Transparency v. PAYGO in Health Reform Legislation

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One of the looming questions for health reform legislation in the 111th Congress is how will it be paid for?  Or will that be less of a concern because deficit spending in a recession is deemed to be OK?

In earlier times, (i.e., 1990s), the projected costs of legislation had to be “paid-for” under the so-called PAYGO rules – which stands for “pay-as-you-go.”  However, in recent years those rules have lapsed or been waived.

Three recent nuggets of information indicate that transparency in the legislative process may be replacing PAYGO in the coming years.  First was the Obama Transition Team’s extra-ordinary level of transparency, exemplified by their policy of having information from all meetings with outside groups being posted on the Change.gov…

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Health Reform in a Changed Political and Policy Environment

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Several pieces of information and events have recently made me appreciate how the policy and political environment for health reform will be very different in 2009 from what we’ve seen before.

First was an article in the November 22nd issue of National Journal, (“The New Power Landscape”), which describes how the process for influencing legislation (a.k.a. lobbying) will be different in the coming years: “On the way in is a more collaborative approach that relies on identifying allies and building coalitions with other interest groups, as well as grassroots organizing.”  The article specifically posits that the importance of access to influential people, (i.e.…

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McCain Plan Would Tax 100% of Health Insurance Costs

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I had a revelation tonight at an event about women’s health issues in the Presidential election at the Kennedy School of Government’s Institute of Politics.  One of the speakers was Gail Wilensky – a Senior Health Care Advisor to Senator McCain’s campaign. I asked her a question about how Senator McCain’s proposal to eliminate the tax deduction for employer provided health benefits would effect non-profit organizations since they don’t pay taxes.

Gail Wilensky’s answer really shocked me.  I’ve been doing health policy work for about 20 years, and following the election’s health issues for the last year.  What she said was that it wouldn’t matter whether the person worked for a non-profit or a for-profit company, since the employee would be the one paying tax on the entire cost of their health insurance – whether it was their contribution, or dollars coming from their employer.…

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ERISA: The Unbridged Chasm of Health Reform – Challenges for Massachusetts and Federal Action

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A recent Boston Globe article about a possible legal challenge to Masschusetts’ health reform initiative indirectly raised one of the most stubborn challenges in health reform:  The Federal ERISA law.  (See below for more about ERISA.)

The contentious issue in Massachusetts is a proposal to require employers to both pay at least 33% of full time employees’ health insurance premiums and ensure that at least 25% of their employees are covered by their health plan. (The current requirement is that they do one or the other.) So why should this difference be the basis for a law suit?  Actually, there isn’t really any legal difference. …

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Cutting Medicare Physician Payments – Beyond the 10.6%

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The focus on Medicare payments to physicians for the last six months has been on the 0.5% increase Congress enacted for the first 6 months of 2008 to replace the 10.1% reduction that would have occurred under Medicare’s Sustainable Growth Rate (SGR) formula. Legislation to continue this rate for the rest of the year failed a required procedural vote in the Senate last week.* This leaves Medicare physician payments after June 30th uncertain – although it is expected that Congress will do something in the next week, or three.

However, beyond the impending Medicare 10.6% reimbursement reduction for all physicians, the Graham Center of American Academy of Family Physicians published a short report on June 13th that expands the analysis to include pending change in how Medicare reimburses physicians in Physician Scarcity Areas (PSAs), and Health Professional Shortage Areas (HPSAs).…

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Health Care Cost Containment – Reality versus Rhetoric

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Cost Containment
Controlling Healthcare Costs
Reducing Health care Spending
Eliminating Waste, Fraud and Abuse
Creating More Value from Healthcare Spending
Increasing Cost Effectiveness for the Healthcare Dollar

These are the types of headlines and catch phrases that we are going to see over the next 6 months as the healthcare focus in the 2008 elections zeros in on spending and costs.

A couple of weeks ago I wrote about how the economy has become the #1 issues of concern for the 2008 elections. Because of this, costs and spending will be the major focus for the political debate about healthcare reform.…

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A Perfect Stormy Mess for Health Reform

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A year ago the hype in healthcare was about state-based reform initiatives. Massachusetts was implementing its law, and several other states – including California – were considering their own proposals for increasing insurance coverage as a first step towards universal coverage and cost containment.

How things have changed in a year. Not only has California’s initiative crumbled under the expected costs to employers, but the economic downturn has undercut states’ healthcare expansion ideas, and may force them to cut back Medicaid enrollment and/or services. This week’s National Journal has an article titled “State’s Rapidly Shifting Gears,” that discusses these and other issues, including how a few years ago states cut their Medicaid payments to providers, so that on average Medicaid pays physicians 69% of Medicare levels, and how pending Federal Medicaid rules and proposals would reduce funding for State Medicaid programs making it difficult for states to reverse these payment reductions.…

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Evidence Based Medicine – NICE or Nasty?

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The US Medicare Payment Advisory Commission (MedPAC) recently released a report on “Creating a Center for Evidence-Based Medicine” that was prepared by an outside analysis group. Before dissecting the MedPAC report, let me just lay out some of the more controversial aspects of evidence-based medicine (EBM):

  • How are the results of EBM research used for coverage or payment?
  • Are the EBM conclusions based upon reviews of prior studies or on research done specifically for the EBM analyses?
  • Are the EBM conclusions relevant only for a clinical research situation, or do they reflect real-world practices?
  • All medical practices evolve and “best medical practices” are reflected last in textbooks…..
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NPR Story on Presidential Candidates’ Health Plans

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I caught part of the report on NPR this morning about the Presidential candidates’ positions on healthcare. The gist of the story was that Clinton favors more extensive individual mandates than Obama (who only favors mandates to cover children), while McCain favors tax credits to make health insurance more affordable.

Whoever becomes the next President, something will clearly be different starting in 2009. Regardless of the candidates’ campaign/political statements, the next President’s actions on healthcare (unlike in foreign affairs), will largely depend on what they can negotiate with the next Congress – which seems like it will be more Democratic than it is currently, but probably not with 60 Senators to force votes on matters that the minority finds objectionable.…

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