Jun. 11--President Barack Obama visits Green Bay on Thursday, as his administration begins a final push toward the most sweeping changes in the nation's health care system since Medicare was introduced in 1965.
With Congress working to pass legislation by early August, the once-improbable goal of significant health care reform stands a chance of becoming a reality.
"The big story here is how far and how fast health care reform has come in 2009," said Jonathan Oberlander, a professor at the University of North Carolina-Chapel Hill, who has written extensively about the obstacles to such reform.
Obama has outlined only guiding principles for reform and left the details to the five congressional committees crafting legislation. Among the possibilities:
--Prohibiting health insurers from turning away new customers who have pre-existing medical conditions.
--Providing a subsidy, perhaps in the form of a tax credit, for people who can't afford health insurance, and requiring everyone to buy health insurance.
--Creating a government health plan, perhaps limited to small businesses and individuals, that would compete with private insurance companies.
--Capping the tax deduction for employer-provided health benefits and mandating that large employers provide health benefits or pay a penalty.
--Paying hospitals and doctors for efficiency and quality rather than the volume of services they provide.
When legislation emerges, parts are certain to provoke opposition, and the obstacles to health care reform should never be underestimated. Also, Republican opposition is likely to swell once details become public.
"The hard stuff is still left," Oberlander said. "There is going to be a tremendous amount of fighting over the details."
But Democrats control the Senate and the House, and the leaders of key committees in both are committed to reform. The Senate also has passed a budget resolution that gives it the option of using "reconciliation" with the House to pass health reform. That would enable legislation to pass with 51 votes instead of the 60 needed to overcome a filibuster.
"These guys are playing a chess game," said Stephen Parente, a professor at the University of Minnesota and a former adviser to Arizona Republican Sen. John McCain's presidential campaign. "They are simultaneously looking at multiple moves and fallback positions."
The Obama administration in many ways has drawn on the Clinton administration's failed bid for health care reform -- and used it as a model of what not to do.
The administration worked to bring different interest groups, such as the insurance and pharmaceutical industries, to the table. It held off on releasing details that could be attacked. And it has tried to link health reform to the economic crisis.
More than anything else, the administration has moved quickly, recognizing that Obama's popularity might never be higher than in the first year of his presidency.
Republicans contended that the legislation could pass before people realize its implications.
"We are going to make huge decisions about the health care sector -- one-sixth of the economy -- with very little debate about the consequences," Rep. Paul Ryan (R-Wis.) said last month.
Ryan is one of the key sponsors of an alternative plan put forward last month. That proposal includes some of the broad ideas that Democrats are discussing, such as the use of income tax credits to subsidize coverage for low-income households, but it would rely more upon the private market.
"Something absolutely needs to be done," said Reince Priebus, chairman of the Wisconsin Republican Party. "But I think it is going to take the collective work of everyone to sit down and come up with the solution."
Obama has focused on how reform would build on the existing system and not affect people who are happy with their health care or coverage.
The administration has stressed the connection between rising health care spending and the federal deficit. And it has tied reform not just to providing coverage for the uninsured, but also to making the health care system more efficient.
"It's a dramatic, just a dramatic, difference in the language," said Thomas Oliver, a professor at the University of Wisconsin School of Medicine and Public Health. "It's about building a better system."
In Green Bay, Obama is likely to note the widespread variation in how medicine is practiced and the huge variation in costs, after adjusting for demographics, among different parts of the country with no clear difference in quality.
Wisconsin's health care system overall is among the most efficient in the country. But cost variations can be seen in the state.
Medicare spent on average $5,812 in 2006 for each beneficiary in La Crosse and $6,180 in Appleton, compared with $8,127 in Wausau and $7,578 in Milwaukee, according to the Dartmouth Institute for Health Policy and Clinical Practice. This means spending in La Crosse is 23% lower than spending in Milwaukee.
The variation is more pronounced nationally.
Medicare spent $16,351 on average in Miami, for example, and $10,103 in Dallas, in 2006.
Obama probably will cite unneeded MRIs, surgeries and hospitalizations that underlie that variation.
"We've come a long way in the recognition of the problems," said Chris Queram, president and chief executive of the Wisconsin Collaborative for Healthcare Quality, a consortium of health care systems, physician groups, employers and other organizations. "The challenge is how to address them."
Obama is likely to talk about the need to change the way in which doctors and hospitals are paid, putting more emphasis on primary care.
"There are no quick fixes," Queram added. "You are talking about one-sixth of the economy. It is not something that can be mended with one single change."
Some of those fixes also will be unpopular. But true health care reform inevitably will require tradeoffs, and some of those tradeoffs will mean hard choices.
"There is no such thing as painless health care reform," Oberlander said. "At the end of the day, there are going to be things not to like."
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