Editor’s Note: In the post below, Tim Jost looks at provisions of the Senate Democratic health reform bill dealing with Medicare, Medicaid and CHIP, and many other significant topics. In earlier posts, Jost took a first look at the Senate bill, provided a detailed look at several issues that arise under the bill’s insurance reforms, and discussed abortion coverage and the constitutionality of the individual mandate.

My first three posts have dealt with Title I of the Senate bill, which contains the insurance reform, mandate, and affordability subsidy provisions of the bill.  Title I is only the first of nine titles of the bill, however.  This post will present an overview of the remaining eight titles of the bill, which deal with Medicaid and CHIP; Medicare (focusing on quality and efficiency); prevention, wellness, and public health; the health care workforce; transparency and program integrity; improving access to innovative therapies; and the CLASS (community living assistance services and support) program.  The revenue provisions of the bill will not be examined. Read the rest of this entry »

Editor’s Note: In the post below, Tim Jost looks at how the Senate Democratic health reform bill treats abortion coverage, and also at the question of the individual mandate’s constitutionality. In earlier posts, Jost took a first look at the Senate legislation and provided a detailed look at several issues that arise under the bill’s insurance reforms. In a later post, Jost looks at the bill’s provisions on Medicare and other topics.

Abortion. Early drafts of the health reform legislation attempted to ignore the issue of abortion, but in American politics, abortion is an issue that refuses to be ignored.  The problem is that current federal law only permits public funding for abortions involving rape, incest, or physical endangerment to the life of the mother.  Many private plans, however–perhaps most—cover all medically necessary abortion. 

Once federal premium subsidies are made available to purchase private insurance, therefore, the problem becomes whether to ban subsidies for any plan that covers abortion, thus significantly reducing private coverage for abortion, or to try to segregate in some way the premium subsidies, allowing private plans to still cover abortion but only with private funds.  The Capps Amendment, adopted by the House Energy and Commerce Committee tried the second approach. The full House adopted instead the Stupak Amendment, which adopted the former approach.  The Senate bill is closer to the Capps Amendment. Read the rest of this entry »

Editor’s Note: In the post below, Tim Jost provides a detailed look at several issues that arise under the insurance reforms included in the Senate Democratic health reform bill. In an earlier post, Jost provided a first look at the bill. In a third post, Jost looks at how the bill treats abortion coverage and also at the question of the individual mandate’s constitutionality. In a final post, Jost looks at the legislation’s provisions on Medicare and other topics.

My first post presented a broad overview of the Senate bill, HR 3590 and a more detailed analysis of the bill’s provisions that go into effect prior to the 2014 general effective date.  This post will examine in detail four additional issues that arise under the bill’s insurance reforms.  There are 1) how the bill addresses implementation, administration, and enforcement; 2) the different categories of insurance coverage available under the bill and the requirements that attach to them; 3) how the exchanges function and the various types of coverage they will offer; and 4) the risk adjustment programs the bill creates.

Implementation, Administration, and Enforcement

The immediate addressee of most of the provisions of Title I of the Senate bill, “Quality, Affordable Health Care for All Americans,” is the “Secretary,” by which is meant the Secretary of Health and Human Services.  The House bill creates a new federal agency, the Health Choices Administration, whose Commissioner is primarily responsible for implementing the legislation.  The Senate bill, by contrast, calls on existing federal agencies to implement the bill, primarily HHS, but also the Department of the Treasury, which would implement the excise taxes imposed by the bill’s individual and employer mandates; the Department of Labor, which assists with the implementation of the provisions of the bill dealing with employment-related health plans; and the Department of Homeland Security, which helps to ensure that unauthorized aliens do not in any way benefit from the legislation.  Read the rest of this entry »

Editor’s Note: In the post below, Tim Jost takes a first look at the Senate Democratic health reform legislation. In a second post, Jost provides a detailed look at several issues that arise under the bill’s insurance reforms. In a third post, Jost looks at how the bill treats abortion coverage and also at the question of the individual mandate’s constitutionality. In a final post, Jost examines the bill’s provisions on Medicare and other subjects.

As readers of Health Affairs are undoubtedly already aware, the Senate Democratic leadership has released HR 3590, the 2,074-page Patient Protection and Affordable Care Act.  The bill combines the Senate Health, Education, Labor, and Pensions (HELP) Committee bill marked up this summer and the Senate Finance Committee bill marked up earlier this fall.  On the whole, the combined bill resembles the Finance bill more closely than the HELP bill, but it does include important elements from the HELP bill, the most prominent of which is provision for the community health insurance (public) option. 

As has been widely reported, the CBO has scored the gross cost of the coverage provisions of the Senate bill at $848 billion over 10 years, less than the cost of the House bill, and as reducing the budget deficit by $130 billion over 10 years.  The CBO also projects that the bill would reduce the number of uninsured by 31 million by 2019, leaving 24 million nonelderly Americans uninsured.  The bill would cover 92% of the nonelderly population–94% of the nonelderly population excluding unauthorized immigrants. 

This post will describe the new programs and regulatory requirements that would take effect immediately under the bill and briefly summarize HR 3590’s insurance reform, affordability, and mandate provisions.  My next post will take a closer look at the bill’s insurance reforms, including the exchanges, public plan, cooperatives, and other insurance options created by the bill.  A third and possibly fourth post will analyze the Medicaid, Medicare, quality, public health, workforce, program integrity, innovative medical therapy access, “CLASS Act,” and revenue provisions of the bill.  I will not address the politics of the legislation, which will be closely followed and breathlessly reported by the media. Read the rest of this entry »

Editor’s Note: In the post below, John Wennberg and Shannon Brownlee discuss the controversy over a proposed study of regional variations in Medicare spending. Wennberg and Brownlee rebut claims that spending and utilization variations among academic medical centers are due to differences in patient income, race, and health status. In another post coming next week, Wennberg and Brownlee will rebut claims that academic medical centers with higher utilization and spending produce better outcomes.

To the casual observer of health care reform legislation, the reaction from several prominent medical centers to a modest provision in the House health reform bill might seem perplexing. The bill provides funding for a two-year study by the Institute of Medicine (IOM) looking at regional variation in Medicare spending, something that has been documented several times over by the Dartmouth Atlas.

It’s a seemingly sensible provision, yet the response from more than a dozen academic medical centers makes it seem as if this study represents a major threat to the lives of thousands of patients. In op-eds, blogs, letters to members of Congress, broadsides in the press, and now in a report from the American Hospital Association, administrators and physicians decry both the Dartmouth Atlas’ findings and the proposed IOM study as a threat to “the future quality of American health care” and a lot of “malarkey.”

Of course, it isn’t the Dartmouth Atlas or the study that these medical centers object to, but rather what the Centers for Medicare and Medicaid Services (CMS) might do with the information. The House bill gives CMS the power to use the results of the IOM study to rein in Medicare spending by rewarding more efficient providers – those that use fewer medical services to care for a given population while maintaining equal or better outcomes compared with the national average. CMS would also be permitted to clamp down on reimbursements to providers that are less efficient. Read the rest of this entry »

From the very beginning, a central tenet of health care reform was that no one would lose coverage they already have. That’s why so many women are outraged by the Stupak amendment to the health reform legislation recently passed by the House.  It goes against one of the fundamental tenets of health care reform: do not leave anyone worse off than they were before reform.   

Under the Stupak amendment, millions of women would either lose access to health care benefits, or worse, lose benefits they currently have if they purchase health insurance in the new exchange. The Stupak amendment prohibits any coverage of abortion in the public option and prohibits anyone receiving a federal subsidy from purchasing a health insurance plan that includes abortion coverage. It also prohibits private health insurance companies participating in the exchange from offering a plan that includes abortion coverage to both subsidized and unsubsidized individuals.

This leaves few possibilities for abortion coverage: An insurance company could offer a separate plan for women without subsidies that includes abortion coverage in its basic package. Also, an insurer could theoretically offer a single-procedure rider for abortion coverage, separate and apart from its broader health insurance policies. At best, the logistics involved make this a highly unlikely option. At worst, other provisions of the bill actually prevent health plans from doing so. Read the rest of this entry »

Editor’s Note: In addition to John Wennberg and Shannon Brownlee (photos and bios above), authors of this post include James Weinstein, MS, DO, and Elliott Fisher, MD, MPH. Weinstein is chair of the Department of Orthopaedic Surgery at the Dartmouth-Hitchcock Medical Center. Fisher is Director of the Center for Population Health at The Dartmouth Institute for Health Policy and Clinical Practice and Professor of Medicine and of Community and Family Medicine at Dartmouth Medical School.

Now that Congress appears to be on its way to passing some sort of health insurance reform legislation, attention is turning to our dysfunctional, disorganized, and wasteful delivery system.

Both the House and Senate bills contain a little something for everyone in terms of delivery system reform, but how close they come to fulfilling that ambition will depend in large measure upon achieving four major goals:

1. Improving the science of health care delivery;
2. Fostering the expansion of organized systems of care;
3. Establishing informed patient choice as the standard of care for elective surgeries, tests, and procedures;
4. Constraining the undisciplined growth in health care capacity and spending.

A Science Of Health Care Delivery

Both House and Senate bills would create new institutes (the Patient Centered Outcomes Research Institute in the Senate Finance Committee bill), aimed at providing much needed comparative effectiveness research. While such research is necessary for improving outcomes, it is not sufficient. The nation’s research priorities must also include the development of a science of health care delivery, which is currently a black box. Patients with similar conditions are treated in very different ways by different providers, few of whom devote any research effort at all to determining how best to allocate resources and how to achieve the most effective care pathways. Read the rest of this entry »

Editor’s Note: This is Tim Jost’s fourth post examining HR 3962, the House’s health reform legislation. Previous posts focused on measure’s health care financing reforms, the legislation’s provisions for an insurance exchange and a ”public option,” and HR 3962’s delivery system reforms and other provisions.

How did HR 3962 change on Saturday night?

As everyone knows by now, the House passed HR 3962, the Affordable Health Care for America Act, late Saturday night, November 7 by a vote of 220 to 215.  I examined the contents in the original HR 3962 in three posts late last month.  Prior to passing the bill, the House adopted both a manager’s amendment and the Stupak abortion amendment.  It also rejected a Republican substitute amendment and a Republican motion to recommit with instructions.  This post briefly describes the amendments to HR 3962 that the House adopted prior to passing the legislation.

The most important amendment was the Stupak amendment, which the House adopted by a vote of 240 to 194.  All but one Republican voted for the amendment (one voted present), as did sixty-four Democrats.  The Stupak amendment extends to all health services funded under the Act the prohibition found in the current Hyde Amendment, which forbids Medicaid payments for abortion except in cases of pregnancies caused by rape or incest or where the pregnant woman’s life is endangered by physical disorder, illness, or injury. Read the rest of this entry »

Editor’s Note: What follows is the transcript of a roundtable on public opinion and health reform that took place on October 13,  the day the Senate Finance Committee approved its version of health reform legislation. Participants included Bob Blendon, professor of health policy and political analysis at Harvard; Chad Bohnert, director of marketing and e-commerce at Zogby International; Mollyann Brodie, vice president, public opinion and survey research, at the Kaiser Family Foundation; and Bill McInturff, partner and co-founder at Public Opinion Strategies. Highlights of the roundtable are also available.

CHRIS FLEMING:  Thank you all for joining us. I’d like to address the first question to Bob Blendon. Bob, obviously this is a pretty momentous day in the health reform process.  The Senate Finance Committee is set to approve its version of the health reform bill.  Could you give us your assessment where you think things stand now in terms of public opinion?

BOB BLENDON:  My take is relatively simple.  The public expects some bill to be enacted.  There’s a real sense that something has to happen.  The problem is this: If you look at polls that were taken in the last eight days which asked about the legislation that was being considered before the Congress, or the president put forward, not one of them has majority public support. So what you have is the sense that the public wants a healthcare bill to be passed.  As a result, I can’t imagine something not coming out of this Congress.  But there’s a lot of concern about what’s included in these bills, and the concerns are around issues that are not all about if there is a public plan or employer mandate. They are about the cost of services for people, concerns about taxes, about the deficit, about Medicare cuts.  So I believe there will be a lot of public concern about the final legislation that emerges. The bottom line is we’re moving towards a final bill, but the desired content of it in the public’s mind is not settled. Read the rest of this entry »

Editor’s Note: Tim Jost wrote 3 posts analyzing the House health reform bill HR 3962. The first looks at financing reforms, the second post delves into the public option, health insurance exchanges, and more. A new 4th post analyzes what changed in the bill the House approved Saturday night.

In this final post, I will explore the remaining 1600 pages of HR 3962.  Although these provisions have received less attention (except from the interest groups immediately affected by them), they will in fact work important changes in the American health care system.

First, however, I will mention a few provisions buried in the health care financing reform provisions—the first 400 pages of the bill—that are worth noting.  First, the “compromise” worked out on abortion in the Energy and Commerce Committee is included in the bill. Currently federal funds cannot be used to pay for abortion except in cases of rape, incest, or life endangerment.  But, according to some reports, most private insurance plans cover abortion. If private plans are to be more heavily regulated and funded through premium subsidies, what affect will this have on abortion?

HR 3962 prohibits the requirement of abortion as an essential service that must be covered by private health plans or by the public plan.  The bill also prohibits the use of affordability subsidies to pay for an abortion, although the bill does not contain the accounting procedures that the Senate Finance bill uses to implement this requirement.  The federal and state governments may not discriminate against providers or plans for refusing to cover, provide, or refer for abortions (although the government is not prohibited from discriminating against those that do).  Exchanges may not discriminate against plans that cover or refuse to cover abortions.  Federal and state abortion and conscience protection laws are expressly not preempted.  In sum, the abortion issue is addressed but neither side of this contentious issue is likely to be satisfied. Read the rest of this entry »