WASHINGTON - Several Washington insiders told the audience at the Catholic Legislative Advocacy Conference here that CHA has the opportunity to play an essential role in the health care reform debate: It can provide a clear and passionate vision and give guidance and political cover to politicians willing to make hard policy choices.

Speakers said that CHA can help politicians identify and build consensus around the difficult trade-offs that will be necessary to fund meaningful health care reform in an era of growing budget constraints.

"We need the expertise that is in this room," Sen. Robert Casey Jr., D-Pa., told the audience at the opening dinner at the Grand Hyatt Washington. About 100 health care leaders from CHA member systems and facilities attended the conference, which opened March 10 and culminated March 12 on Capitol Hill where advocates visited members of Congress.

"We need your passion and we need your voice to keep (health reform) on the front burner in Washington, especially in a year like this when we are going to elect a new president and there will be changes made in the Congress," Casey said.

The following morning, economist Eugene Steuerle struck similar chords on the hard choices ahead when he painted a sobering picture of a long-term squeeze on the federal budget that could bring on what he called the next big "fiscal turning" - an era in which any increased spending on most domestic programs will need to be offset by tax increases, cuts in defense spending or pared growth in retirement and health spending.

Steuerle, a senior fellow for the Urban Institute, a nonpartisan social and economic policy group in Washington, said the low tax, high spending mentality that has prevailed in Washington in recent years is unsustainable. Not only will politicians have to stop playing Santa Claus, they will have to make unpopular program cuts and perhaps raise taxes, he said.

"And they are going to be attacked," for doing so, Steuerle said. He reminded the audience that Democrats and Republicans both have experienced political upheavals brought on by voters unhappy about Washington's response to pocketbook issues. A tax increase contributed to the defeat of President George H.W. Bush in his bid for a second term, and dissatisfaction with Washington spending was a factor in the Republican sweep of the 1994 midterm election during the early years of the Clinton administration.

"Policy makers are desperately looking for someone to come in and say, 'Do it this way,'" Steuerle said. "I think the Catholic Health Association could really stand out there and help them in terms of discussing trade-offs." For example, CHA might say, "We are willing to accept a little less money here, if you can give us children's health insurance as a trade-off."

Aranthan Jones, a senior hill staffer who appeared on the federal budget panel with Steuerle, said that absent a vision of the excellence that is possible in the American health care system, the debate over meaningful health reform risks being bogged down in technocratic minutia, fiscal constraints and turf battles. As policy director for the House of Representatives Majority Whip office of James Clyburn, D-S.C., Jones is in the thick of efforts to move legislation through the House.

Jones said an overarching vision on health reform could embolden politicians to take the controversial votes needed for comprehensive health policy change. A wholesale change sought by some might involve the dissolution of separate systems of Veterans Administration health care, for-profit health care, Medicare and Medicaid and health programs for the uninsured, he said. The incremental change sought by others would require everyone to pay for a system that will leave many behind, Jones said.

Money is going to be a continuing obstacle to reform. Jones said that given the economic downturn, there will be hypersensitivity to tax increases and continuing pressure to grow the $400 billion federal budget deficit projected for both FY 2008 and 2009. The current push for economic stimulus programs contradicts the "pay-go" environment in Congress, which requires increases in spending to be offset with budget cuts.

Budget constraints played a role in the defeat of efforts last year to reauthorize and expand the State Children's Health Insurance Program. "Everybody was for children's health care, but nobody wanted to find the money to pay for it," Jones said. President Bush vetoed legislation that would have added $50 billion to the program over five years and a follow-on compromise bill that would have increased the program's budget by $35 billion.

Casey said that in January 2007, when he entered the Senate as a freshman, no one anticipated the fight that erupted over children's health care. After all, SCHIP expansion was backed by the majority of politicians of both parties. "In the end President Bush stood in the way," Casey said.

Casey said that federal regulations enacted last year that serve to restrict access to Medicaid and SCHIP are "wreaking havoc across the country on the most vulnerable in our society." Attempts will be made to contain the damage until a new administration takes office next year, he said.

Despite the obstacles, this year can be productive for health policy reformers, Casey said. "If we have a year of debate and discussion and arguing and comparing and contrasting (health reform) plans, I think we may get something done in '09" when a new administration enters the White House. "Presidential leadership" is the missing ingredient in efforts to achieve health reform, he said.

Dan Hale, executive vice president of community benefit and public affairs for Trinity Health of Novi, Mich., and chairman of CHA's Covering a Nation initiative, urged health care advocates to build local support for health care reform and to work to keep it as a top priority in the presidential election. "We still believe if change is going to happen, there has to be a groundswell from the American people," he said.

Diane Rowland, executive vice president, Henry J. Kaiser Family Foundation, addressed the health reform plans put forth by the leading three presidential candidates. Rowland noted that while there were only slight differences between the plans of Democrats Barack Obama and Hillary Clinton, their focus differs sharply with the reform priorities of Republican candidate John McCain, which rely largely on the private sector rather than government-based measures.

Nicole Tapay is senior health policy advisor for Sen. Ron Wyden, D-Ore., author of the Healthy Americans Act. She told the audience that the proposed legislation would require Americans to accept changes to the health care system. For example, it would move the insurance tax break to individuals from employers. It would fundamentally alter the insurance market by requiring private insurance companies to take all applicants without regard to preexisting conditions. And, through the creation of a competing government insurance plan, it would give individuals access to coverage with benefits comparable to the package offered federal employees. Medicaid beneficiaries would be moved to the new government-sponsored insurance program.

Tapay asked for input from Catholic hospitals on provisions of the bill meant to strengthen Medicare programs related to chronic disease management.

Elizabeth Hall, acting director of the office of legislation at the Centers for Medicare and Medicaid Services, said in the session on Medicare that Congress is expected to revisit plans to cut physician reimbursement before new pay schedules take effect July 1. Hall said that, from the perspective of the Bush administration, any such legislation would have to have bipartisan support. "We will all have to work together to make that happen," she said.