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Assessing the next options for health reform

January 22, 2010
by Daniel Guarnera
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The discussion now should focus on the central components of the legislation

Comprehensive healthcare reform has eluded American presidents since Harry Truman, so no one expected that President Obama’s attempt would go smoothly. Even so, Republican Scott Brown’s Jan. 19 victory over Democrat Martha Coakley in a special election to represent Massachusetts in the U.S. Senate is particularly ironic: Brown will take the seat vacated when healthcare champion Sen. Edward Kennedy died; the Democrats lost an election in one of the nation’s most historically liberal states; and Massachusetts is the only state that already has a robust universal healthcare system, the model for the bill now before Congress. Brown will bring the number of Republicans in the Senate to 41, enabling a unified GOP caucus to filibuster—or prevent a vote on—the health reform bill.

Policy-makers in Washington are still processing what the Massachusetts election will mean for health reform. Some have concluded that reform should either be scrapped altogether or scaled down significantly. There are other options to salvage the current bills, however. One possibility is that the House of Representatives could simply pass the reform bill that the Senate has already approved (although the House Speaker on Jan. 21 openly questioned whether there was enough House support for this). Although the Senate bill was more moderate in some ways than the House bill, they both share the same fundamental approach, and once passed by the House the legislation would be ready to be signed into law. (Additionally, a new bill could be introduced to make desired tweaks.) Another option is a procedural tactic called “reconciliation,” which would place limits on the amount of money that can be spent and the length of time provisions are in effect, but would require only 50 Senate votes.

Despite the angst caused by Brown’s election, however, the Democrats still have 78 more representatives and 18 more senators than the Republicans, so the ball still is very much in their court. If they decide to fight for health reform, they will have to overcome a problem that has plagued them since the start of the process: Most people are very unfamiliar with what the reforms would actually do.

While media coverage has focused in a monomaniacal way on politically charged issues such as “death panels” and abortion, the most central components of the bills have gone largely unexplained and undiscussed in the public square. More detailed information about what the health reform proposals would mean for addiction professionals can be found at Here are the five most important things to know about the Senate’s version of the health reform bill:

• Each state would set up an insurance “exchange” where small employers and individuals would be able to buy insurance at lower rates than currently available because they would be part of larger risk pools. Low-income people who are currently uninsured would receive subsidized insurance through the exchanges. There would be no new government-run plans.
• Large employers would be required to provide insurance to their employees or face financial penalties that would be used to pay for enrollment in the exchanges. Small employers would receive tax credits to buy insurance.
• Eligibility in Medicaid would be raised to 133 percent of the federal poverty level. Adults without dependent children would be able to enroll in every state for the first time.
• Health plans would be required to provide a minimum level of benefits, including non-discrimination against people with pre-existing conditions, as well as substance use disorder benefits (large employers are exempt from the latter requirement, although they still must comply with the new parity law).
• There are a variety of additional programs, including workforce development initiatives, incentives to provide coordinated care, and chronic disease prevention programs.

Countless stumbling blocks still could prevent this iteration of healthcare reform from ever becoming law. However, as we enter the next (and, one way or another, final) stage of the health debate, we owe it to ourselves as a nation to better understand the central policy components of the bill—rather than merely the latest political developments—before it is accepted, rejected, or modified by Congress over the next few weeks.

Daniel Guarnera is Director of Government Relations at NAADAC, The Association for Addiction Professionals. He is a regular blogger on the

Addiction Professional Web site, covering policy issues of importance to the addiction field. His e-mail address is

Additional resources on health reform:

NAADAC, The Association for Addiction Professionals

Kaiser Family Foundation

Health Affairs