Angie: December 2009 Archives

What do farming and medicine have in common?  In the latest edition of The New Yorker, Dr. Atul Gawande explores the parallels between agricultural cost control pilots in the early 1900s and the potential to use health care control pilots to control health care costs nearly 100 years later.  Just like the agricultural crisis in the early 20^th century,  Dr. Gawande that the current health care cost crisis also monopolizes a large percentages of the American economy, had "unmanageably costly sectors," and seems intractably difficult to remedy.    

In the absence of a sweeping solution to costs, the current health overhaul legislation pursues a piecemeal approach, cobbling together lots of pilot projects to see what works. Similarly, an  agricultural cost crisis in the early 1900s (when more than 40 percent of family income went toward food) eventually produced a medley of U.S. Department of Agriculture-run pilots, spurring Gawande's optimism that the similar "hodgepodge" of proposed pilots in the proposed health care legislation could have similar results.  Farmers quickly learned that following the pilot programs offered a solution to their cost problems.  For example, Texas farmers who followed a pilot program to improve soil quality and plant yield, quickly earned an additional $700 in the first year of the program and quickly expanded the program  to reap similar benefits in future years. 

Although Gawande doesn't address this in his article, we have previously reported in this blog that federal health care pilot programs, despite successful results, do not have a good history of being widely adopted. 

To read the entire article in The New Yorker, click here and for our previous blog post on health care pilots, click here. 

Debate on Senate health care reform bill continue this week, with the on again off again public option the subject of intense behind the scene negotiations.  Politico reports that a potential deal took shape on Monday that would put the public option on the chopping block in exchange for big expansions of Medicare and Medicaid.   The public option may still survive, but in a much weaker form:

[N]egotiators [are] still struggling to craft a compromise that could satisfy moderates worried about the too-heavy hand of government -- and liberals who would be giving up on their cherished goal of a federal health insurance safety net.

After five days of intensive talks among five moderates and five liberals, the outlines of a compromise aimed at appeasing both ends of the Democratic political spectrum were emerging: a plan designed to expand insurance coverage without creating a new government-run program.

The Senate has rejected an amendment proposed by Senators Ben Nelson (D-Nebraska)  and Orrin Hatch (R-Utah) that would have placed greater restrictions on funding for abortions in the Senate health reform bill.  From MSNBC:

By a vote of 54-45, the Senate sidetracked an amendment by Democratic Sen. Ben Nelson of Nebraska and Republican Sen. Orrin Hatch of Utah that would ban any insurance plan getting taxpayer dollars from offering abortion coverage. The restrictions mirrored provisions in the House-passed health care bill.  The Senate bill currently allows insurance plans to cover abortions, but requires that they can only be paid for with private money. The legislation calls for insurance plans that would receive federal subsidies in a new insurance marketplace to strictly separate public funds from private dollars that would be used to pay for abortion.

Last month the House approved abortion restriction similar to those in the Senate amendment in order to help secure passage of the bill.  The failure of this amendment to pass the Senate may sidetrack the entire bill.  Seven Democrats supported Senator Nelson's amendment and it is uncertain if they will vote for the bill without it.    

Read the full story here and read coverage from The New York Times here.

Friday's Wall Street Journal health blog  notes major physician organizations are divided on the Senate health care reform bill.  As reported earlier on this blog, the AMA sent a letter to Senate Majority Leader Harry Reid (D-Nevada) saying that it supported some but not all of the bill's provisions and that it would reserve judgment until the bill's final version is settled on. 

Among other things, the group likes that the bill makes insurance more accessible, eliminates copayments for certain preventive health services and increases research on which treatments are most effective.  AMA succeeded in keeping out of the bill some provisions that irked doctors. A Senate Finance Committee proposal to penalize doctors who administer the greatest quantities of test and treatments, designed to penalize over-users, didn't make it into the Senate bill.

But lots of other provisions that worry doctors did. AMA is against the bill's call to give more power to an independent commission that could cut Medicare spending. It's opposed to Medicare payment changes that take money from specialists' payments and increases pay for primary care doctors. It's also against reworking the Medicare payment system to reward doctors for producing better health outcomes, which is says can't be measured scientifically....

MSNBC is reporting the results of a new poll, showing that 59% of Americans are in favor of some kind of public option, but the poll also revealed serious doubts about Congress' ability to control costs or improve quality of care.   Highlights from the poll include the following:

·         Believe in public option: 59.9 percent yes, 40.1 percent no.

·         86 percent of Democrats support the public option versus 57 percent of Independents and 33 percent of Republicans.

·         Quality of healthcare will be better 12 months from now: 35 percent strongly disagree. 11.6 percent strongly agree. 29.9 percent put themselves in the middle.

·         Believe the amount of money spent on healthcare will be less 12 months from now: 52 percent strongly disagree, 13 percent strongly agree.

·         23 percent believe it will be easier for people to receive the care they need a year from now.

Read the full story here. 

Debate on H.R. 3590, the "Patient Protection and Affordable Care Act" continued this week and is expected to continue over the next two weeks.

As of Friday morning, 92 proposed amendments to the bill had been officially filed, although it is not certain how many of them will actually be voted upon.  So far, two amendments have been formally adopted: 

• An amendment by Sen. Barbara Mikulski (D-Md.) was adopted by a 61-39 vote to ensure coverage and eliminate co-payments and deductibles for certain preventive services for women. The Mikulski amendment requires health insurers to cover evidence-based recommendations supported by the Health Resources and Services Administration in addition to those receiving a rating of "A" or "B" by the U.S. Preventive Services Task Force (USPSTF). 


• An amendment written by Sen. David Vitter (R-La.), which was adopted as part of the Mikulski amendment, provides that the USPSTF recommendations on mammograms issued last month are not considered the most current, so those issued earlier are to be used.

In an effort to forge a compromise that will help win passage of the Senate health care reform bill, Senator Tom Carper (D-Delaware) has been working closely with liberal and conservative Democrats, as well as Sen. Olympia Snowe (R-Maine) to come up with yet another version public option.  It is believed  that the version of the public option currently in the bill does not have enough votes to pass.   As reported in The Hill,

Sensing that his bill may need changes, Reid recently called on Carper and Sens. Charles Schumer (D-N.Y.) and Mary Landrieu (D-La.) to come up with new legislative language on the hot-button issue of the public option.  Carper indicated that significant progress has been made and it is a question of when, not if, the new healthcare plan will be unveiled. Carper initially said an outline of his measure could be issued later this week, but later said it is more likely to emerge next week ....

As the Senate begins debate on its health reform bill, Kaiser Health News dug through the 2,074-page bill and found several special interest provisions that have thus far flown under the radar.  Congress has a long history of adding items that may not be able to get passed on their own to larger comprehensive bills that are more likely to be approved by both houses and the Senate health care reform bill is no exception.  Some of the special interest additions to the bill include the following:

Nursing Mothers Get A Break

Employers would be required to provide an unpaid "reasonable break time for nursing mothers" in the first year after giving birth. Women would be provided a private place, other than a bathroom, to use a breast pump. The provision exempts companies with fewer than 50 workers if the requirement would impose "an undue hardship," a determination left to the employer to make. To encourage businesses, the legislation would give them a tax credit toward the costs of providing a suitable space for women...

Learning To Be An Adult
Being a teenager is tough. The Senate wants to help with a provision allocating $400 million from 2010 to 2015 to help teens make the transition to adulthood.  The money goes to states primarily to set up sex education programs. But the money can also be used for "adult preparation" programs that promote "positive self esteem, relationship dynamics, friendships, dating, romantic involvement, marriage and family interaction...."

Retiree Health Benefits

The Senate bill includes a provision designed to ease out-of-pocket costs for retirees who are under 65 but who still get health insurance from their former employer.  The bill would create a temporary "reinsurance" program under which the government would pick up 80 percent of some high-cost insurance claims filed by retirees...

The AMA wrote a letter to Senate Majority Leader Harry Reid (D-Nev.) Dec. 1 concerning the Senate's proposed health system reform bill. The bill--in the form of a substitute amendment to H.R. 3590, the "Patient Protection and Affordable Care Act"--represents a melding of previous proposals reported by the Senate Committee on Health, Education, Labor, and Pensions and the Senate Finance Committee. In the letter, the AMA does not make a formal statement of support or opposition to the legislation in its current form. Given that Senate floor consideration is expected to last several weeks and the legislation will be amended, the AMA is reserving judgment on final passage of the Senate bill until later in the debate.

The AMA also released today a handy point by point comparison of the Senate and House health care reform bills along with AMA commentary on the major provisions.

Read the letter here and the AMA comparison of the Senate and House health care reform bills here. 

Debate has begun on the Senate's health care bill and the first proposed amendments have been introduced.  As reported in the Washington Post,

The initial amendments offered illustrated the legislation's vast scope and lingering vulnerabilities. The first, co-sponsored by Sens. Barbara A. Mikulski (D-Md.) and Olympia J. Snowe (R-Maine), would increase preventative health care for women at a 10-year cost of $940 million. One aim of the measure is to blunt concerns raised last month when an independent commission recommended that women undergo mammograms less frequently.   The second amendment, authored by Sen. John McCain (R-Ariz.), would strip out the bill's primary revenue source, nearly $500 billion in Medicare cost savings. Although AARP and other seniors groups have said otherwise, Republicans are attacking the cuts as a threat that could eventually shorten lives.

The debate over the Medicare amendment was especially heated, reports the Wall Street Journal:

In a November 28 editorial, The New York Times argues that even a weak public plan would be better than no public plan because it would expand the choices available to millions of Americans.  After first discussing the limitations of the public option as it currently exists in the House and Senate health care reform bills, the NYT concludes that even a weak public option would be worthwhile:

The presence of a public plan could serve as a brake on unwarranted premium increases by the private companies. The C.B.O. [Congressional Budget Office] said a public plan with negotiated rates would place "downward pressure on the premiums of private plans." A public plan would also provide a safe harbor for people who do not trust the insurance industry and would prefer a government plan even if its premiums were higher. And it would be a place to test innovative ideas for controlling costs and improving quality.

The C.B.O., a notably cautious evaluator, could be wrong in its assessments. The plan might turn out to be better at negotiating lower rates. And with no need to turn a profit, it might be able to charge less than private plans and attract millions more people than expected. That could force private plans to lower their own rates.

We are not holding our breath. The public plan could face enormous practical problems entering markets where private insurers already have well-established networks of providers or where hospital groups already have the upper hand in negotiating with insurers.

Even a weak public plan would be better than no public plan. It would expand the choices available to millions of Americans and could help slow the relentless increases in the cost of health insurance. Congress certainly owes Americans a more rational and informed debate.

Read the full editorial here. 

The Senate's health care overhaul bill would substantially reduce premium costs for 57 percent of people who buy subsidized coverage through new exchanges, while rates would hold steady or decline slightly for large and small employers, a long awaited analysis from the Congressional Budget Office showed today.

People who buy their own coverage but don't qualify for government subsidies, however, could see increases of 10 percent to 13 percent, mainly because the coverage offered in the exchanges would cover more benefits compared with what is currently purchased, and thus would be more expensive.

Read the full CBO report here.