- President Barack Obama wrapped up a historic bipartisan health-care summit on Thursday by hinting that Democrats might go it alone if the two political parties cannot reach consensus on a comprehensive health bill. Obama is committed to a bill that provides coverage for the 30 million Americans lacking insurance and prevents insurers from penalizing those with pre-existing conditions.

Obama said that two parties might be able to reach agreement on 95 percent of the issues, but he says expanded coverage and pre-existing conditions may turn out to be gaps that cannot be closed.

He stressed that Democrats wouldn't abandon their legislation and start the process from scratch, as Republicans had urged, and that he would not hold another summit like the one Thursday. He added that Republicans might have political reasons for opposing what the Democrats propose simply because the GOP's constituency does not embrace the Democrats' approach to health reform.

If the gap cannot be bridged, "I think we have to go ahead and do something, make some decisions. That's what elections are for. We have honest disagreements about the vision for the country. We'll go ahead and test those out in the next several months until (the) November" mid-term elections.

Obama's closing comments sounded as though his party might be willing to take the controversial step of using the budget reconciliation process to get a bill through Congress.

The summit comes at a time when the number of uninsured Americans continues to grow, more middle-class families and retirees are paying higher premiums to keep their coverage, the working poor are threatened by spending cuts for the very public-health centers on which they rely for care -- and everyone seems frustrated.

"I don't expect much to come out of this meeting, but I'm keeping my fingers crossed," says Bill Reichert, a semi-retired piano technician from Maryland Heights. "I'm not hopeful, but I do wish something good would happen. I think I'm a realist. I just don't think it's going to go anywhere, but I'd like somebody to prove me a pessimist."

Legislators debate reform

Outside of the bipartisan session, some Republican leaders were critical. U.S. Rep. Roy Blunt, R-Springfield, took part in a conference call with members of the House GOP Healthcare Solutions Group, which Blunt chairs. He repeated the GOP opposition to the Democratic health-care proposals. Blunt said that from what he had seen of the summit on TV, he was "not sure how much discussion is going on."

Actually a lot is being discussed, and President Obama (right) tried several times to keep the focus on areas on which both sides agree and areas on which they could reach compromise.

In a pool report, after the meeting participants broke off for lunch, Obama told reporters: "I think we're establishing that there are actually some areas of real agreement and we're starting to focus on what the real disagreements are. If you look at the issue of how much government should be involved -- the argument that Republicans are making really isn't that this is a government takeover of health care, but rather that we're ... regulating the insurance market too much. And that's a legitimate philosophical disagreement. We'll hopefully be able to explore it a little more in the afternoon."

Sen. Alexander Lamar, R-Tenn. (right), summed up the GOP position and strategy early when he urged Democrats to take their health-care bill off the table and start from scratch. He likened the Democrats' legislation to a "car that can't be recalled or fixed. We'd like to start over."

Sen. Majority Leader Harry Reid, D-Nev., shot back that Alexander was "entitled to your opinion but not to your own facts. Let's make sure that we talk about facts." Reid said 58 percent of voters would be disappointed if Congress did not address health insurance this year and that 60 percent wanted a system that gives consumers more choice and insurance companies more competition.

In his comments at the summit, Sen. Dick Durbin, D-Ill., told colleagues: "When it comes to the wealthy in health care per capita, we're the wealthiest people in America. The Federal Employees Health Benefit Program administered by the federal government, setting minimum standards for the health insurance that we enjoy as individuals and want for our families, is all we're asking for in this (Senate) bill for families across America."

He added that "If you think it's a socialist plot and it's wrong, for goodness sakes drop out of the Federal Employees Health Benefit Program. But if you think it's good enough for your family, shouldn't our health insurance be good enough for the rest of America? That's what it gets down to. Why have this double standard?"

Reid and Alexander both touched on the hot button issue of whether Senate Democrats might use the budget reconciliation process, allowing a simple majority, to pass health legislation. Reid stressed that the GOP had raised that issue but that Reid and Speaker Nancy Pelosi, D-Calif., hadn't brought up the matter. Still, Alexander tried to get Democrats to make a promise that they wouldn't resort to the reconciliation process.

Reconciliation and health-care reform

Some scholars say, however, that the reconciliation process is being depicted in a false manner.

Sidney D. Watson (right), a law professor with St. Louis University's Center for Health Law Studies, says budget reconciliation bills are "used almost every year to pass important legislation. In fact, almost all the most important initiatives in health care and health reform over the last 30 years have been passed via budget bills."

Likewise, Sara Rosenbaum, who chairs the Department of Health Policy at George Washington University, says that with few exceptions, the reconciliation process has been the way health reform has taken place. She cites these examples:

• 1982 -- TEFRA: The Tax Equity and Fiscal Responsibility Act first opened Medicare to HMOs
• 1986 -- COBRA: The Consolidated Omnibus Budget Reconciliation Act allowed people who were laid off to keep their health coverage and stopped hospitals from dumping ER patients unable to pay for their care
• 1987 -- OBRA '87: Added nursing home protection rules to Medicare and Medicaid, created no-fault vaccine injury compensation program
• 1989 -- OBRA '89: Overhauled doctor payment system for Medicare, created new federal agency on research and quality of care
• 1990 -- OBRA '90: Added cancer screenings to Medicare, required providers to notify patients about advance directives and living wills, expanded Medicaid to all kids living below poverty level, required drug companies to provide discounts to Medicaid
• 1993 -- OBRA '93: created federal vaccine funding for all children
• 1996 -- Welfare Reform: Separated Medicaid from welfare
• 1997 -- The Balanced Budget Act created the state-federal children's health insurance program, or CHIP
• 2005 -- Deficit Reduction Act reduced Medicaid spending, allowed parents of disabled children to buy into Medicaid

Still, some Missourians say the reconciliation would be the wrong approach.

"That's crazy," Dan Mehan (right), head of the Missouri Chamber of Commerce, says of the talk about budget reconciliation. He says that approach by Democrats sends the message that "people don't like it, but we're going to do it anyway. That's what they are saying. You have a lot of people saying Washington has run amuck. They're not listening to us, and we've had it."

Reconciliation, he says, "flies in the face of opening it up to other ideas. It would only cast an even more negative pall over this issue."

He adds that Republicans at the summit should try to acknowledge the need for some reforms.

"We do have the best health-care system. Is it perfect? No. Is it costly? Yes. But I think we need to experiment with a more market-oriented solution or depend on supply and demand. You don't need to force people to have coverage if people don't want coverage."

Medical malpractice should be on the table, says Mehan, along with wellness programs that encourage people to take better care of themselves and avoid visits to the doctor or the hospital.

The public is "concerned that they would pay more and have fewer choices and that everything is going in the wrong direction," says Mehan. "It's better to do no harm than to make a big mistake that you really would have a tough time correcting. Let's get it right."

He also warns that state budget shortfalls might worsen because nobody in or out of state government seems to know what will happen once federal stimulus money, which has helped states balance their budgets, runs out.

"The state is going to have major cuts," he says, "and we're going to have to figure out what to cut and how to grow (revenue). If we grow more, we'll be better (able) to withstand these kinds of downturns. That overall will help protect programs like Medicaid and education."

Future of community health centers

Joe Pierle, head of the Missouri Primary Care Association, is alarmed about Republican proposals for cuts in community health centers. Community health centers have been featured prominently in all of the health-reform legislation because of their vital role in providing health care to the poor, and often uninsured. President Obama's proposal requested $11 billion in additional funding -- a significant increase over the $7 billion in Senate bill but less than the $12 billion in the House bill.

Pierle says, "Missouri's community health centers disproportionately see more low-income uninsured and underinsured than any other provider. On average 42 percent of a health center's patient base is uninsured. So any effort to provide affordable access to health coverage would have a significant positive impact on our patients. Affordable health coverage coupled with initiatives to address access to services will improve health access for our patients and their quality of life."

Even with health reforms proposed by Democrats, Pierle points to analyses showing that federally qualified health centers will still have a patient base of about 25 percent uninsured.

"So state funding for community-based health centers is critical to our ability to meet growing demand for medical, dental and behavioral health services."

Missouri has 23 federally qualified health centers. These serve an estimated 350,000 Missourians, Pierle says. He says each center gets between $200,000 and $600,000 in state funding, or roughly $10 million in total funding for all centers, making up about 10 percent of their budgets.

Federal grants comprise only 25 percent of the budget for each center. Pierle says that's why the centers rely "significantly on investments from other sources, such as state government, private foundations, and local communities."

Meanwhile, the National Association of Community Health Centers says it welcomes the bipartisan discussion. Dan Hawkins (right), senior vice president for the group, says Obama's latest proposal would offer $11 billion for community health centers over the next five years.

He says most of the money in the president's proposal would be used to expand existing centers and develop new ones. The new centers, he says, would be in communities with few or no health centers today.

He estimates that the money would mean opening roughly 7,500 new health centers. This would extend preventive and primary care to an estimated 20 million more people by 2015, doubling the number of those now being served, he says.

"Health centers are needed to turn the promise of enhanced coverage into the reality of better care. Ultimately everyone benefits when people have both insurance coverage and a place to go for preventive care," he says.

Ideas embraced by the St. Louis Business Health Coalition came through in some of the comments at the summit. For instance, Sen. Tom Coburn, R-Okla., who also is a physician, talked about rewarding doctors on the basis of quality rather than quantity of care. Louise Probst (right), head of the Business Health Coalition, has been urging federal lawmakers to "change the way health-care providers are paid to encourage high-quality, efficient care."

She also says lawmakers need to attack the reasons health-care cost continues to rise. "Ironically, costs could be lower if health-care quality improved. At least one-third of the money spent on health care is wasted on wrong medications, unneeded surgeries, preventable infections and other waste."

She adds that the Institute of Medicine reports that roughly $17 billion alone is wasted through preventable medical errors. Providers need to be more transparent about the cost and quality of health-care services and use technology more efficiently, she says.

But she adds that reform shouldn't mean putting additional pressure on "already stretched" American businesses. Instead, she says, reforms should address the underlying reasons so many Americans, including large and small business owners, find health care "prohibitively" expensive.

Even so, she says, 95 percent of American companies with more than 50 workers to provide health coverage. She says penalizing companies for not providing insurance would have little effect because the penalties would only affect companies with more than 50 workers. Citing a Rand Corp. study, Probst says "an employer mandate would move the needle less than 1 percent."

Although the Missouri Chamber thinks Democrats are headed in the wrong direction, John Arensmeyer (right), CEO of the Small Business Majority, a national group, said he was pleased by the level of support that small businesses got during the summit. But he added that "the time for talking is over. It's time to take action and pass reform legislation now."

He cited instances in which millions of self-employed people and small businesses were being notified of double and even triple-digit increases to their  premiums. This development, he said, made it "more important than ever that legislators help small businesses get the relief they desperately need."

He said the current system was pricing increasing numbers of small businesses out of the health-insurance market. Roughly 60 percent of businesses with fewer than 10  workers no longer offer insurance, he said. Economic studies by the Small Business Majority show that the future for small businesses will be bleak in the absence of health reforms, he said.