The Insider: Last minute collapse on doc payments, Medicaid and COBRA subsidies a bad omen?
In the lead-up to passing the health reform law, Congress debated what to do about the Medicare physician payment problem. Under current law, the formula for setting Medicare physician payment rates, known as the Sustainable Growth Rate, or SGR, will impose large and escalating annual cuts on physician reimbursement. The SGR issue was ultimately separated out from health care reform, and doctors were assured that the issue would be addressed before the scheduled payment cut June 1. Physicians pressed for a permanent solution to the problem but because of the price tag, Congress scaled back, first to a 5-year patch and then to a 19-month fix. The scaled-back SGR patch passed the House just before the Memorial Day recess, but without enough time for the Senate to act. Theoretically that means that a Medicare payment cut of over 20 percent kicks in today, but CMS is holding onto claims for a couple of weeks assuming that when the Senate comes back they will enact a retroactive payment increase.
While the physician payment fix is likely to get sorted out, two other critical provisions face a more uncertain future. With unemployment still high and state budgets still in trouble, House and Senate leaders attempted to extend enhanced federal Medicaid payments to states through the end of state fiscal year 2011 (the enhanced payments are currently scheduled to end halfway through the year) and to continue the subsidy of COBRA premiums created by ARRA last year. But in what’s being described as victory for House fiscal conservatives, both of these measures were struck from the House legislation late last week, and whether the Senate will restore them remains uncertain. Roughly 20 states are already counting on the extra Medicaid help in their state budgets.
However, that victory may prove short-lived. Both the COBRA and Medicaid provisions themselves are popular with core Democratic constituencies, and it’s entirely possible that the Democratic Blue Dogs who have drawn a line in the sand in the name of controlling federal spending will be punished at the polls, not rewarded, if the Medicaid and COBRA funding is not restored. They could lose support from the Democratic base without picking up any offsetting support from more conservative voters.
If funding is not restored there are several implications that go beyond politics. The first is harm these cuts do to low- and moderate-income families who will lose coverage or services as a result. Second, the loss of COBRA subsidies is a blow to the drive to provide health security for all, while the loss of Medicaid funding will certainly turn up the heat on the already charged debate over the role of Medicaid in reform. Finally, if there is a more conservative Congress in 2011 as anticipated, future debates over federal health care funding and implementation could become similarly difficult, with Congress unable to agree on funding for provisions in PPACA that are authorized but lack an appropriation.
The immediate implication for health care reform advocates is that we need to redouble our efforts to persuade the Senate to revive the COBRA and Medicaid funding. It’s time to step in to keep reform on the right track. More on Living in Chicken Little Land
You know it’s Chicken Little time when people can (and do) go on about how awful health reform is without any regard to the available facts.
Exhibit A: Public opinion. The most recent Kaiser tracking poll (pdf) shows that the top concerns opponents have about health care reform is that it will increase health care spending and is not paid for.
Both the Congressional Budget Office and the CMS Office of the Actuary have refuted these claims in the past. CBO has found that health reform will reduce the deficit (pdf) while the CMS actuary projects that reform will provide coverage to over 30 million people with a negligible increase in costs. Recently, a Commonwealth Fund/Center American Progress analysis has suggested that both CBO and CMS are being too conservative in their projections. Essentially both agencies assume no savings at all from efficiency gains, quality improvements and delivery system changes–sources that could, by moderate estimates, generate a potential $600 billion savings over 10 years.
Exhibit B: state government. Numerous states have vociferously complained about the burden the Medicaid expansion, a core component of health reform, will impose on them; many going so far as to file a lawsuit to block the expansion.
The facts? A new paper released by the Kaiser Commission and the Urban Institute tells a different story (pdf). The study shows that on average health reform will add only 1.4 percent to state Medicaid spending between now and 2019. This is very similar to the 1.25 percent estimate developed by the Center on Budget and Policy Priorities. And neither of these forecasts take into account savings to states from changes in the delivery system or from reductions in spending on services that are now 100 percent state funded but will be covered by Medicaid in the future. Although state by state estimates vary, in no state does the federal government contribute less than 94 percent of the cost of the expansion.
Unfortunately, it isn’t much use telling the truth to people whose minds are already made up. Facts don’t matter to Chicken Little, who gets all his information from the Fox (news). As we noted in the last post, the only thing that will persuade these folks is when the sky doesn’t fall in 2014 and, at least for some, they start receiving benefits under the law. Then they’ll probably join the “keep government out of my Medicare” crowd.
DoJ presents its case The Department of Justice has, in several legal briefs, laid out its basic arguments against the lawsuits seeking to undermine health reform. Here’s a CliffsNotes version of the arguments:
• States have no standing relative to the individual coverage requirement, which applies to individuals, not states (duh). • There is no need to block the law from going forward now since there is no possible injury until April 2015, when penalties for failure to purchase coverage would be due. • Individuals who now claim the law would require them to purchase coverage can’t know their circumstances in 2014, so the “injury” is purely speculative. • State residents cannot vote to exempt themselves from federal law they don’t happen to like. • The minimum coverage requirement is a reasonable part of the regulatory scheme that governs economic activity related to health care and health insurance, and thus falls within the Commerce Clause, • Tax penalties associated with the requirement to purchase coverage fall within Congress’ power to tax and spend for the general welfare. Call it what it is—then change course
When responding to repeal proponents it’s important to: a) Call the attacks what they are: an attempt to preserve an unsustainable status quo that leaves millions without coverage and millions more who have coverage at risk of financial ruin.
b) Turn to the benefits of the law—reform will: • Provide security to millions of working Americans • Guarantee people access to the same plans as members of Congress • Help women, children and people with serious medical conditions get more affordable and more secure coverage • Strengthen oversight of insurance premiums and help people get better value for their premium dollar
–Michael Miller, director of strategic policy