Health issues—some time-sensitive, others surprising—will take center stage on the congressional and administration agenda in 2009.

As a result of the November elections, achievement of both systemic health care reform as well as movement on individual health legislative issues are now a shared priority of President-elect Barack Obama and a Democratic–controlled Congress.

Comprehensive Health Reform

With 47 million Americans uninsured and health costs escalating, expanding health insurance coverage and curtailing health care costs while providing incentives for improved health care quality will be paramount goals in any health reform effort.

President-elect Obama’s health care pronouncements to date indicate a desire to work toward universal coverage, with the federal government occupying an important, but not exclusive, role. The Obama plan embodies the “play or pay” concept, which would require large employers that do not offer or make a meaningful contribution to the cost of quality health coverage for their employees to contribute a percentage of payroll toward the costs of a national insurance plan. Eligibility for Medicaid and the State Children’s Health Insurance Program (SCHIP) would be expanded. For those who do not have employerprovided health care and who do not qualify for existing federal programs, a new national health insurance program would be created. Individuals could choose between the new public insurance program and private insurance plans that meet certain coverage standards. Income-based federal subsidies for people who do not have access to employer-sponsored health insurance or do not qualify for public plans would be available. Benefits in the public plan would be similar to those offered to Members of Congress through the Federal Employees Health Benefits Program. While President-elect Obama has not called for mandated individual coverage, he has called for mandatory health insurance coverage for all children. President-elect Obama has also called for spurring increased adoption of health information technology and establishment of a comparative effectiveness institute that would review the relative effectiveness of different interventions. Information resulting from comparative effectiveness research would help form the basis for evidence-based decision making in health care delivery.

Congress is poised to consider President-elect Obama’s ideas alongside an array of alternative comprehensive health reform measures. Senate Finance Committee Chair Max Baucus (D-Mont) is a key player on health matters because the Finance Committee has exclusive jurisdiction in the Senate over Medicare, Medicaid, and SCHIP. Baucus has made health reform a priority and will work diligently to achieve it. As set forth in a November 6, 2008, letter to President-elect Obama, Chairman Baucus’ plan will call for universal coverage, pooling arrangements, controlling costs, a focus on prevention, and shared responsibility between individuals, employers, and the government. Senator Baucus has already put forth legislation calling for a comparative effectiveness institute, and he and Finance Committee Ranking Republican Charles Grassley of Iowa are looking for ways to pay for value, so that value rather than volume is rewarded in health care delivery.

Senator Edward Kennedy (D-Mass), chairman of the Senate Committee on Health, Education, Labor, and Pensions, has dubbed health reform his foremost priority and his staff is busy working on a health reform proposal and conducting a series of roundtable discussions on aspects of systemic reform. Additional legislators, organizations, and others in the health sector are also laying down markers and proposals for health reform.

With the worsening economic outlook, many who desire health reform wonder where the money will be found to pay for it. Key factors affecting any domestic spending, such as spending on health legislation, include the burgeoning budget deficit, the $700 billion cost of the recent financial rescue package, and the ongoing wars in Iraq and Afghanistan. In addition, if the Democrats fail to gain a filibuster-proof majority in the Senate, Republicans will be able to use the filibuster to affect and to thwart legislation. Onlookers also will want to assess whether Democrats heed the lessons learned from the failed health reform efforts of 1993–1994.

Some early indicators of the path that the health system reform process may take will be provided when Presidentelect Obama makes his selections for Secretary of the Department of Health and Human Services, Administrator of the Centers for Medicare and Medicaid Services, Commissioner of the Food and Drug Administration, and White House domestic policy advisors. Already, the selection of Rep Rahm Emanuel (D-Ill) as White House Chief of Staff bodes well for legislative success on all fronts, including health care, because he has shown that he is an extremely effective results-oriented legislator—having risen to the fourth highest post in the House Democratic leadership after only 6 years in Congress—and having effectively served in the Clinton White House.

Douglas M. Mancino, Esq, is a partner in the Health Law Department of McDermott Will & Emery LLP, Los Angeles. Karen S. Sealander Esq, is legislative counsel in McDermott’s Health Law Department in Washington, DC.