Intended for healthcare professionals


Democrats and Republicans air differences on health reform in television summit

BMJ 2010; 340 doi: (Published 01 March 2010) Cite this as: BMJ 2010;340:c1176
  1. Janice Hopkins Tanne
  1. 1New York

    Democrats and Republicans agreed to disagree in a seven hour healthcare summit chaired by President Barack Obama and broadcast live on national television on 25 February.

    The president said that both sides were close and asked them “to bridge the gap.” He said that for five decades attempts had been made to provide health care to all Americans and called for consensus on a “serious effort” to introduce legislation in a month or six weeks.

    He spoke of taking his daughters to the emergency room and thinking about what would he do if he were a parent without health insurance. He told how his mother, dying from ovarian cancer, spent the last six months of her life arguing over the telephone with insurance companies to cover her treatments.

    The unusual summit meeting was called by President Obama to make progress on the stalled health reform bills. Passing health reform is a priority for the president, who wants to provide health insurance to at least 31 million of America’s 46 million uninsured people.

    The House of Representatives and the Senate passed different bills late last year. An attempt to merge the bills ended when the Democrats lost a Senate seat, leaving them with only a 59 to 41 majority in the Senate (BMJ 2010;340:c463, doi:10.1136/bmj.c463). Sixty votes are needed to pass a bill in the Senate, while only a simple majority is needed in the House of Representatives.

    A controversial solution called reconciliation, usually used for budget bills, might allow a health bill to be passed in the Senate with a majority of only 51 votes, without threat of a filibuster (talking the bill to death). The House of Representatives would pass the Senate’s health reform bill with some changes to resolve problems that House members find in the Senate bill. The Senate would then vote on the bill under the reconciliation rules, allowing passage with a simple majority. Several Democrats have suggested that a simple majority vote was the democratic way.

    The president opened the summit by saying that lack of health care was “one of the biggest drags on our economy and one of the biggest hardships for families . . . It affects those with and without insurance.”

    The president and the Democrats argued that the US healthcare problem was too complex for piecemeal solutions. They said that lack of health care or inadequate health insurance caused at least half of personal bankruptcies, put American businesses at a disadvantage in the global economy, caused personal tragedies, and was inefficient and expensive. They said that employer provided insurance locked people into jobs they could not leave because they would lose their insurance and that “entitlement” programmes required by law, such as Medicare for elderly people and Medicaid for poor people, were going broke and increasing the deficit.

    The Democrats called for comprehensive change. Insurance companies should not be able to deny coverage to patients with pre-existing conditions, should not be able to drop patients from their schemes when they became ill, should not have lifetime or annual limits on medical care, and should be restrained from imposing huge rises in premiums on people who buy personal policies (rather than being covered through employment). They also said that children should be able to stay on their parents’ insurance scheme until their mid-20s.

    They called for insurance exchanges where individuals and small businesses could shop for the insurance plan that best suited them, similar to the exchange covering members of Congress and millions of federal employees. By banding together in pools, individuals and small businesses would gain more buying power. Democrats said that their plan would cover about 30 million of America’s 46 million uninsured.

    The Republicans said that the bills passed by the House and the Senate late last year should be scrapped. They said that American people objected to government takeover of health care, quoting polls and meetings with constituents. Americans did not want Washington defining essential health benefits and putting a federal bureaucracy in charge. Instead, they said, the process should start again with incremental steps that everyone agreed on. Their plan would cover three million of America’s uninsured people.

    At least two Republicans said it was probably unconstitutional to have a mandate requiring Americans to have health insurance.

    Democrats and Republicans agreed on some insurance reforms, such as that people should be able to buy insurance policies across state lines (insurance is regulated by individual states). But they did not agree on federal regulation regarding coverage. Democrats said that there should be national standards of what policies should cover, probably set by the federal Department of Health and Human Services. Republicans objected to federal regulation, saying that would decrease competition.

    Republicans said that malpractice reform would reduce costs and reduce doctors’ practising “defensive medicine,” ordering many tests just to cover themselves. Democrats saw some point in that but said that malpractice reform would not bring major savings.

    The parties argued over changes to Medicare. Democrats want to reduce the Medicare Advantage programme, which pays insurance companies 15% more than regular Medicare in hopes of improved outcomes. They said that the Advantage programme did not result in better outcomes, just higher costs to the federal government. Republicans objected to the proposal to set up a board similar to the UK National Institute for Health and Clinical Excellence to review what treatments worked and what didn’t. They called such a board “unelected bureaucrats.”

    Both sides agreed that there was fraud in the Medicare system. One Republican suggested using “undercover patients” to root out doctors cheating the system with excess tests and procedures.

    They differed, however, over the accuracy of the estimates made by the nonpartisan Congressional Budget Office about what the different proposals would cost.

    President Obama closed the meeting by saying that he believed there to be agreement on the need for reform of the insurance market to allow small businesses and individuals to participate in insurance exchanges, perhaps setting minimum benefits for plans, purchasing insurance across state lines, and malpractice reform. He said it had been worthwhile to make the effort for discussion at the summit but asked for a serious proposal soon, while hinting that he might favour passing health reform with a 51 vote majority in the Senate.

    The New York Times said in an editorial that “differences between Democrats and Republicans are too profound to be bridged” (, 26 Feb, “After the summit”).

    The editorial continued: “It is up to the Democrats to fix this country’s dysfunctional and hugely costly health care system . . . Mr Obama needs to keep explaining to Americans that this health care reform is critical—to give them security, to hold down costs and ease the strain on federal budgets.”


    Cite this as: BMJ 2010;340:c1176


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