As we shake off the carb-coma and make our pre-resolutions, Congress and the Administration head into a sprint to the holiday recess fraught with health policy implications. Unlike every December in recent memory, there isn’t very much Congress actually has to do. Here are the top five things you need to know to follow the fun and prepare your organization for the changes afoot. A key theme to take home is that December 2013 is a month of anti-deadlines.
- The Nov. 30/Dec. 1 “fix” to Healthcare.gov was set arbitrarily and has simply teed up another pivot point for opponents to pounce. We already know the wand hasn’t tapped the electro-synapses of the site yet to make the dang thing work like it should. Expect more incremental improvements through the month and enrollment numbers to come in above current rock-bottom expectations, with a healthy chunk coming from the proud, the few … the state-based exchanges.
- The Dec. 13 deadline for budget conferees to produce a joint resolution is similarly fictional and self-imposed. While there are some burgeoning reports that co-chairs Murray and Ryan might be able to agree to FY14 funding levels and potentially alleviate some of the sequester, the buzz-o-sphere in Washington still has deep doubts. Even if the two negotiators come to agreement, House and Senate leadership have the bigger challenge of getting a bipartisan deal through their chambers.
- Jan. 15 is the real deadline for a budget agreement and the real goal is writing a check to fund the government through Sept. 30. A budget resolution is helpful to give appropriators time to write actual spending policy, but it can be bypassed if the end-game is a continuing resolution that keeps current funding allocations in place. (Congress hasn’t passed an actual budget resolution since Democrats controlled both chambers.) At the end of the day, we’ll be back to the all-too-familiar roundtable of congressional leaders and Obama reps hatching a last-minute deal to avert a shutdown.
A minority of the Members of Congress are threatening to cause the United States government to default on its debts, unless the majority members agree to repeal or defund the Affordable Care Act, which Congress passed just a few years ago. There will presumably be some sort of negotiated solution. I worry that the negotiation range is being defined in a skewed way, between one pole and a moderate status quo, which is already the result of a prior negotiation. Seems like we have a one-way ratchet here.
My thought: perhaps the negotiations should go both ways, so that the end-result is more balanced. What if the Democrats made symmetric threats to cause default, unless:
- Medicare is expanded to cover all the poor who do not qualify for Medicaid (filling the gap the Supreme Court created in its “coercion” opinion),
- The Federal government creates a public health insurance option, to compete along with the corporate insurers (which was killed in final negotiations to pass the ACA),
- The Federal government gets explicit authority to provide insurance subsidies in the health insurance exchanges it sets up for states that have refused, oh and, as a kicker,
- Ronald Reagan International Airport (DCA) is re-named Jimmy Carter International Airport.
Ok, that last one is silly, but it might make for a fun bargaining chip, since it symbolizes the strategic game that is now being played, as we re-legislate settled questions. Positional bargaining is not pretty or enlightened, but if these chips can be traded, we might end up in the fallback position of keeping the Affordable Care Act as the negotiated compromise that it already is. Of course, the ACA is also the default rule, which has a nice double meaning in this context.
Christopher Robertson, JD, PhD is a visiting professor at Harvard Law School, an associate professor at the James E. Rogers College of Law, University of Arizona, and a research associate with the Edmond J. Safra Center for Ethics at Harvard Law School. He blogs at the Petrie-Flom Center’s Bill of Health, where this post originally appeared.
Congress is in recess, but you’d hardly know it. This has been the most do-nothing, gridlocked Congress in decades. But the recess at least offers a pause in the ongoing partisan fighting that’s sure to resume in a few weeks.
It also offers an opportunity to step back and ask ourselves what’s really at stake.
A society — any society —- is defined as a set of mutual benefits and duties embodied most visibly in public institutions: public schools, public libraries, public transportation, public hospitals, public parks, public museums, public recreation, public universities, and so on.
Public institutions are supported by all taxpayers, and are available to all. If the tax system is progressive, those who are better off (and who, presumably, have benefitted from many of these same public institutions) help pay for everyone else.
“Privatize” means “Pay for it yourself.” The practical consequence of this in an economy whose wealth and income are now more concentrated than at any time in the past 90 years is to make high-quality public goods available to fewer and fewer.
In fact, much of what’s called “public” is increasingly a private good paid for by users — ever-higher tolls on public highways and public bridges, higher tuitions at so-called public universities, higher admission fees at public parks and public museums.
Much of the rest of what’s considered “public” has become so shoddy that those who can afford to do so find private alternatives. As public schools deteriorate, the upper-middle class and wealthy send their kids to private ones. As public pools and playgrounds decay, the better-off buy memberships in private tennis and swimming clubs. As public hospitals decline, the well-off pay premium rates for private care.
Us and Them
And after all we’re only ordinary men
The wanna-be congressman appeared with his neat hair and pressed suit, a competent yet compassionate expression on his face. ”The first thing I am going to do when I get to congress is to work to repeal Obamacare,” he said, expression growing subtly angry. ”I will do everything I can to give you back the care you need from those who think big government is the solution to every problem.”
My wife grabbed my arm, restraining me from throwing the nearest object at the television. I cursed under my breath.
No, it’s not my liberal ideology that made me react this way; I’ve had a similar reaction to ads by democrats who demonize republicans as uncaring religious zealots who want corporations to run society. I am a “flaming moderate,” which means that I get to sneer at the lunacy on both sides of the political aisle. I grew up surrounded by conservative ideas, and probably still lean a bit more that direction than to the left, but my direction has been away from there to a comfortable place in the middle.
It’s not the ideology that bugs me, it’s the use of the “us and them” approach to problem solving. If only we could get rid of the bad people, we could make everything work. If only those people weren’t oppressing us. If only those people weren’t so lazy. It’s the radical religious people who are the problem. It’s the liberal atheists. It’s the corporations. It’s the government. All of this makes the problem into something that isn’t the fault of the person making the accusation, conveniently taking the heat off of them for coming up with solutions to the problems.
The ink was barely dry on the PPACA when the first of many lawsuits to block the mandated health insurance provisions of the law was filed in a Florida District Court.
The pleadings, in part, read:
The Constitution nowhere authorizes the United States to mandate, either directly or under threat of penalty, that all citizens and legal residents have qualifying health care coverage.
State of Florida, et al. vs. HHS
It turns out, the Founding Fathers would beg to disagree.
In July of 1798, Congress passed – and President John Adams signed – “An Act for the Relief of Sick and Disabled Seamen.” The law authorized the creation of a government operated marine hospital service and mandated that privately employed sailors be required to purchase health care insurance.
Keep in mind that the 5th Congress did not really need to struggle over the intentions of the drafters of the Constitutions in creating this Act as many of its members were the drafters of the Constitution.
And when the Bill came to the desk of President John Adams for signature, I think it’s safe to assume that the man in that chair had a pretty good grasp on what the framers had in mind.
Here’s how it happened.
Q: What’s going on with the farm bill? Any chance for improving it?
A: I wish your question had an easier answer. The farm bill has to be American special-interest politics at its worst.
As Stacy Finz has been reporting in the main news and Business sections of The Chronicle, the failure of the recent super-deficit reduction plan also brought an end to a secret committee process for writing a new farm bill. Now Congress must follow its usual legislative procedures. The farm bill is again open for debate.
Advocacy is much in order. The farm bill is so enormous, covers so many programs, costs so much money and is so deeply irrational that no one brain – certainly not mine – can make sense of the whole thing.
It is all trees, no forest. The current bill, passed in 2008, is 663 pages of mind-numbing details about programs – hundreds of them – each with its own constituency and lobbyists.
The farm bill was designed originally to protect farmers against weather and other risks. But it grew piecemeal to include programs dealing with matters such as conservation, forestry, biofuels, organic production and international food aid.
You can’t believe the play that little athenahealth gets in Washington, DC… and thank goodness for it because no one has a clue about HIT.
How could they really?
I mean, there are 535 people in our federal legislature (give or take) and there are like a million different market spaces in the nation. This is why I have such a hard time with federal control of things. It’s impossible for them to know what’s going on…there are just not enough hours in the year.
As I’ve been thinking about care coordination and the complete lack of sustainable models or entrepreneurship in that space, it occurred to me that it’s currently not clear that it is legal for RECEIVERS of electronic health information to pay senders for the value of that health information. This means that the sender has no real motivation to send useful, relevant data in a timely manner (I know I’d pay the doc who sent me exactly what I needed about a patient more than I’d pay the doc who sends over a 30-page PDF) and that our industry will take a long time to understand the true health information exchange needs of providers.
I wanted to bring the concept with me to the Hill that Meaningful Use, in my opinion, is use that is meaningful to a medical care provider in the actual doing of business. In a space with such clear demand, we’ve got to let innovators develop a way to supply information that the market (providers of care) needs, if we want to improve outcomes and reduce costs.
So I flew down to Washington and it was tons of fun… me and Lauren Fifield and the lobbyist and a full dance card on Capitol Hill.
First, we met with Sally Canfield, policy director for Sen. Marco Rubio, R-Fla.
She’s a true health policy veteran who likes getting—and will give you—the straight story. She’s also one of the only people on the Hill with whom I could speak at my normal (lightning) pace and know she can keep up. We talked about everything from the potential fall of hospitals (Need a hospital? Just scan the horizon for a construction crane)…to the alarming rate of physician employment…to making Meaningful Use really meaningful…to encouraging care coordination…to life in the cloud.
When new members of Congress are sworn in this January, there will be a total of 19 doctors in Congress – 3 Senators and 16 Congresspersons. That will be a 27% increase over 2009,from 15 to 19, in doctor members of Congress. These doctors will make up 3.5% of the 535 members of Congress, but will fall far short of the 10.7% who were signers of the Declaration of Independence.
Eighteen of the 19 new members are Republican. This may say something of the mood of America towards health reform, but it may have little effect on whether the health reform bill is repealed or retained in its present form.
Fifteen of the 19 are from the South or West, 5 are Ob-Gyn specialists, and 12 represent specialties who perform surgery. What this means or portends I do not know. Perhaps they will not hesitate to perform surgery on the bloated national budget and cut deficits. I take solace in recent polls, which indicate 77% of the public trust doctors to do right thing vs. 11% who trust Congress.
Here is the list of the 19 doctors in Congress:
- Tom Coburn (R, Republican), Oklahoma, family physician and ob-gyn
- John Barasso (R, Wyoming), orthopedic surgeon New Senator
- Rand Paul, (R, Kentucky), ophthalmologistContinue reading…
Following the shift to a Republican majority in the U.S. House of Representatives, the pre- and post-election focus of GOP leaders on repealing all or parts of the Patient Protection and Affordable Care Act (PPACA) have led to much discussion and media attention on whether the few true health IT aspects of the Act are in jeopardy, and has even extended speculation – and in some cases confusion – as to whether physician and hospital incentive funds within the government’s previous Meaningful Use initiative are also a target.
There are several foundational elements – and one major point of Meaningful Use funding – that should allay concerns for current and future funding for the adoption of certified electronic health records (EHRs).
Fundamentally it’s important to note that the Health Information Technology for Economic and Clinical Health (HITECH) Act, from which the Meaningful Use program and its funding originates within the American Recovery and Reinvestment Act (ARRA) of 2009, is an entirely different statute than PPACA.
Bipartisan support for the tenets and the spirit of HITECH dates back at least seven years, and it is also noteworthy that the Office of the National Coordinator for Health Information Technology (ONC), which administers Meaningful Use, was created by the Bush administration and a Republican Congress.
Politics aside though, the reason that Meaningful Use funds are secure is because they are drawn from the Medicare Trust Funds held by the U.S. Treasury, and are therefore not subject to annual Congressional budget appropriations or oversight.
In other words, the funding is grounded in law, and has inherent flexibility to encompass the number of ambulatory practices and hospitals seeking Meaningful Use incentives capture. The incentive payments are procured through the Centers for Medicare and Medicaid Services (CMS).
What’s Next With Health Care (And Why This Process Was Madness)
By MARIAN WANG
Sometimes things are a little clearer in retrospect. Now that health care reform has passed in the House, it seems there are two main questions in people’s minds:
- What’s next?
- Why, procedurally, was the legislative process so confusing and painful to watch?
Let’s answer that second question first. To help do that, we’ve drawn up some helpful infographics.
Exhibit A – How, originally, we thought health care legislation would play out procedurally. This is typically how proposed legislation is melded between the two houses.
Exhibit B – How things would’ve worked under “deem and pass ,” or a self-executing rule. After questions were raised about the constitutionality of “deem and pass,” the House ended up not going that route.
Exhibit C – How it looks like it’s going to happen, after all.
In that last graphic, the yellow marker (5) is where we’re currently at. President Obama reportedly will sign the Senate bill on Tuesday , which means that part of health care legislation is law. The House-passed reconcilliation portion, consisting of 153 pages of “fixes” to the Senate bill (compare the two bills with our side-by-side comparison app ), will then move to the Senate (6), and if it passes, on to presidential sign-off (7).
As for the “What’s next” question, Kaiser Health News has a good list  of some of the provisions that will take effect in 2010. Most of the bigger changes that will affect millions don’t go into effect in 2014.
Marian Wang blogs for the ProPublica news service. This post first appeared on the ProPublica blog. You can write Marian Marian.Wang@propublica.org.