thehill.com/blogs/blog-briefing-room/news/73151-cbo-pegs-nelsons-deal-for-nebraska-at-100-million. Accessed: February 11, 2010
4. CBS News Article: “Obama Reneges on Health Care Transparency.” Available at: http://www.cbsnews.com/stories/2010/01/06/eveningnews/main6064298.shtml. Accessed: February 11, 2010
5. Washington Post. Nancy Pelosi’s health-care strategy. Available at http://voices.washingtonpost.com/postpartisan/2010/01/nancy_pelosis_health-care_stra.html. Accessed February 11, 2010.
6. Huffington Post. Americans have a prescription for congressional health care delirium. Available at http://www.huffingtonpost.com/s-ward-casscells-md/americans-have-a-prescrip_b_455739.html. Accessed February 11, 2010.
7. PBS News Hour. Pelosi: health care reform will advance “on many fronts.” Available at http://www.pbs.org/newshour/rundown/2010/01/pelosi-health-reform-will-move-on-many-fronts.html. Accessed February 11, 2010.