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The Democrats' turn to lead

The Lancet 2006; 368:2033 DOI:10.1016/S0140-6736(06)69813-9


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In polls, US voters consistently say they want health-care reform. They are worried about the steadily rising cost of care. They are worried about losing their insurance coverage. They are worried about the solvency of Medicare, the federal insurance plan for the elderly and disabled that will soon see its number of enrollees balloon as the post-World War 2 “Baby Boom” generation reaches retirement age.

Nevertheless, health-care reform received little attention in last month's mid-term election in the USA. Instead, the focus was on the war in Iraq and the performance of President George W Bush and the scandal-plagued Republican-led Congress. So, although the Democrats came away with a stunning victory that gave their party control of both the US House of Representatives and the US Senate, the party cannot claim to have a mandate to enact major health-care reform.

As a result, the Democrats are likely to proceed cautiously over the next 2 years, pushing popular incremental changes while they work to lay the groundwork for a debate over health-care reform in the 2008 presidential election.

The Democrats have already promised to introduce and pass two health-related bills in the first 100 hours of the next Congress, which convenes next month. First, they will pass legislation to change the Medicare prescription drug programme so that Medicare can negotiate directly with drug companies for lower prices. Under the current plan, drafted by Republican legislators in close consultation with the pharmaceutical and insurance industries, patients must enrol in prescription plans offered by private insurers. The legislation expressly forbids Medicare from negotiating prices even though other federal agencies have been able to use their purchasing power to negotiate steep discounts. The ban, the Democrats have argued, is an expensive giveaway to the pharmaceutical and insurance companies.

The second health-related bill the Democrats promise to pass in their first 100 hours will seek to end Bush's ban on federal funding of embryonic stem-cell research. Popular support is so strong that, should Bush veto the legislation, it is likely that enough Republicans will cross over to vote with Democrats to override the veto.

Over the long term, the Democrats are likely to impede, if not roll back, several Republican initiatives to expand coverage and reduce costs by injecting more “market forces” into health care, including efforts to promote high-deductible insurance policies, called health-savings accounts, and initiatives to move Medicare patients into health-maintenance organisations.

To date, these initiatives appear to have done little to slow the rise in health-care spending or to curtail the rise in the number of uninsured, whose number grew by 5 million to 42 million during the 6 years of Bush's presidency. The Democrats say the health-savings accounts are essentially a tax break for the wealthy and healthy that lures them away from traditional insurance plans. Those plans, because they are left with a risk pool of sicker, poorer, higher-cost patients, must then raise premiums and force employers and individuals to drop coverage.

To expand coverage, the Democrats plan to introduce tax credits for small businesses that purchase health insurance for their employees. Many of the uninsured are low-wage workers employed by small businesses. The Democrats also plan to push for full enrolment of uninsured children in an existing publicly funded health-insurance programme. Currently about 70% of eligible children are not enrolled. For older Americans who do not yet qualify for Medicare and who, because of their age, often find it difficult to obtain affordable health insurance, the Democrats hope to pass legislation to allow them to buy into the Medicare system.

While it is likely that these initiatives will prove popular, they still leave intact a troubled system that is unacceptably expensive, inefficient, and unfair. The real challenge for the Democrats, then, is to draw up a comprehensive health-care reform agenda that they can sell to the American people and run on in 2008. Democrats no doubt remember that the last time they advanced a comprehensive health-care reform initiative, President Bill Clinton's ambitious universal health-care plan, they lost first the House and then the Senate. Those defeats led to a decade of Republican control of Congress that ended only with last month's election. Are the Democrats willing to risk defeat again by advancing a plan that no doubt will require sacrifices by all and may be unpopular with many? How the Democrats meet that challenge will demonstrate to voters whether their Party has the political skill and courage to lead.

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