Health Policy

Alex Wayne writes about health policy for CQ Today and CQ Weekly. He's covered domestic policy for Congressional Quarterly for five years, and before that worked for newspapers in North Carolina and Florida.

This discussion is over, but please read the transcript below.

• Jen from Portland ME: Hi Alex - What do you anticipate will happen over the next few months in Congress and how involved will the WH be in the drafting of House and Senate health reform bills? Will Congress pass a Budget Resolution after the detailed Budget is released with a larger reserve fund? Thanks.
• Alex Wayne: Congress is going to kick off a long series of hearings on issues related to a health overhaul (we don't use the word "reform" around here) next week. We should have some bills to pore through by summer, and the House might actually pass something by August.
  
  
  
  I don't think you're going to see a White House bill. Obama's probably made his definitive statement on health reform with his budget, last week. But they'll continue to publicly nudge Congress to act when they feel the need, and Obama's people are going to be in all the important meetings, I'm sure.
  
  
  I don't think Congress will go bigger on the reserve fund. More likely, the Blue Dogs force Democrats to go smaller. And it looks like the congressional resolution might actually pass before Obama's detailed budget comes out, curiously.
• Pat from Stevensville, MI: Because it does not matter what policies are proposed, there is going to be questions and opposition. Why do we just go for Universal Care Coverage for everyone and forget about basketful of policies that will take a lawyer to figure out?
• Alex Wayne: That's exactly what insurers have proposed: pass an individual mandate requiring everyone to purchase insurance, and they'll agree to cover anyone, pre-existing conditions notwithstanding. ("Guaranteed issue," for the wonks.)
  Kind of a "do the minimum, and leave the details to us" sort of proposal. I haven't seen much interest in Congress.
• Walt from Vernon, CT: Who will determine if euthanasia is an economical solution to end game expenses?
• Alex Wayne: There's not much that's certain in the health care debate, but this I can promise: unless you're talking about stray animals, Congress isn't going to entertain any serious discussion of euthanasia.
• MJ on Capitol Hill:

  I think people don't understand the Obama health care plan.

  Most people see it as either do nothing, or universal health care covered by the government. Who would get covered under Obama's plan?

  More importantly, is there a slippery slope here in which employers become less likely to offer good health benefits if they believe the government is stepping in for the uninsured? And third, if we switch to a complete government system some day, what are the odds that my employer will raise my pay comensurate with the $4,000 employer portion of my current plan?

• Alex Wayne: So officially, there is no "Obama health care plan." All he's proposed is that Congress should spend $634 billion over the next ten years to begin overhauling the system, and oh by the way, here are some guidelines as you lawmakers develop the policy (reduce costs, improve quality, let people keep their employer-sponsored insurance, etc.)
  Republicans and business lobbyists are very concerned that a big expansion of public health insurance programs (Medicaid, Medicare, or something new) could weaken the employer-sponsored health insurance system.
  
  I think that if the government created what's being called a "public plan option" to compete with private insurance, then yes, you would probably see either some employees dropping their employer's insurance -- or some employers opting not to offer it.
  
  Whether employers would start paying increased salaries in place of the health insurance they no longer have to offer is probably a question that would be decided by negotiations between workers and their employers. (Congress could legislate it, but I sort of suspect they wouldn't.) Obama's budget director, Peter Orszag, thinks that higher pay would be the natural outcome of a comprehensive health care overhaul (i.e., one that reduces costs and expands coverage) -- and that a lot of people don't currently realize the extent to which their take-home pay is reduced because of health costs. 
• Linda from CA: Would the Physical/Occupational/Speech Language Pathology therapy caps be addressed (rescinded?) in the new policy?
• Alex Wayne:

  That specific issue is not addressed in Obama's budget. (The detailed charts -- the good stuff -- are at the end.)

  But if you're a health provider, it's probably safe to assume that someone in Congress is interested in messing with the way you're reimbursed under government health programs. There's a high interest among lawmakers in coming up with new payment systems that reward "performance" -- meaning health outcomes, if they can figure out how to fairly and accurately measure those.

• Dominic in NY: What causes the cost of a procedures to vary widely across the country? I am talking about apples to apples comparison by procedure code. I recently had a kidney stone blasted (procedure called lithotripsy, code 50590) and the hospital billed it a rate 5x the rate of my previous procedure, and it was paid at 16x my previous procedure. Is there a clearinghouse for data on these kind of costs that a consumer could use to cost compare?
• Alex Wayne:

  Obama's budget director, Peter Orszag, is very interested in these sorts of questions.

  He says that the wide variation in the cost of care across the country correlates very closely with the number of specialists in different areas. In a place like New York or Los Angeles or Miami, a patient might bounce between a number of different specialists without ever visiting her family physician. So her care won't be very well coordinated. In a place like North Dakota, on the other hand, the thinking goes that more doctors are general practitioners, and they do more care coordination -- talking with specialists to make sure everyone's on the same page about a patient's course of treatment.
  
  
  As for a clearinghouse: There isn't one. (Some lawmakers would like to make one.) You can dig through the fee schedules at CMS' Web site, but good luck finding what you're looking for. Medicare's consumer site isn't very helpful, either; it's almost as if the government doesn't want people to know what it's paying for your health care. 
  Crazy talk, I know.
• Sally, northern New Jersey:

  Currently, it is hard to find health-care practitioners who will accept Medicare and Medicaid rates unless you have supplemental private insurance.

  How can you justify cutting these rates and still expect to have practitioners participate in a public program that competes with private programs? Shouldn't all rates be set at a figure based on actual cost, somewhere between the current low of public programs and the current high of the most expensive private programs?

• Alex Wayne: I don't know that your supposition is completely accurate.
  Medicaid is infamously low-paying, and you're correct with regard to that program -- in many areas, there seems to be a shortage of doctors and dentists who accept Medicaid.
  But Medicare pays much better than many private health insurance plans. My doctor, in fact, told me the other day that he'd be happy to work in a "Medicare-for-all" system -- he noted pointedly that Medicare pays better than, say, United Health Care's HMO (my insurer). 
  
  
  
  
  Not saying all docs feel that way, but a good number seem to.
• Bonnie from Bethesda: How will reform impact the care and pocketbooks of those who currently have good health insurance through their employers?
• Alex Wayne: Obama says in his budget that people who have insurance through their employers and like it should be allowed to keep it under any overhaul. But if you make $200,000 or more (or $250,000 for a couple), you would pay higher taxes under his plan, too.
  There might be further effects on those who already have good insurance ... I suppose you might see more crowded doctors' offices, since up to 46 or 47 million Americans without insurance would suddenly have it. And depending on the changes Congress makes to provider payments as part of an overhaul, it might be easier or more difficult to get some kinds of procedures, drugs and other treatments.
  
  
  We won't really know until the legislation is developed.
• Linda from Miford CT :

  Malpractice insurance premiums are always a concern for doctors and hospitals. If we are going to get a grip on costs that ultimately will cap charges as Medicare does now. Perhaps a national non profit insurance pool like our national flood insurance program would be a fair trade for medical professionals to have available. 

  ...   Is this something being considered ?

• Alex Wayne:

  This is a good question on a subject that I frankly don't know a lot about. "Tort reform" generally isn't a priority for most Democrats, but Republicans are still interested in it. Obama didn't include malpractice issues among the eight "principles" for a health care overhaul that he included in his budget -- he's much more focused on patient/consumer concerns than providers. 

  However, the issue was raised at his health forum yesterday, and Obama indicated at least some interest. Here's what he said in his closing remarks, as he was summarizing the discussion:

  "Last set of points that we thought were notable:  Senators Grassley and Hatch and Congressman Dingell all discussed the need to address medical malpractice and reduce defensive medicine as a cost saving measure."

• Moderator: Thanks for joining us in our "Live Online" chat about federal health policy and the bills moving through Congress. Let the conversation begin!
• Alex Wayne: Great to be here, and thanks for sparing some of your Friday afternoon to talk health policy. I'll try to answer everything, even after the chat officially ends, so be sure to check back later to see if I got to you. Let's do this thing up Bill Simmons-style!
• Susan from Maryland: How does a citizen find out where and how the states are spending the FMAP?
• Alex Wayne: I'd start with your state's budget documents for the details. You won't find that kind of information in the federal budget -- even the detailed one that will come out in April. You might also poke around at CMS' Medicaid page.
  And the Kaiser Family Foundation is a great source of information on Medicaid, although perhaps not at the level of detail you're looking for.
• Drew from Boston:  Many if not most parts of the US have a shortage of primary care doctors, gynecologists, emergency care,and other specialties. In short, the demand is now less than supply and demand will continue to grow. We are embarking on the path of significantly increasing our investment in health care. Considering the shortage of doctors and the high cost of their education, does it make sense for government to make medical education free for those who qualify?
• Alex Wayne: Doctors are paid as handsomely as they are today in part because of the high expense of their education; many of them face years of indebtedness once they enter professional practice. So I would suggest that if Congress were to consider a policy of free medical education for all those who qualify, doctors might also have to accept significantly lower remuneration.
  Knowing Congress, doctors who took advantage of such a program also could expect significant strings attached; at the least, I could see Congress specifying quotas in different specialties.

  This isn't a policy proposal that I've heard discussed at all in Washington, by the way.
• Ben from DC: With government healthcare expenditures already soaring, why is the Obama administration planning to spend even more?
• Alex Wayne: Here's how the argument goes:
  Government health care expenditures are soaring because the existing programs are massively inefficient. Payment systems don't reward quality care and might even encourage bad care. The costs are wildly different to treat the same condition in different parts of the country -- even though there's no real differences in outcomes. 
  So Obama wants to spend more money over the next ten years in order to take care of most or all of the uninsured (numbering around 47 million or more today), and at the same time change policy in the existing health programs (Medicare and Medicaid, primarily) to make them more efficient. The expectation is that over the long term -- more than a decade -- the money we save by increasing efficiency will balance out the money we spend to get everyone covered and improve the system.
  We'll still be spending a heck of a lot on health care under any scenario, but Obama and his allies think we could spend it a lot better. 
• Richard from La Jolla: How did Max Baucus get to be in charge of health care reform?
• Alex Wayne: Strictly by his seniority. 
  
  
  Baucus was elected to the Senate in 1978 and joined the Finance Committee sometime relatively soon after that (don't know the exact date -- apologies).
  
  
  As older senators retired or died, he rose up the ranks until he was the senior Democrat on the panel.
  
  
  And so when Democrats took over Congress in 2006, Baucus became chairman by default.
  
  
  Democrats don't believe in awarding chairmanships based on merit -- it's all about seniority. By contrast, Republicans say they consider merit -- but usually that just means more politically astute members of their party can leapfrog more senior members by raising more money for campaigns. 
  
  
  I would suggest that neither system is perfect.
• Ira from Maryland: Has Hillary Clinton been consulted about what's going into the Obama health plan?
• Alex Wayne: She was traveling the Middle East yesterday, during Obama's health forum at the White House.
  
  
  I'm not saying that was by design, but it was an interesting coincidence. As far as I know she hasn't had much say in Obama's health proposals.
• Joe from San Francisco: What special interest groups have already announced their opposition to what Obama wants to do?
• Alex Wayne: The one that leaps to mind immediately is the National Association of Wholesaler-Distributors, a business lobby. 
  
  
  They ripped his budget the day it came out, so it doesn't look like they'll be particularly helpful to him as the overhaul proceeds.
  
  
  Rep. Joe L. Barton of Texas, the senior Republican on the Energy & Commerce Committee, is so far shaping up as the biggest thorn in Obama's side in Congress. He also doesn't think much of Democratic health proposals -- here's a quote from a statement he put out yesterday:
  
  "Not all of the Democrats’ ideas are objectionable. Just nearly all."
• Jane in Altoona, Pa.: Who is the single most important person on Capitol Hill when it comes to getting something big done on health care?
• Alex Wayne: Great question, with a lot of potential answers. With 58 Democrats in the Senate (and counting), it's tempting to say Harry Reid, the majority leader, or Max Baucus, the Finance chairman. 
  
  
  But I'd probably say Charles Grassley, the senior Republican on the Finance Committee. If Baucus and Edward M. Kennedy can develop a plan that wins Grassley's support, then Grassley can probably bring a few other Republicans with him.
• Bridget in White Plains N.Y.:

  Is this inviting any comparisons to Clinton's failed health plan?

  Why would Obama and the Democrats think it could work this time around?

• Alex Wayne: Absolutely. Almost every story I write mentions Clinton's failed attempt to overhaul health care. The comparison is natural.
  
  
  Obama is very conscious of the mistakes Clinton made -- his first nominee for HHS Secretary, Tom Daschle, is practically an expert on the topic. (And don't think Daschle doesn't maintain some influence in this debate.) So far, they are very obviously trying to do things differently. 
  
  
  For example, they're trying to get a bill done fast (Clinton took a year just to write his plan); and they're trying to let Congress develop the policy (Clinton did it within the White House).
  
  
  One problem Clinton experienced -- and that could bedevil Obama -- is distraction. Obama's trying to juggle a lot of issues already. Any more, like a foreign policy crisis (on top of the existing ones), could be enough to derail a health care overhaul.
• Julie from Kalamazoo, Mich.: OK, you picked Grassley for the most important person to get something done. Who on Capitol Hill is the biggest nemesis to a new health care system?
• Alex Wayne: That's easier. Mitch McConnell, the Senate Republican leader.
• Ann from VA: What level of trust is out there that health care reform will be achieved this year? How can we trust that the big companies armed with lobbyists will not derail these efforts? Everyone needs to understand that ALL of us need to contribute to the solution.
• Alex Wayne: People I talk to who were around during the 1990s effort at a health care overhaul, and before, say that the environment has never been better. Democrats have stronger control over the policy levers of this town than they are likely to ever have again. 
  
  
  So if they can't get it done in the next two years, I would suggest that they can't ever get it done -- or at least, they won't be able to accomplish anything as ambitious as what they're envisioning today.
  
  
  Also, a lot of the big companies and organizations that previously fought a sweeping health care overhaul now want it done, because health care costs are increasingly weighing down their balance sheets. General Motors is a good example of that.
  
  
  All that said, you're right to be skeptical. Strange and unexpected things happen in this town every day.
• Dale in West Virginia: Are there upper limits on what the government will pay for a serious illness?
• Alex Wayne: Not that I know of. That's probably part of the reason the costs of care under Medicare, in particular, vary so widely across the nation.
• Doris in Arizona: Under Obama's vision, who determines medical necessity -- a doctor or a government employee?
• Alex Wayne: I'm sure that Obama would say doctors.
  
  
  But I think you're referencing what's called "comparitive effectiveness research" -- an initiative to have the government study which drugs, procedures and other treatments work best for a given disease or condition. The "economic stimulus" bill Congress just passed includes $1.1 billion for that kind of research, far more than the government's ever spent before.
  
  
  There's debate in Congress about how far to take that research. Do you let Medicare decide it won't pay for a given drug or procedure because according to CER, it doesn't work as well as something else?
  
  
  That hasn't been decided.
• Jon from MD: What are the chances that the federal government will create a universal health care system
• Alex Wayne: I wouldn't want to put odds on it. 
  
  
  If you mean a single-payer system, like expanding Medicare to cover everybody, I would say the chances are very poor: Obama has said he doesn't support that sort of system.
  
  
  If you mean some kind of hybrid public-private system in which Medicaid covers most poor people, Medicare covers the elderly, and everybody else at least has access to private insurance that's affordable and comprehensive, I'd say the chances are much better. But even under that sort of system, I don't know if it'd be accurate to call it "universal health care."
• Eva in South Dakota: If this passes, what happens to private health insurance companies in America?
• Alex Wayne: Depends on what the plan ultimately looks like. Right now, there's no legislation to talk about.
  
  
  I think health insurance companies are going to be involved in whatever system results from the policy debate. They might even have a bigger role in our lives, as the policy could very well result in private insurers covering most of the 47 million uninsured people in this country.
  
  
  If Democrats succeed in making a "public plan option" part of the policy, however, things could be different ... that could result in people leaving their employer-sponsored insurance to join the public plan, or employers dropping health insurance as a benefit. This is going to be a major flashpoint in the months ahead. 
  
  
• Ritchie from Detroit: Would every citizen automatically be eligible for government health insurance if this Obama plan gets passed?
• Alex Wayne: Well, again, there is no "Obama plan," so we don't really know what it will look like.
  
  
  But no, I don't think every American would be eligible for government health insurance under the likeliest scenarios. I think it's much more likely that Congress passes some kind of plan that involves expanding private insurance to cover more people.
  
  
  As for timing ... the new system probably wouldn't be open for enrollment immediately; just a guess here, but I think Congress would want to give insurers and government agencies a few months to gear up for all the new business.
• Mary in Cincinnati: Under Obama's plan, will doctors effectively be barred from practicing if they refuse to perform abortions?
• Alex Wayne:

  Obama is seeking to overturn a regulation that former President George W. Bush enacted late last year that allows health providers to refuse to provide medical services based on personal principles. (I hope I'm wording that right, because I didn't cover the regulation.)
  Anyhow, no, I haven't heard of any proposed policy that would require doctors to perform abortions. And it continues to be federal policy that Medicaid and other federal health programs can't pay for abortions. 

• Larry from Wyoming: Why doesn't Obama just set this campaign promise aside until the ecoomy straightens up?
• Alex Wayne: Obama argues that it's a "fiscal imperative" to overhaul health care, as part of a far-reaching plan to restore and reconfigure the economy. His energy policy is part of it, too.
  
  
  He sees it as all one ball of wax. There are plenty of Republicans who think like you do, though -- that he should focus on the immediate, acute economic problems first.
• Roger, Vancouver WA: One of the major epidemic facing America is obesity. We have tried to find an affordable program to assist with this problem. Can you assure me that a corner stone of any health plan will be preventative care? America currently has a "sick care" system to treat problems when they become major health problems. Can we PLEASE have a HEALTH care system and insurance/coverage to go with with to help people with eating disorders.
• Alex Wayne: I think I'm safe in saying that EVERYONE in Congress says they would like to see a health care system that provides more preventive care. I've never heard an argument against it.
  
  
  The problem they have is that existing payment systems under Medicare and Medicaid generally don't encourage preventive care. Doctors are reimbursed based on the number of procedures they perform.
  
  
  But once you start tinkering with payment systems, you start crossing paths with lobbyists for health providers. A lot of people have a vested interest in the system the way it is; unless they agree that it's in the nation's best interest, they may fight any changes.
• Moderator: Thanks for the great questions, everybody, and thanks to you, Alex, for your very comprehensive answers. Hope you'll be back for another chat soon. Meanwhile, our next "Live Online" guest will be Taegan Goddard on March 19.
• Alex Wayne: Thanks everybody. You kept me on my toes. If you haven't seen an answer to your question yet, please check back later.
• Mark from Connecticut: Alex, everyone agrees that home health care is favored by the public and should play an important role in helping us contain health care costs. $100 a day for a home visit versus $500 a day for nursing home care, $5,000 a day for hospital care. yet, both the President and MedPac want to CUT billions from Medicare home care reimbursements. For profit home care providers, who almost exclusively serve Medicare patients because of Medicare's profit margins, are using Medicare to make billions for their investors, while nonprofit providers, who now make up only 14% of the nation's home care providers, are all on the verge of bankruptcy because they also care for medicaid, HMO and private insurance patients at rates well below their actual costs. What can nonprofit home care providers do to help the president and congress understand that more Medicare cuts will actually end home health as an option for most americans because the nonprofit providers will be forced to close down?
• Alex Wayne: This is a great question, and an issue I want to explore in greater depth in the near future.
  
  
  As you know, home health care -- particularly in south Florida -- is an industry that is absolutely riddled with fraud. I think that Obama's proposed cuts are in part aimed at that issue.
  
  
  But unfortunately, we don't really know how his cuts would work because there's very little detail in his budget. The additional budget documents he releases in April should shed more light on the subject, and I plan to do some reporting on it too.
  
  
  I'm guessing you're a nonprofit home health care provider ... drop me a line at awayne@cq.com if you'd like to talk more about this.
• Pat from VA: What is being done to cover still unemployed workers who no longer receive unemployment benefits? Or those workers who invested even their own salaries to prevent a business from going south and now are unemployed, without unemployment benefits, not eligible for benefits as they were not able to collect a salary when the business was coming to a close. Where are any benefits for those who really tried to succeed, but failed in this economy?
• Alex Wayne: Right now, nothing is being done for those people. If their incomes are low enough, they may qualify for Medicaid. Otherwise, they are joining the already swollen ranks of the uninsured.
  
  
  The economic stimulus bill includes a provision to make COBRA health insurance coverage more affordable. But the subsidies last only nine months, and if you lost your job before September of last year, you're not eligible at all.
  
  
  Further, there have been some reports that employers and the government are having trouble implementing the COBRA subsidies.
  
  
  Presumably, under a health overhaul, the government would make some kind of insurance available to unemployed people and would probably subsidize it, too. But even with the subsidy, the insurance might not be affordable for some people -- and they still might not qualify for Medicaid.
  
  
  Just another example of why this is such a tough issue for Congress to address ...
• Chuck NJ:

  What about tort reform?

  How about letting the legal profession know that in addition to the medical and insurance business that the lawyers will also face more demands, including less money for their work and effords to sue everyone for money. 

• Alex Wayne: As I said earlier, tort reform was mentioned at Obama's health forum yesterday, and Obama himself expressed some interest in the issue.
  
  
  But it's not among the eight "priorities" for a health overhaul that he listed in his budget.