Percentage complete: 47*
As a candidate, Barack Obama made a series of fairly specific promises on health care ($10 billion a year for health IT, loan forgiveness for rural doctors) and drew some bold lines in the sand (universal coverage, prevent insurers from discriminating). After a year in which the compromises of Congress required him to bend and sway on the specifics of reform, he's probably glad he didn't make any more promises than he did.
The expansion of the State Children's Health Insurance Program in February moved him closer to completing his pledge to insure all children, adding 4 million uninsured youngsters to the program's rolls. Soon after, the stimulus package included funding for electronic health records and Vice President Joe Biden announced the first White House adviser on violence against women, checking another pledge off the list.
But Obama can't claim any significant victory until the House and Senate versions of health care reform bills are reconciled and sent to his desk. He has dedicated significant political capital, time and energy during his first year in office to health care reform, his top domestic priority. Campaign promises such as those to end discrimination based on pre-existing conditions, help individuals purchase private insurance plans and provide every American with insurance coverage won't be realized until the long legislative battle is over, and even then they may be compromised.
Many of Obama's health-related campaign pledges were vague and lofty, but as the legislative push began in earnest last year, he waded into more specific policy plans. Here's a look at some of the public promises Obama made after his election and how they played into the health care debate.
Reform The Payment Structure
At a town hall in June, Obama told the crowd, "We should change the warped incentives that reward doctors and hospitals based on how many tests and procedures they do." In other appearances, he made similar comments about abandoning the fee-for-service structure that Medicare currently uses to reimburse doctors. Speaking to the American Medical Association, he said the government should explore penalizing hospitals for readmissions and move towards bundling payments for treatment.
Despite Obama's urging, bundling never became central to the health care bills. Both chambers set up pilot programs to explore bundled payments and medical homes in depth, but that was largely the extent of it. The readmission penalties, though, do appear likely to pass; both the House and Senate bills would set up a panel to review readmission rates and penalize hospitals that fail to meet certain benchmarks.
Passing A Budget-Neutral Plan
In a July 17 address, Obama made one thing very clear: "Health insurance reform cannot add to our deficit over the next decade, and I mean it." He kept up his call for the bill to be budget-neutral throughout the debate, even setting a $900 billion price tag in his joint session address. While the bill's cost has been a constant sticking point (Republicans say it spends too much too early without enough tangible benefits), the Congressional Budget Office said the bills that passed both chambers would actually reduce the federal deficit over 10 years. Both also came in under the $900 billion mark.
Invest In Prevention
While he had talked this up during the campaign, President Obama placed greater emphasis this year on his call for investment in prevention and wellness programs. "We will require insurance companies to cover routine checkups and preventive care, like mammograms and colonoscopies," he said in an address in July.
Funding and requirements for preventive care turned out to be an easy, bipartisan issue. Shepherded by Sen. Tom Harkin, D-Iowa, the language for prevention passed without much debate and is sure to be a large part of the final bill. Both bills require insurance companies to cover preventive tests and screenings, and they also increase grants for community wellness programs designed to get people exercising and healthy before they drive up health care costs through emergency care.
Explore Tort Reform
An issue beloved by Republicans and largely ignored by Democrats, tort reform became a controversial part of the health care debate. After months of Republican lobbying for medical malpractice reform to be part of the bill, Obama made a concession in his joint session address.
"I'm proposing that we move forward on a range of ideas about how to put patient safety first and let doctors focus on practicing medicine," he said. "I know that the Bush administration considered authorizing demonstration projects in individual states to test these ideas. I think it's a good idea, and I'm directing my secretary of Health and Human Services to move forward on this initiative today."
Reform Physician Pay
In an Oct. 5 address to a group of doctors at the White House, Obama nodded to one of physicians' biggest concerns. "We are working to fix the flawed sustainable growth rate formula by which doctors are reimbursed under Medicare," he said. The SGR formula traditionally underpays doctors and would result in a scheduled 21 percent pay cut for 2010.
But despite Obama's promise, Congress did not pass a physician pay fix as part of a health care bill. The high cost of reforming the system long-term would have added upwards of $200 billion to the bills, making it nearly impossible for them to be budget-neutral. A separate bill to reform the pay formula passed the House but failed in the Senate. Instead, Congress passed a short-term fix as part of a defense spending bill that would adjust the formula for the first few months of 2010. Senators promised to revisit the issue.
"Percentage complete" refers to the average progress made completing each promise in this category -- not the percentage of promises that have been completed. If Obama has made no effort to complete a promise, he gets 0 percent for that promise. If he's taken some identifiable steps short of legislation or an executive order, he gets 25 percent. If legislation has been introduced or significant progress is apparent, he gets 50 percent. A 75 percent mark is awarded if most elements of completing a promise are in place but more work needs to be done. A 100 percent mark is given when the promise has been fulfilled.