Thursday, October 29, 2009

Revised House bill would expand Medicaid, offer public option, cover 96%, and lower the deficit

Today, Speaker of the House Nancy Pelosi (D-CA) released a new version of the health care reform legislation that is derived from an earlier bill (H.R. 3200) approved by the House's three health committees. I am still making my way through the bill, so will have more to say about it in future posts. As reported in The Washington Post, the bill is likely to attract broad support among Democrats but no Republican votes.

The biggest difference with H.R. 3200 is that the bill expands Medicaid to all persons up to 150 percent of the federal poverty level, instead of 133% in the earlier bill. Medicaid, once the poor sister of the popular Medicare program, would now be the single largest source of health insurance in the United States. To increase physician participation in Medicaid, the bill would increase Medicaid payments to primary care physicians over several years until they at least equal Medicare pay rates in all states.

It is also substantially less expensive than H.R. 3200, with an estimated cost of less than $900 billion over 10 years, according to the CBO, and would reduce the deficit by $104 billion over the same ten years. One reason that the cost has gone down is that it is cheaper to enroll people in Medicaid than to offer them subsidies to buy private health insurance coverage. It also removes the cost of repealing the Medicare SGR physician pay formula from the legislation; instead, the House leadership has introduced a separate bill that would repeal the SGR and create two separate spending targets, a higher one for evaluation and management and preventives services, and a lower one for all other services, although both categories would be allowed to grow faster than under the current SGR. How the House plans to move the SGR bill outside of health reform legislation remains to be seen.

The bill includes a permanent 5% Medicare bonus for office and hospital visits provided by primary care physicians, 10% in health professional shortage areas. There would be a modest expansion of graduate medical education (GME) training positions for primary care, and new and expanded loan repayment for primary care clinicians who satisfy a service obligation.

And, on the public plan, the new bill would offer individuals who qualify for subsidized coverage the ability to enroll in a government-administered plan that would negotiate its payment rates with physicians and hospitals instead of using the Medicare rates.

Today's question: What is your initial reaction to the new health reform bill?


Steve Lucas said...

My concern is cost and the governments inability to control cost. From the Review & Outlook section of the Oct. 20 WSJ we find the first item in the chart in the center of the column:

Medicare Year 1965 PREDICTED COST $12B ACTUAL COST $110B

Moving the SGR becomes accounting sleight of hand.

This does not appear to be clear and transparent.

Steve Lucas

Unknown said...

Spelling corrected!!

Agree with Steve that cost isn't effectively addressed. Having said that, there are positives for IM:

* The public plan is not tied to Medicare/Medicaid rates, but must be negotiated with providers
* Moving Medicaid payments to Medicare rates for primary care
* 5% bump in PC payments
* Support for PC training
* Covering 96% of US citizens
and the Senate bill includes better measures to control costs:
* Independent Medicare Commission
* Tax on high priced health plans

So we are at (or nearly at) a "moment of truth" to quote Paul Krugman NYT column today. "It’s not a perfect bill, by a long shot, but it’s a much stronger bill than almost anyone expected to emerge even a few weeks ago. And it would lead to near-universal coverage."

I agree with Krugman (and I usually disagree with him). The status quo is just not sustainable and the process to get to this point has been laborious and painful. It is the last swing of the bat on health care for years. It's this OR the status quo.

I support getting on board with these 2 bills and putting college efforts into getting our voice into the final discussions and influincing the subsequent regulatory processes.

Rich Neubauer MD said...

Perhaps the most remarkable thing about the new house bill is that we are all still here talking about health care reform actually happening. After all the ups and downs, the sad moments when it seemed it would all simply fall apart, and the (few) exhilarating moments in the debate, we may be approaching a conclusion.

I agree that the lack of meaningful cost control is disturbing, but as I’ve said in other postings, I think this will have to come later and it is likely to engender another long arduous painful discussion.

I don’t think there is enough in the current bills to turn around the primary care crisis, but I also think the things that need to be done to do that cannot happen unless we start with the system reforms now under discussion. I think ACP should continue to push until the bitter end for the most robust primary care provisions possible in the current legislation. The more we get done now the further along we will be in coming years as primary care and access issues continue.

The role of small practices in this country is high on the list of concerns from our members, and for good reasons. We are clearly in a time of upheaval and that is not comfortable or reassuring. However, ACP has positioned itself to be a strong and important advocate for what is right for patients, and at the same time has been an advocate for how internists as professionals can survive in a tough and changing environment. The discussion of Accountable Care Organizations and how small practices can succeed will be an important and ongoing discussion and ACP is well positioned to be a strong voice in that discussion.

I agree with David. There are many things here that prompt us to support this first important step in reforming the health care system even as we hold our noses on some things and express disappointment that the changes do not address some fundamental things of great import. The status quo is a completely unacceptable alternative.