Democrats Dig in Against Health Care Outcry
By Edward Epstein, CQ Staff
August 13, 2009 -- The outspoken, sometimes rowdy opposition at town hall meetings this month so far isn't causing many congressional Democrats to back away from plans to pass sweeping health care overhaul legislation this year.
Interviews with about a dozen Democratic House members reveal they think a lot of the loud criticism they have encountered over theAugust recess has been ginned up by Republicans, conservative commentators, or groups spending large sums of money to try to derail President Obama's top legislative priority. In most cases, the noisy opposition has only firmed up the Democratic members' determination to get a bill done this year.
Rep. Gene Green, D-Texas, who has already held four sometimes heated town hall meetings on health care this month, said he thought the critics might "have overplayed their hand" in what he said were organized efforts to disrupt town hall meetings and spread misinformation. "At least it has with me," he said.
And Rep. Frank Pallone Jr., D-N.J., said that "right-wing efforts to disrupt meetings might make members realize a lot of what they're hearing is misinformation. What I hear people say is that insurance is unaffordable for many of them and they want us to do something about that."
Sen. Claire McCaskill, D-Mo., said her contentious town hall meetings this week, which were heavily covered on cable news networks, were dominated by constituents who don't represent the majority of her state's voters. "While we listen to everyone, most people who come have made up their minds," she said on MSNBC Wednesday. "I'm still trying to find compromise and middle ground."
While the Democrats say they remain resolute, it remains to be seen if the Congress will really be as stalwart when it returns after Labor Day. Obstacles abound. Public support for the health care ideas outlined by Obama and Democratic leaders is dropping in public opinion polls, and the Democrats in Congress have yet to produce complete bills in either chamber, much less bring legislation to the Senate or House floor for a vote.
And Republicans, so far almost completely united in their opposition to the majority's health care ideas, think the Democrats are in big trouble on their proposals that they say are increasingly scaring many Americans amid a recession and a significant expansion of the federal role.
"August was supposed to be the Democrats' chance to turn the numbers around, but if things continue on their current course, Democrats will be in the same (if not worse) position they were when they left town; on the defensive and pointing fingers," the National Republican Congressional Committee said Thursday in a memo sent to GOP House members and the media.
But Democrats who have faced the toughest going back home say all the fury directed at them has backfired. No one has had a rougher time than Rep. David Scott, D-Ga., who this week had a swastika spray painted on his congressional office sign in Smyrna, Ga., after a town hall meeting. Federal authorities are investigating the incident.
Scott, a member of the Congressional Black Caucus, said he has also received letters containing racial epithets.
"This is serious, serious business," Scott said. "What role does a swastika, these depictions of the president, have in the health care debate? We cannot allow this hate and racism to clutter the debate on health care."
As the only member of Black Caucus who is also a member of the conservative Blue Dogs and the business-oriented New Democrats, Scott said he is in a unique position to help serve as "the glue to pull together a bill."
"I know in working with all of them that we can pull this together and get a bill," he said.
Missing: 'Folks in the Middle'
Rep. Tom Perriello, a Virginia Democratic freshman whom Republicans are making a top target in 2010, said he had already held eight town hall meetings in August, one of which ran 5 1/2 hours. He plans several more.
At the sessions thus far, he said, "there weren't a whole lot of swing voters in the room. We're getting the most spirited advocates on both sides."
Perriello said his job now is to "go out and reach those folks in the middle." But he added, "Frankly some of those in the middle have checked out for the summer. They are going to barbecues and other things."
Rep. David Wu, D-Ore., said he found participants about equally divided for and against Democrats' plans in two town halls he's held.
"People are genuine. But there is orchestration on both sides. Initially, the anti-people were more organized. But it seems evenly balanced now," Wu said. "My constituents want a variety of things. Some are reconcilable. Some are not."
Pallone, who chairs the Energy and Commerce Health Subcommittee, said he's been struck by how much misinformation his constituents have about the health issue. "People come up to me and say that we're going to take away their Medicare, which of course we aren't going to do," he said.
"We know that these things aren't true, and they aren't going to influence members."
Arkansas Democrat Mike Ross said media reports about protesters at an Aug, 5 event he held with fellow Democrat Vic Snyder at Arkansas Children's Hospital in Little Rock were overblown.
"The press portrayed that as being out of control, and I didn't realize it was out of control until I started reading the reports of it," said Ross, a Blue Dog who ultimately supported the health care proposal in the Energy and Commerce Committee. "It was reported a lot different than it was."
Ross, who held a telephone town hall meeting on health care Thursday evening and is holding in-person town halls on the issue Friday and on Aug. 27, said that he has held more than 35 town halls this year and that the Aug. 5 event was the only one at which there had been any disruptions.
"We've only had the crowd get rowdy at one of them, and that wasn't even in my district," he said.
When asked if he detected a shift in his constituents' attitudes since he had returned home for the August break, Ross said a small group were afraid that health care proposals could negatively affect them. But Ross blamed special interests and alarmist ads for stirring up those concerns, saying the majority of the people he had spoken with still were in favor of overhauling health care.
"I have a lot of people thanking me for slowing it down and giving members of Congress a chance to read the bill and listen to their constituents—and these are people who are for health-care reform," Ross said. "There's a small group that are frightened—they're scared or they're angry — and I think they have every right to be. I welcome everyone in my town hall meetings."
Kathleen Hunter, Bart Jansen, Alan K. Ota, Bennett Roth and Greg Vadala contributed to this story.
Bolder Action Needed to Bend Cost Curve, Coalition Says
By John Reichard, CQ HealthBeat Editor
The language is polite, but a new report by a coalition pushing for better preventive care says the congressional health overhaul effort is missing the mark when it comes to managing chronic disease and isn't doing enough to bend the health spending curve as a result.
"While everyone agrees that making health coverage affordable is the key to providing health care to all, no congressional proposal has yet put forth a plan for how we deliver, administer, and pay for health care that is bold enough to make this goal attainable and sustainable while being comprehensive enough to improve health," says the report by the Partnership to Fight Chronic Disease.
Current overhaul proposals "are a great start, and certainly preferable to the status quo, but...there is more work to be done and bolder action needed from Congress," said Ken Thorpe, the partnership's executive director.
"To 'bend the spending curve' we need comprehensive reform of the payment and delivery systems, creating a system that truly incentivizes high quality care through prevention, care coordination, and other efforts," added Thorpe, a health policy professor at Emory University, during a telephone press briefing Tuesday.
For example, Thorpe said that current proposals do not go far enough to "bundle" payment—in other words, to pay multiple providers a single payment that incentivizes them to avoid unnecessary tests and procedures. Through better coordination of treatment, more of the payment is left over for providers to pocket.
Thorpe also pointed to presentations Monday at a White House event on various health care systems he said effectively coordinate care and offer preventive services. The systems included the Geisinger Health System in Pennsylvania and the Dartmouth-Hitchcock Clinic in New Hampshire. Legislation should go beyond current proposals for pilot programs in this area, Thorpe suggested.
"Our belief is that we have ample evidence about how to proceed with preventing and managing chronic disease nationally and that while the pilots are a great start, if we wanted to be more aggressive with this we could build on those experiences that we have nationally already, scale them and replicate them in the Medicare program and I think we could do this within the next three years."
"We'd need some funding to do it" but every dollar invested in care coordination would yield two to four dollars in savings based on the White House presentations Monday, he said.
The report says that current proposals do not do enough to build on various existing programs, such as a University of Pennsylvania program that aims to better plan oversight and treatment of patients once they leave the hospital to avoid readmissions and skilled nursing facility care.
Thorpe also said he would like to see bolder congressional action to promote "community health teams" of nurses and social workers to work with smaller medical practices to provide "medical homes" to better oversee the treatment of those with chronic disease.
The House overhaul measure (HR 3200) provides $1.5 billion over five years for a pilot program in this area, but Thorpe estimated that if $25-to-$30 billion were invested instead to build the teams nationally over 10 years, $100 billion could be saved nationally by cutting hospital admissions in half.
While policy analysts and politicians emphasize better preventive care as a goal of health overhaul efforts, the Congressional Budget Office isn't scoring savings as a result.
Poll: Americans Favor Strongest Possible, Low-Cost Children's Health Coverage
By Melissa Attias, CQ Staff
August 13, 2009 -- A three-to-one majority of Americans would oppose the elimination of the Children's Health Insurance Plan (CHIP) if a health insurance exchange, an alternative to CHIP proposed in overhaul legislation, is more costly for families and provides children with fewer benefits, according to a poll released Thursday by bipartisan children's advocacy group First Focus.
The poll, conducted by Lake Research Partners, comes amidst concerns that the health insurance exchange (the Exchange) could lead to higher out-of-pocket costs for families while reducing benefits. On Capitol Hill, the House Energy and Commerce Committee passed an amendment by Rep. Diana DeGette, D-Colo., that would ensure that no child is moved from CHIP to the Exchange until the secretary of Health and Human Services certifies that the coverage is comparable or superior. Similarly, the House Education and Labor Committee passed an amendment by Rep. Bobby Scott, D-Va., that would guarantee children access to screening, diagnostic and treatment services under the Exchange.
"No goal in health insurance reform is more important than making sure every child has the comprehensive coverage they need," said Sen. Sherrod Brown, D-Ohio, in a news release. "Children who are covered under Medicaid and SCHIP must be guaranteed the proven benefits package they have today, and we must clear out the red tape that keeps uninsured children from gaining access to these crucial public health programs."
In contrast, the poll shows that 52 percent of Americans would be willing to eliminate or phase out CHIP if the Exchange provides children with comparable benefits. Yet Sen. John D. Rockefeller IV, D-W.Va., said he opposes eliminating programs like CHIP that are already successful.
"Today, millions of children receive the check-ups and preventive exams they need only because of Medicaid and CHIP—federal programs that work," Rockefeller said in the release. "We should not experiment with the stable health care coverage children have today by exposing them to coverage in the Exchange that may have higher cost-sharing for families and provide far fewer benefits for children."
A survey of 1,000 registered voters nationwide, the poll also found that 87 percent of Americans support ensuring that all children have health care coverage, while 68 percent support providing all children with coverage even if it increases their taxes. In addition, 78 percent of voters said they believe it is extremely or very important that "all children in America are provided health care coverage as part of health reform," according to the poll, while 71 percent said that coverage should include legal immigrant children.
"It is clear that Americans believe children should be a top priority in health reform and it is clear that they support providing all young people with health insurance coverage," said First Focus President Bruce Lesley in the news release.
Finally, participants said they would be less likely to vote for a candidate who supported a health care plan that reduced the level of coverage for children by nearly a four-to-one margin, according to the poll results.
"As the debate moves forward in Congress, I hope that all members will listen to their constituents on the need to do no harm to children," said Sen. Bob Casey, D-Pa., in the news release.
Approximately 15 percent of respondents identified health care in general as their top concern, according to the poll, second only to the economy at 40 percent.
Obama Town Hall Meeting Spotlights Medicare Role in Overhaul
By Jane Norman, CQ HealthBeat Associate Editor
August 11, 2009 -- President Obama's town hall meeting on health care in Portsmouth, N.H., on Tuesday failed to draw the heckling, shouting, and even effigy-hanging that have occurred at town hall meetings with members of Congress in other U.S. cities in recent days.
But Obama did purposefully focus attention on Medicare issues that are worrying seniors, who polls have found are the most skeptical about the president and congressional Democrats' plans to overhaul the health care system. For example, a Gallup Poll released July 31 found that seniors are the least likely of all age groups to say that an overhaul will improve their situation.
Obama acknowledged that's what the polls say, added that it's "understandable" because seniors often require more health care, and put special emphasis on speaking directly to Medicare beneficiaries.
"Well, first of all, another myth that we've been hearing about is this notion that somehow we're going to be cutting your Medicare benefits," said Obama. "We are not. AARP would not be endorsing a bill if it was undermining Medicare, OK?"
The seniors' group, however, issued a statement shortly after the presidential event to make it clear no endorsement has been issued.
"While the President was correct that AARP will not endorse a health care reform bill that would reduce Medicare benefits, indications that we have endorsed any of the major health care reform bills currently under consideration in Congress are inaccurate," said Tom Nelson, AARP chief operating officer.
Obama perhaps most importantly confronted fears about "death panels," which some Republicans have charged would make end-of-life decisions for ill seniors. The Web site Politifact rated as "pants on fire" a statement by former Alaska Gov. Sarah Palin on Facebook that the elderly "will have to stand in front of Obama's 'death panel' so his bureaucrats can decide, based on a subjective judgment of their 'level of productivity in society,' whether they are worthy of health care."
Said Obama: "It turns out that I guess this arose out of a provision in one of the House bills that allowed Medicare to reimburse people for consultations about end-of-life care, setting up living wills, the availability of hospice, et cetera. So the intention of the members of Congress was to give people more information so that they could handle issues of end-of-life care when they're ready, on their own terms. It wasn't forcing anybody to do anything. This is I guess where the rumor came from."
A Republican, Sen. Johnny Isakson of Georgia, is a strong proponent of the provision, said Obama. He added: "And somehow it's gotten spun into this idea of 'death panels.' I am not in favor of that. So just I want to—I want to clear the air here."
The actual provision in the House version of the overhaul bill would authorize Medicare payments for an "advanced care planning consultation" between individuals and doctors, if a patient chose to schedule such an appointment. The session is supposed to include an explanation of directives including living wills, durable powers of attorney, and end-of-life services available such as hospice care and palliative care. Orders on how the patient wants life-sustaining treatment to be administered may be written during the consultation.
Obama said the underlying concern is that health care somehow will be rationed. "We do think that systems like Medicare are very inefficient right now, but it has nothing to do at the moment with issues of benefits," he said. "The inefficiencies all come from things like paying $177 billion to insurance companies in subsidies for something called Medicare Advantage that is not competitively bid, so insurance companies basically get $177 billion of taxpayer money to provide services that Medicare already provides."
However, the cutback in Medicare Advantage, which is administered through private health insurance plans and provides a big chunk of money to help finance the overhaul without running up the deficit, also likely would affect millions of seniors.
According to the Kaiser Family Foundation, 22 percent of those enrolled in Medicare in 2009 belong to a Medicare Advantage plan, and since 2003 the number of Medicare Advantage beneficiaries has almost doubled from 5.3 million in 2003 to the current 10.2 million, as of March. Enrollment rates tend to be higher in urban areas than in rural counties.
Kaiser says that Medicare Advantage plans provide basic Medicare benefits and are required to use rebates they receive by bidding below a benchmark to provide extra benefits like vision or hearing, or reduced cost-sharing or premiums. However, groups such as the Commonwealth Fund have argued that Medicare Advantage was supposed to save money for the program and has failed in that mission.
The Congressional Budget Office said in a 2007 report that while reducing the payment differential between Medicare Advantage and the fee-for-service program could result in substantial savings for the government, "it would also diminish the supplemental benefits and cash rebates the Medicare Advantage plans can offer to enrollees and lessen enrollment in those plans."
Obama characterized the reductions as "subsidizing folks who don't need it," referring to insurers, and rejected the notion that changes to Medicare Advantage might affect the more than 10 million seniors who are currently beneficiaries.
"I just want to assure we're not talking about cutting Medicare benefits. We are talking about making Medicare more efficient, eliminating the insurance subsidies, working with hospitals so that they are changing some of the reimbursement practices," he told the audience in Portsmouth.
Prior to the event, former New Hampshire Gov. John H. Sununu correctly predicted the president would receive a "respectful" reception in Portsmouth, though Sununu said he understands the intensity of emotions that have surrounded the health care debate at other town halls around the country. People are upset because they feel there hasn't been a "full debate" in Congress yet, he said. "This idea we have to pass something immediately is not the way to do it," said Sununu, the chairman of the Republican Party of New Hampshire.
AHIP Study Discovers 'Runaway' Out-of-Network Doctor Charges
By Jane Norman, CQ HealthBeat Associate Editor
August 12, 2009 -- Some physicians are billing "runaway charges" for out-of-network care that exceed 1,000 percent of the allowable Medicare reimbursement for the same service, the health insurance industry said in a study issued Wednesday.
The report throws light on an issue that's been little discussed in the many hours of chatter over the health care overhaul moving through Congress—how much it sometimes costs insured consumers who for various reasons use services outside their health insurance networks. The study by Dyckman & Associates prepared for America's Health Insurance Plans (AHIP) found that in some cases, the fees are very high.
For example, researchers found an upper GI endoscopic visual diagnostic exam with a biopsy produced a $12,000 bill from a Texas doctor, while the Medicare reimbursement for the same procedure in the same geographic area is $337.99—which means the charge was a whopping 3,550 percent of what Medicare would pay.
In Virginia, the identical procedure was billed for $6,486 by a doctor, while the Medicare reimbursement there would be $312.60. In Florida, the upper GI procedure was billed for $5,542, in contrast to a Medicare payment of $319.
The May 2009 study included 10 insurance companies in the 30 most populous states and looked at data in a "conservative" approach that excluded high charge outliers that could have reflected coding or billing errors, Dyckman said in its survey methodology. Procedures looked at included benign breast lesion removal, total hip replacement, lower back spinal fusion, colonoscopy with biopsy and tendon repair in the hand.
Susan Pisano, director of communications for AHIP, said that there's been plenty of discussion about insurance companies' payments to providers but little said about provider charges. "We thought it was important if we were going to have a reasonable discussion about this that the question be asked," said Pisano.
In addition, there's a focus on insurance benefits, co-payments and out-of-pocket limits in the overhaul debate and "it occurred to us that policymakers might want to know what consumers are facing in terms of the charges," she said.
"So we asked the question and we got some fairly startling results," Pisano said.
The study also serves as a volley from an industry that's come in for increasingly tough criticism in recent weeks from Democrats who charge that insurers are standing in the way of the overhaul and ginning up outbursts of opposition at town hall meetings, which insurers deny.
On Tuesday, President Obama at a town hall meeting in Portsmouth, N.H., said that a recent report found that in the past three years, more than 12 million Americans couldn't obtain insurance because of a pre-existing condition.
"Either the insurance company refused to cover the person, or they dropped their coverage when they got sick and they needed it most, or they refused to cover a specific illness or condition, or they charged higher premiums and out-of-pocket costs," said Obama. "No one holds these companies accountable for these practices."
Insurers and doctors also have found themselves on opposite sides to a degree in the overhaul fight. The American Medical Association, the largest doctors' organization, in a surprising turn last month endorsed the House overhaul bill (HR 3200) — which includes a public option for health coverage strongly opposed by AHIP.
The AMA said in a statement Wednesday night that the survey does not represent the full picture of physician fees. "The AHIP report is nothing more than a fishing expedition that focuses on the most extreme outliers of the billions of health insurance claims filed annually. To call this representative of the entire physician community is grossly misleading," said J. James Rohack, president of the AMA.
Pisano said the endorsement by the physicians' group did not prompt the study. "I wouldn't look at it that way at all," she said. "We were hearing from our members about problems consumers are facing who go out of network."
AHIP says that doctors' out-of-network charges ought to be on the table for discussion because there's no cap or limit on bills that may be unreasonable. "As policymakers pursue health care reform, we encourage them to look at how much is being charged for services, particularly since higher charges don't mean high quality of care," said Karen Ignagni, president and CEO of AHIP, in a statement.
Pisano said the study also drives home the point that insurance companies are able to ensure affordable care for the insured by forming networks of physicians who agree to lower rates, thus controlling health spending.
However, insurers also have been accused of underpaying for out-of-network charges. New York Attorney General Andrew Cuomo in January reached a settlement with UnitedHealth after he said the company wasn't paying enough of the "usual and customary charges" it was supposed to pay for out-of-network care. Under the agreement, a new database of billing information for the entire country will be created and run by a nonprofit organization, with the help of $50 million paid by UnitedHealth, according to Cuomo's office.
Specter Tells Grassley to 'Stop Spreading Myths' on Overhaul
By Jane Norman, CQ HealthBeat Associate Editor
Republican Sen. Charles E. Grassley of Iowa and Democratic Sen. Arlen Specter of Pennsylvania engaged in a dispute via Twitter on Friday over Grassley's remarks about end-of-life provisions in the House health overhaul bill.
While at a Netroots Nation meeting in Philadelphia, Specter tweeted to Grassley: "Called Senator Grassley to tell him to stop spreading myths about health care reform and imaginary 'death panels.'"
In a follow-up tweet, Specter added that he "had to leave a message—for now. I will talk to him soon."
Grassley was quick to respond. "Specter got it all wrong that I ever used words 'death boards.' Even liberal press never accused me of that. So change ur (sic) last Tweet Arlen," Grassley tweeted.
The exchange came after Grassley's much-publicized comments on Wednesday in Iowa that "we should not have a government program that determines if you're going to pull the plug on grandma."
Grassley, one of six bipartisan Senate Finance Committee negotiators, was discussing language in the House bill that would allow Medicare to reimburse doctors for an "advanced care planning consultation" for seniors, if they choose to have such a session.
Former Alaska Gov. Sarah Palin has popularized the term "death panels" for the provision, drawing rebuttals from AARP and others—and apparently using a description that Grassley would avoid.
Meanwhile, White House officials invited to criticize Grassley's "pull the plug on grandma" line handled the flap gently, suggesting they're reluctant to disrupt the bipartisan negotiations.
Liberal talk show host Ed Schultz on MSNBC called Grassley's comments a "flat-out lie" while interviewing Linda Douglass of the White House Office of Health Reform.
"And are you telling us that the White House still thinks he's a really good guy and going to operate in good faith for a bipartisan agreement?" asked Schultz.
"Well, you know, Senator Grassley has been working very hard, as you know, with Senator Baucus and the other senators on the Senate Finance Committee to try to craft a compromise piece of legislation that would have bipartisan support, that would lower costs, that would protect your choices of your doctor and your plan," said Douglass.
"So, Senator Grassley has been working on all of that for many, many weeks very hard," she said. "Obviously, he's got a point of view about this particular provision, but he has been working with the other senators to try to come up with health reform legislation."