Last week and this
week in Washington
have been even crazier than any before in the health care reform soap opera
of 2009. I recently heard a modern philosopher opine (can't remember his name)
that "life is a first-class opera played by a tenth tier cast." If you tuned in
to C-Span this week to observe the Senate Finance hearings, you’d understand.
Actually, this health reform debate is more a soap opera, at least as Mr.
Baucus' long awaited bill was received. Baucus likes the bill very much. I’m
not sure anyone else in his Chamber does. Nonetheless, I predict it will be the
platform for the final bill for two reasons: first, the CBO marks up the costs
over ten years at less than $900 billion ($856 B), AND they say it will
actually save money over time. The other two major bills cannot claim this
Second, at least one Republican might vote for it (Snowe—R-Maine).
But most of what the bill contained when Baucus put it out will likely be
amended away. It’s becoming a platform, not a plan. Democratic colleagues
Rockefeller and Wyden have been the most critical of Baucus, particularly in
requiring coverage with insufficient subsidies for lower income families.
House leaders still think their Tri-Com bill (HR 3200) will be the real
platform, with Ms. Pelosi and others clarifying that the 'public option' (not
included in Mr. Baucus' bill) must be in the final legislation. But their
proposal is more expensive -- even though they ‘fix’ the SGR. They don’t finance
the SGRrrr fix though -- they just sort of write it off as part of the debt, not
part of the next budget.
The Senate doesn’t buy that approach. They say it has
to be paid for (adding $245 billion to the House bill cost if so) -- hence the
Senate chose to band aid patch it for one year only to prevent the 21 percent cut in
physician reimbursement from kicking in this January, even though it kicks in
the following January. (They don’t yet
seem too concerned about the 27 percent cut to cardiology practices looming in 2010
relating to the Medicare Payment Rule, however. The Rule has nothing to do with
health system reform and these bills -- it’s just an ugly manifestation of the
present mess -- but it’s a worse predicament).
is clear that neither Democrats or Republicans on the committee are completely
satisfied with the final product and those not included in the “Group of Six”
negotiations over the past weeks want to have their voices heard.
opening statements by members, the markup started with a tense tone as Chairman
Baucus, committee members, and CBO Director Doug
Elmendorf held a contentious discussion over the “safe speed” of CBO’s work to
produce budget scores on the proposal and amendments. Republicans have called
for “transparency,” with several hours of debate on an amendment by Sen.
Bunning requiring final legislative language and CBO budget scores 72 hours
prior to the committee’s final vote (the amendment failed).
markup is slow going, with hundreds of amendments lined up dealing with
coverage, delivery system, and financing and debate over many amendments
lasting hours and at times becoming heated. Several attempts to strengthen the
bill’s provision on medical liability have failed so far, as did an attempt by
Sen. Cornyn (R-TX) to address the SGR fix. Sen. Cornyn also offered an
amendment to strike the controversial Independent Medicare Commission from the
proposal, but it failed. Later, an amendment by Sen. Rockefeller to modify the
Commission, which is based on a bill of his, passed. So far the MedPAC on
steroids piece is alive in there. The “public option” is not.
very controversial aspect is the creation of a new system of modifiers to
payment based on quality of care in relation to resources spent. This provision
would thus penalize higher spending regions with lower payment. It’s true that
variation in spending is very uneven. The Dartmouth Atlas folks (Wennberg and
Fisher) deserve credit for publishing that variation based on Medicare spending
per capita, but it’s based entirely on claims data. And, it doesn’t include
socioeconomic and credible risk adjustment data, and that must be included
before variation can be fairly linked to payment or to fair comparisons of
geographies. ACC has proposed using clinical
data (NCDR) to help look more carefully into this variation.
markup continues next week.
All eyes continue to be on Sen. Snowe, who may be the lone committee
Republican to vote with Democrats for passage of the bill.
Despite the controversies, and after all the amendment
hubbub, the Dems should still have the votes to get a bill out in both Houses
in my view. In the Senate, after Massachusetts Governor Deval Patrick on
Thursday appointed Paul G. Kirk Jr., a former aide and longtime confidant of
the late Sen. Edward M. Kennedy, as an interim senator, that 60th
vote should be there soon. We’ll see.
*** Image from Flickr (Brent and MariLynn).***