Intended for healthcare professionals

Observations Yankee Doodling

US healthcare reform is in the dustbin

BMJ 2010; 340 doi: (Published 27 January 2010) Cite this as: BMJ 2010;340:c500
  1. Douglas Kamerow, chief scientist, RTI International, and associate editor, BMJ
  1. dkamerow{at}

    Can one state’s senatorial election really scuttle the whole thing?

    The initial conventional wisdom about the race for the late Edward Kennedy’s US Senate seat was that there was no chance that the Republican candidate, Scott Brown, could defeat the Massachusetts attorney general, the Democrat Martha Coakley. It’s a heavily Democratic state, it was Kennedy’s seat for almost 50 years, and it was crucial for the Democrats to maintain their 60-40 advantage in the US Senate.

    As everyone now knows, this conventional wisdom was wrong. In the fading days of the campaign Coakley’s large lead evaporated and Brown won handily, with 53% of the vote.

    The second bit of conventional wisdom about this race, explaining the amazing upset, was that it was a vote against President Obama’s policies, especially healthcare reform. A perfect storm, pundits said: a weak Democratic candidate, a poorly run campaign, and voters impatient for economic recovery, all in a state that already had passed its own universal health coverage law and thus “didn’t need” a new federal law.

    As everyone may not know, however, the answer to whether this conventional wisdom is correct is—we don’t know. And we never will. Because the outcome of the race was a foregone conclusion for so long, none of the news organisations paid for the exit polling that would have told us what motivated a large number of independents to vote Republican. Was it health reform? Economic woes? Disaffection with the overwhelmingly Democratic governance in Massachusetts? An insider running in an outsider environment? Whatever caused it, the result of this state race has had cataclysmic implications nationally.

    If you have lost track of the healthcare reform saga over the holidays, here is where it stood on the eve of the Massachusetts election: both houses of Congress had passed different bills, either of which would have revolutionised the US healthcare system. To get a bill passed in the Senate huge and unsavoury compromises had been made that benefited unions, specific states, anti-abortion advocates, and others. Daily meetings were taking place to come up with a compromise version of the two bills that would be acceptable to both houses of Congress and to the White House.

    This was entirely a Democratic effort. Early attempts to involve at least a token number of Republicans failed, and both bills passed with no Republican votes. To get a final bill through the 100 member Senate the Democrats needed all 60 of their votes, because of arcane rules involving the so called filibuster. As anyone who has seen Jimmy Stewart in Mr Smith Goes to Washington knows, one senator can trump the majority by holding the floor and speaking forever. This has evolved from actually holding the floor to threatening to filibuster, and 60 votes are required to defeat it. Because any negotiated compromise on the healthcare bill would have to be ratified in both houses, the Massachusetts vote has had incredible repercussions.

    So what happens now?

    Initially some people suggested that the Democrats try to vote quickly on a compromise before the Senate seated its newest member. But even Democratic senators realised that such a move would be subverting the will of the people. Others proposed that the House of Representatives, dominated by Democrats and without a filibuster rule, should just adopt the Senate version and send it to the president for signature. Soon after the election, though, the Democratic speaker of the House, Nancy Pelosi, announced that she didn’t have the votes to pass the more conservative Senate bill. A third procedural trick would use something called “reconciliation” rules to pass the bill. This strategy, which would require only a simple majority for passage, was abandoned because it only applies to matters affecting financial appropriations, and parts of the bills don’t involve money.

    President Obama immediately suggested that a bipartisan effort could start anew to focus on aspects of reform that all parties agreed on, such as insurance reform, cost reduction, and helping out small businesses. Cynics dubbed this proposal “health care lite,” and even the president conceded that it was unlikely to happen. Republicans, sensing victory, are not interested in coming to the negotiating table. And to get insurance reforms (no exclusions on the basis of pre-existing conditions, no lifetime maximums, and so on) you have to have universal coverage. That means subsidies for those people who cannot afford care, which breaks the budget. Suddenly it isn’t health care lite any more.

    So does this mean that the results of a single state’s senatorial election will actually derail what looked until last week to be a reasonably good chance of a major change in the US healthcare system? Is there any way to salvage important reform from this mess?

    I think it looks very unlikely indeed. Certainly the president can make some administrative reforms in the programmes he controls, such as Medicare and Medicaid, to move them aggressively towards rewarding quality rather than quantity of care. He can encourage and help other states to follow Massachusetts’ lead in covering more of their citizens. He can use his bully pulpit to try to gain support for a streamlined bill that doesn’t have all the special interest provisions that made the current Senate bill so odious.

    But I don’t think anyone is optimistic that significant healthcare reform will emerge this year or any time soon. We had our opportunity and we squandered it.


    Cite this as: BMJ 2010;340:c500

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