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Latest move on health care bill: No one’s happy

HR 3200 health bill
REUTERS/Jonathan Ernst
Rep. Henry Waxman’s copy of health care legislation titled “America’s Affordable Health Choices Act of 2009” sits on his desk Thursday as the House Energy and Commerce Committee marked up the bill.

WASHINGTON, D.C. — In an effort to dislodge weeks of gridlock over the health-care reform bill, House Democrats made the controversial move Wednesday to cut roughly $100 billion from the cost of the legislation while redefining the terms of the oft-debated public insurance plan option.

The agreement — made between House leaders and four key members of the party’s fiscally conservative Blue Dog group — was supposed to help move the bill through its last committee before Congress leaves for its August recess this Friday.

But it could end up creating even more acrimony among the Democrats, both from Blue Dog members who do not think that the compromise goes far enough, and now from lawmakers on the left, who claim that the changes have only weakened the legislation.

“It is a deal breaker,” said Rep. Keith Ellison, D-Minn., who is a member of the Democrat’s Progressive Caucus. “I will not vote for this version of the bill.”

“I just philosophically don’t agree with what the Energy and Commerce Committee is doing in some of the areas of the bill,” said Rep. Collin Peterson, D-Minn., who is a founding member of the Blue Dogs and among those who have not supported Wednesday’s deal.

In general, the agreement would cut the overall cost of the more than $1 trillion bill by reducing eligibility for subsidies available to help the uninsured buy coverage. In other words, people with low or moderate incomes could still get federal subsidies, but they might be required to spend a greater percentage of their own income. The deal would also shift the government-run public insurance option from a plan based on Medicare rates to one in which the government would negotiate with private insurers, doctors, hospitals and other providers.  In addition, it would exempt more small businesses — those with annual payrolls of $500,000 or less — from mandates that employers cover their workers or pay a new federal excise tax.

‘Controversial meeting’
Peterson called the changes a step in the right direction, but said that a large number of Blue Dogs still found the alterations to be too minor or misguided.

“This was very controversial [Wednesday] morning in the Blue Dog meeting,” Peterson said. “From what I could tell, other than the four guys that were going to vote for it in committee, I don’t think anyone else was for it. … They are just under pressure to get it out of committee.”

Peterson’s main problem with the current plan is that the Medicare reimbursement system, which is a fee-for-service model, is still not fully addressed.

Rep. Collin Peterson
Rep. Collin Peterson

Last week, Rep. Betty McCollum, D-Minn., reached an agreement with House leaders to incorporate two studies in the bill that would move towards implementing a fee-for-quality system. While the study requirements include a timeline for enactment, Peterson said that they do not go far enough.

“There isn’t enough reform of the system,” Peterson said. “It’s all these kinds of independent studies. And having been around this place for a long time, I don’t have a lot of confidence that is going to happen.”

Currently, states that provide more health care services, like New York, New Jersey, Florida, Texas, and California, get reimbursed at higher rates. Meanwhile states that provide fewer services, but might have better quality health care, like Minnesota, Wisconsin, and Washington, get reimbursed at lower rates.

The problem, he said, is that quality of care is not a factor in setting reimbursement rates. Instead, the system rewards more tests and services regardless of outcome.

“The problem that no one wants to talk about is the money that is being paid to those high-cost, low-quality areas,” said Peterson. “The problem is that the political power is in those areas.”

Wednesday’s agreement would also expand Medicaid, but would require states to pay around 7 percent in additional costs.

According to Peterson, that is also a problem for some Blue Dogs.

“We don’t think we should let the states off the hook,” Peterson said. “That’s another cost that we don’t have to incur.”

Conflict with Blue Dogs
The Progressives, on the other hand, have their own concerns with the legislation — some in direct conflict with the Blue Dogs.

Ellison argued during an interview on Thursday that the expansion of the small business exemption would only cause employers to ditch their insurance, dumping more people into the system, and raising costs.

“It is somewhat ironic because the faction that was doing the negotiations, and insisting on the changes, has made a public case that they are trying to reduce costs,” said Ellison. “But many of their demands actually stand to increase the cost.”

Ellison added that he also thought the changes to the public option would increase costs because the plan would end up paying higher rates, which would still not be tied to quality of care.

Cash-strapped providers, however, have pushed for a system that would pay higher rates than Medicare, which currently reimburses 20 to 30 percent below the rates paid by private insurance plans.

But, it is debatable how much the agreement would substantively change the public plan. In the original legislation, the public plan could use Medicare rates for three years. After that point, the secretary of Health and Human Services would negotiate rates with providers. Now, rates would be immediately negotiated.

Still, Ellison said that the adjustment would result in higher initial costs for the consumer and would allow for the continuation of a payment structure that is divorced from quality.

In addition, Ellison said that the possible requirement that states pay a portion of the expanded Medicaid coverage would only add additional burden on their resources.

“It is a bad deal and I am disappointed that a fairly small number of people are imposing their will on the whole caucus,” Ellison concluded.

The full House, however, will not be voting on the legislation any time soon. On Thursday, House leadership made it clear that even if the deal leads to the bill passing out of the Energy and Commerce Committee this week, it will not come to the floor until September at the earliest.

Given the continued disputes and the incredible complexities of the legislation, Peterson said, that was a very good thing.

“We have three or five bills out there right now,” Peterson said. “What I hope to do over August is go out and talk to my people about all these different ideas and what they think about it.”

Cynthia Dizikes covers Minnesota’s congressional delegation and reports on issues and developments in Washington, D.C. She can be reached at cdizikes[at]minnpost[dot]com.

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Comments (12)

  1. Submitted by Kyle Edwards on 07/30/2009 - 01:13 pm.

    Good job Keith, keep up the good work.

  2. Submitted by Richard Schulze on 07/30/2009 - 01:23 pm.

    We spend 2.3 trillion dollars per yr in this country on health care. Everyone agrees that it is too much and that we are bankrupting the country with this kind of spending.

    The problem is that everyone of those dollars is someones revenue stream. And they don’t want to give it up. What you’re seeing right now is the irresistible force of heath care reform meeting the immovable object which is a very powerful and very entrenched industry that counts on that revenue growing every year faster than inflation. Something has got to give.

    Between now and the fall, we will see battles waged far and wide over what health care reform will look like.

    If the answer is covering everyone and to not make changes to how we operate this incredibly expensive system. We will simply be throwing fuel on an existing fire.

    We need to reform the delivery system, to make it rational, fair and to make it more economically efficient.

    The power of the industry and the people that support it is incredibly formidable.
    We cannot afford to go with the status quo.
    We need to move from the status quo and change the trajectory of spending and the increasing number of uninsured.

  3. Submitted by Glenn Mesaros on 07/30/2009 - 03:23 pm.

    Obama health-care policy advisor Ezekiel Emanuel announced a new “Complete Lives System” for selecting which sections of the population should be killed, in his article “Principles for Allocation of Scarce Medical Interventions.”

    Published Jan. 31, 2009 in the British medical journal Lancet, Emanuel’s euthansia-selection article appeared 11 days after President Obama’s inauguration. Then on March 19, Emanuel was appointed to the Federal Coordinating Council on Comparative Effectiveness Research, to begin the design of a Federal system for withdrawing care from those chosen for death.

    Emanuel sums up who is to be treated, and who is to die:

    “When implemented, the complete lives system produces a priority curve on which individuals aged between roughly 15 and 40 years get the most substantial chance, whereas the youngest and oldest people get chances that are attenuated.” This may be justified by public opinion, since “broad consensus favours adolescents over very young infants, and young adults over very elderly people.”

    Emanuel decrees that we must not kill only the elderly, but also infants.

    “Strict youngest-first allocation directs scarce resources predominantly to infants. This approach seems incorrect. The death of a 20-year-old woman is intuitively worse than that of a 2-month-old girl, even though the baby has had less life. The 20-year-old has a much more developed personality than the infant, and has drawn upon the investment of others to begin as-yet-unfulfilled projects…. Adolescents have received substantial substantial education and parental care, investments that will be wasted without a complete life. Infants, by contrast, have not yet received these investments…. It is terrible when an infant dies, but worse, most people think, when a three-year-old child dies, and worse still when an adolescent does.”

    Ezekiel Emanuel is the brother of Obamacare chief of staff Rahm Emanuel.

  4. Submitted by Karen Sandness on 07/30/2009 - 03:29 pm.

    Like Clinton’s health care proposal, Obama’s is too complicated to be appealing. People want to know how the proposals will affect THEM, and such information is hard to come by.

    In trying to appease everyone, the administration is pleasing no one except the die-hard Obama fans. (I’m definitely left of center, but I find Obama timid about making use of his mandate and Democratic majority.) The House bill itself is 1000 pages long. I had to look long and hard for an executive summary, and even that isn’t clear on a number of points. I THINK that the proposal will be a wash for me, but I’m not sure.

    Furthermore, the current House bill is only one of several versions floating around.

    How is the public supposed to know whether they support it or not if can neither understand it in the first place nor figure out which version is under consideration?

    When I lived in Oregon, where they have the initiative system, an attorney with long experience in government told me that when voters can’t understand an initiative, they almost always vote “no.”

    Here’s my exercise for politicians interested in health care reform: Make up a proposal that you can summarize for the public in five sentences. Have explanations of the five sentences prepared for those who have further questions, but start with those five sentences that explain exactly how the proposal will affect the average American.

    If Americans can’t understand the bill, it’s easy for Republicans and moneyed interests to lie about them.

  5. Submitted by Tim Walker on 07/30/2009 - 04:02 pm.

    Glenn, you have completely mischaracterized Dr. Emanuel’s article by using loaded phrases such as “… selecting which sections of the population should be killed …” and “…we must not kill only the elderly, but also infants” and by calling it a “euthanasia-selection article.”

    The gist of the article is this: if we have a scarce medical resource (such as a flu vaccine), how do we decide who gets it?

    Somebody is going to have to make such decisions, Glenn, and in the case of a H1N1 flu vaccine, these decisions will likely need to be made real soon, like this fall.

    Believe it or not, Glenn, government officials will make these decisions, and they will make them regardless of whether a healthcare reform bill is passed or not.

    But you just had to jump all over a scholarly article that discusses all the ethical principles that should enter into such a real-world decision, didn’t you?

    I, for one, am glad that doctors are discussing these things now, Glenn, before the next flu season hits.

    Shame on you for unethically twisting a very good scientific article into a lame attempt at character assassination.

    Have you no sense of decency?

  6. Submitted by Bernice Vetsch on 07/30/2009 - 04:50 pm.

    (1) So America could, were it not for ideology and entrenched corporate interests, choose HR 676 and have FOR ALL AMERICAN RESIDENTS: all medically necessary care as decided by you and your doctor/provider; this care to include mental and dental health, in-home and long-term care; drugs and eyeglasses and special equipment like wheelchairs; and in the process save $400 billion per year while phasing out private insurance over the program’s first l0 years. (Plus, unlike the 1000-page bills now in consideration, HR 676 is only 13 pages long and is very straighforward.)

    (2) Instead, the president and the Congress seem determined to clone the Massachusetts Plan and inflict it on the other 49 states. This will cost over a trillion dollars instead of providing savings (probably even including all the cuts in care and payment being negotiated now); that will punish people financially for not buying insurance policies (nice break for those companies, all those new premiums rolling in); and that will “punish” larger companies with fines of a few hundred dollars for each employee they refuse to insure for thousands of dollars per year.

    Which of these two choices adds yet more private and public bureaucracy to our already overly complex system and irresponsibly adds billions to the national debt while failing to achieve universality? Why in the world can’t Congress see what is so clearly evident to the rest of the world?

  7. Submitted by Bill Coleman on 07/30/2009 - 05:17 pm.

    Who decides now who gets care? Obviously some people are not getting the care that is needed.

    Who decides when very sick very elderly people get too much treatment? What is the motivation for invasive, chest cracking surgery on people who might prefer a more peaceful passing?

    Our medical technology has provided many wonderful tools that can cure diseases and extend lives of 20 week fetuses and 100 year old nursing home residents.

    Someone is making these decision already- $500,000 to treat one very premature baby who will have life-long medical issues instead of proving $10,000 health insurance policies to 50 families.

    There are huge costs of paying for medical treatment of elderly in the last 90 days of their lives – not to make them comfortable, but rather to extend their lives by a few days, months or maybe a year or two maximum.

    Many people I know have been totally frustrated by the current medical decisionmaking that encourages one more procedure, one more try, on a parent or loved one instead of providing a setting where people can celebrate their bonds of family and friendship.

    There is a huge difference between killing someone and letting them die peacefully.

    Just because we can invent these medical advances does not mean that they are useful or affordable.

  8. Submitted by Glenn Mesaros on 07/31/2009 - 08:12 am.

    While the Obama White House pushes Congress to give an “Independent Medicare Advisory Commission (IMAC)” the power to cut medical treatments by cutting Medicare payments, they are not waiting for Congress. The already-existing Centers for Medicare and Medicaid Services (CMS) is making rulings to do the same thing.

    Obama and his chief bean-counter Peter Orszag want to make the CMS the ultimate force in driving Medicare and Medicaid spending down, able to overrule and cut even the IMAC decisions.

    CMS has just promulgated (on July 13) rulings for deep cuts in payments by Medicare/Medicaid to various medical specialists starting in five months, on Jan. 1, 2010. For example: Payments to X-ray, CT, and MRI/MRT scan technologists are to be cut by 30%, on top of a 23% cut enacted (approved by Congress) in 2005. Far fewer such tests will be made as a result, and fewer diseases detected at an early state. Another example: Payments to radiation oncologists are to be cut 20%, which would cause many cancer centers to close, stop accepting Medicare patients, and reduce services to all cancer patients, according to the American Society for Radiation Oncology.

    an alliance of cancer treatment support groups exposed, in a press conference today, that the cuts will actually cause radiation treatment centers throughout rural — and poor urban — districts to close down.

  9. Submitted by Glenn Mesaros on 08/01/2009 - 07:14 am.

    Ezekiel Emanuel, the top healthcare adviser at Obama’s Budget Office and brother of his chief of staff, believes it is “obvious” that people with Alzheimer’s or other forms of dementia (estimated as one of three people who live beyond the age of 65) should be denied health-care, since they are “irreversibly prevented from being or becoming participating citizens.” An essay published in the Hastings Center Report (Nov-Dec 1996) by Emanuel, Norman Daniels and Bruce Jennings, says in part:

    “This civic republican or deliberative democratic conception of the good provides both procedural and substantive insights for developing a just allocation of health care resources. Procedurally, it suggests the need for public forums to deliberate about which health services should be considered basic and should be socially guaranteed. Substantively, it suggests services that promote the continuation of the polity – those that ensure healthy future generations, ensure development of practical reasoning skills, and ensure full and active participation by citizens in public deliberation – are to be socially guaranteed as basic. Conversely, services provided to individuals who are irreversibly prevented from being or becoming participating citizens are not basic and should not be guaranteed. An obvious example is not guaranteeing health services to patients with dementia.”

  10. Submitted by Richard Schulze on 08/01/2009 - 01:02 pm.

    Mr. Mesaros:

    I seem to notice a pattern to most all your comments, and that would be that you snip and paste from the Lyndon LaRouche website.

    Do you think that your time would be better spent coming up with your own original and thought provoking ideas that might stimulate the conversation?

    Or do you think it might be appropriate to link your comments to the website from where you took them in order to give credit to where credit is due? Instead of giving the impression that your “comments” originate from your own thought processes?

  11. Submitted by Eric Ferguson on 08/02/2009 - 01:24 am.

    Here’s simple way to resolve the question of whether the health insurance reform bill includes euthanasia of senior citizens: quote the part of the bill that does that. Of course, there are multiple bills, not one “Obamacare” bill, but try telling that to the deathers. However, for Glenn and all the other deathers out there, I’ll accept a quote and link to any of the bills. If you can’t provide that, all you have is paranoid fantasy.

  12. Submitted by Tim Nelson on 08/04/2009 - 09:22 am.

    It’s a tough choice. Would I like to see Colin Peterson, the gadfly of agricultural welfare, or Keith Ellison, representing the far left, to be the most unhappy?

    I would like to try for both, if we can, and I know we can.

    Congress has a month to find enough cost cutting ideas to pass a good bill. Failing that, they will pass a bad bill.

    If Congress were smart, they would harvest the ideas that Jack Uldrich, and other futurists have put on-line for them.

    If Congress were smart.

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