Democrats can placate Republicans by passing a bill that focuses on baseline health insurance reforms and budget-neutral measures that eliminate preexisting conditions, promote portability and cap out-of-pocket costs.

At the same time, they could roll the dice on legislation loaded with hot-button issues and ambitious provisions that would be filibuster-proof in the Senate by garnering the 51 votes needed for certain budget-related measures to clear the parliamentary maneuver known as “reconciliation.”

The thinking behind this “split-bill” strategy is that it would speed a vote and help President Barack Obama sign a bill by yearend. But there are critics even on the Democratic side, with Sen. Kent Conrad (D-N.D.) doubting that it would be feasible. Bill Sweetnam, a principal with the Groom Law Group in Washington, D.C., has called the approach a “risky political proposition.”

One of the biggest challenges will be finding agreement on key elements in three major pieces of legislation detailed in more than 2,000 pages. For example, America’s Affordable Health Choices Act of 2009 (H.R. 3200) was marked up by the House Ways and Means, Education and Labor, and Energy and Commerce Committees.

“It’s up to the House leadership to merge 3200 from its current three-bill iteration back into one bill for a floor vote that can get 218 votes,” Julie Rovner, a health policy correspondent for National Public Radio, said in a September panel discussion sponsored by the Alliance for Health Reform (AHR).

Senate Finance Committee Chairman Max Baucus (D-Mont.) already has agreed to several compromises on his America’s Health Future Act, despite the fact that it hasn’t garnered Republican support. In another GOP victory, his committee voted down the highly contentious public-plan option.

For Congress to pass health care legislation, “the conversation needs to be about creating a healthy America instead of reforming the health care of America,” explains Cyndy Nayer, president of the Center for Health Value Innovation in St. Louis, Mo., and co-author of “Leveraging Health: Improve Health Status and Bend the Trend on Financial Inflation with Value-Based Designs.”

“If, in fact, we focus on creating a healthy America,” she continues, “then there is nothing to stop a split-bill approach because then we’re actually solving a problem. We would be taking a first step to creating some access and affordability around prevention and primary care.”

Nayer, who says employer-sponsored health plans are a valuable conduit in that they can reinforce appropriate health behaviors five days a week, cautions that attempts to accomplish too much in a single piece of legislation would be like “throwing out the baby with the bath water because we’re not going to come to consensus that way.”

If health insurance is mandated, then subsidies will be necessary to make coverage affordable for low-income Americans, says Henry J. Aaron, a senior fellow with the Brookings Institution’s economic studies program in Washington, D.C.

“Once you’ve done that, you may as well go with the exchanges because that would be a convenient mechanism for the small group market and individuals,” he says.

Aaron noted during a separate AHR briefing in September that regional insurance exchanges, if done right, would over time “greatly strengthen the employment-based system, which is to say you’d end job lock… It would be almost worth the price of admission by itself.”

Aaron has long thought that limiting the reach of a mandate, such as focusing on covering children, would remove sticker shock from the cost equation and win bipartisan appeal. But he’s not sure “how the Obama administration climbs down from the approach that it is now occupying” by pursuing a more expansive view of reform.

Since the Democrats have a sufficient majority in the House, they have the luxury of losing “a fairly sizeable number of members from relatively conservative districts that might not want to sign on,” he observes. The critical question then becomes, can any differences be ironed out in a conference committee? Aaron predicts “trench warfare” at each step along the legislative process.

“I wouldn’t make an even-money bet that something will pass, though it’s entirely possible,” Aaron surmises. “If the Senate passes something and if a conference agrees, I would think that the administration would do everything but hire Mafia leg breakers to line up the necessary votes in the Senate.”

Nayer laments the fact that inflamed emotions and misinformation have trumped constructive discussions on how to best remove waste form the nation’s health care system and offer affordable coverage for everyone.

“We use words like abortion, death panels and health care rationing, which are not anywhere in this legislation,” she says, noting that the debate has reached a point where “we don’t know what’s real. We keep discussing ‘the bill.’ But there is no one bill.”

Still, she’s sanguine that lawmakers will shift the focus to prevention, wellness and evidence-based primary care in employer-sponsored plans, as well as community risk ratings, to help amortize costs, keep insurance companies in business, and improve both medical and economic outcomes. She also firmly believes there are ample resources to provide appropriate care to all Americans.

Guest blogger Bruce Shutan is a former managing editor of Employee Benefit News and a freelance writer based in Los Angeles.

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