Nitty-gritty on healthcare reform: Issues and key players

Los Angeles Times Staff Writer

As the Obama administration and Congress prepare to wrestle with the divisive issue of healthcare reform, here is a checklist of the issues and key players to watch in the forthcoming weeks. Obama has said he wants to sign a bill this year, which means the House and the Senate have to decide on their own bill and then reconcile their differences before Obama gets to act on what he has called one of the nation’s most important challenges.

What has Obama said are his key healthcare policy goals?

* Universality: This would increase the availability of health insurance in all its forms, public and private, by mandating coverage, coupled with government subsidies. There are about 45 million people who lack insurance, though the numbers vary depending on the politics of who is doing the counting.


* Public option: The president has called for some mechanism to stimulate market competition with private insurance companies and to give consumers greater choice in picking a plan. Both aspects, competition and choice, are central in the administration’s plan for changing the healthcare system. Proposals include a government insurance plan, consumer-owner cooperatives and insurance exchanges that give price and service comparisons. Obama has said he prefers a robust public option, but he is willing to take less if it increases competition and choice. This has raised fears among his liberal supporters that he is willing to sacrifice a strong public option for a political victory.

* Deficit neutral: The final plan should not increase the federal deficit, Obama insists. That means a combination of new revenue and cuts in services. Obama has ruled out middle-class income-tax hikes, but different versions of the bill in the House would levy a surtax on the rich. Businesses also could face new taxes to meet healthcare mandates.

* “Bend the cost curve”: Obama argues that two-thirds of the cost of any reform plan could come from within the healthcare system by eliminating unneeded procedures over time. He also called for an end to waste and fraud.

* Insurance reform: The private insurance industry also would face new regulations so that people would not be dropped because of previous medical conditions. Caps on benefits might be eliminated so that consumers wouldn’t face financial ruin as a result of a medical emergency.

* Bipartisan politics: Obama has said he would prefer a bipartisan effort on healthcare reform, but also has insisted that the current system is not sustainable for the government, patients or healthcare providers. He has said he will not allow the Republican desire to hand him a political defeat block change, a stance that opens the door to Democrats trying to pass bills without GOP support.

The players

Though Democrats control the House of Representatives, they have not united around any one proposal. They also face opposition from conservative Republicans on several key points:

Speaker Nancy Pelosi has said there aren’t enough votes to pass healthcare reform unless it contains a robust public option, one that is stronger than Senate Democrats favor. “There’s no way I can pass a bill without a public option,” the California Democrat said.

Important to watch are Reps. Raul M. Grijalva (D-Arizona) and Keith Ellison (D- Minn.), co-chairs of the Congressional Progressive Caucus, which backs a strong public option. In a recent letter signed by 60 lawmakers, the group demanded that a public option be included in any bill.

Pelosi’s principal deputy, House Majority Leader Steny Hoyer (D-Md.) also backs a public option, but his enthusiasm seems tempered by the political realities in his chamber and in the Senate.

“I’m for a public option, but I’m also for passing a bill,” Hoyer told reporters recently. “We believe the public option is a necessary, useful and very important aspect of this, but, you know, we’ll have to see, because there are many other important aspects of the bill as well.”

There is also heat from the right. The Democratic Blue Dog Coalition, so named by moderates and conservatives who have long felt shut out of the party by their more liberal colleagues, forced changes in the bill as it worked its way through the Energy and Commerce Committee. Rep. Dennis Cardoza (D-Calif.) and Blue Dog Coalition Co-Chairman Charlie Melancon (D-La.) were among the key negotiators and will be involved in the final shaping of the bill.

If Democrats are split, Republicans are more united in the House. They argue that healthcare reform is too expensive, will require sizable tax increases and cuts in services (“rationing”) while opening the door to a greater role by government in determining treatments for individuals.

Those arguments will likely carry more weight in the Senate, where Democrats outnumber Republicans 60 to 40. But there are those who are wavering, including Sens. Ben Nelson (D-Neb.), Mary Landrieu (D-La.) and Ron Wyden (D-Ore.). Independent Joe Lieberman (Conn.), who caucuses with the Democrats, is among those who are prepared to vote against a strong public option, giving the GOP some leverage if Senate leaders want to avoid a filibuster fight.

Negotiations are ongoing among the so-called Gang of Six trying to get a bipartisan bill. The bargainers include Finance Chairman Max Baucus (D-Mont.), two conservative Republicans, Sens. Charles Grassley (Iowa) and Mike Enzi (Wyo.), moderate Sen. Olympia Snowe (R-Maine) and Democratic Sens. Jeff Bingaman (D-N.M.) and Kent Conrad (D-N.D.) round out the group.

It is Conrad who has been pushing the idea of a co-op as a way of getting a public role that would circumvent the political land mine of a government-run insurance program. That idea also was being pushed by former Senate Majority Leader Tom Daschle, who with former Senate Republican leaders Bob Dole and Howard H. Baker Jr. have been trying to craft a bipartisan compromise. Daschle was forced to withdraw as Obama’s health czar because of tax problems. A lobbyist, he remains a close advisor to the president.

Fear and favors

One of the key groups in the middle of the healthcare debate is the elderly, who fear Medicare is a target of cuts. Obama has pledged to protect Medicare benefit levels, but plans call for limiting the rate of growth of the program. That may curtail some choices for seniors. There is also the issue of end-of-life planning, which some conservatives have dubbed “death panels” and argue would ration care. None of the bills calls for such groups.

There also have been questions about whether veterans’ health benefits would change. Obama has insisted they wouldn’t and pledged to revamp the Department of Veterans Affairs to provide better service.

Opponents have charged that illegal immigrants would get healthcare. Obama and Democrats note that none of the existing bills would extend care to undocumented workers.