By Caitlin Webber, CQ Staff

January 22, 2008 -- An economic downturn in the United States could threaten access to medical care and serve as the catalyst for comprehensive health care overhaul, predicted an expert during a panel discussion on lessons learned from the 1990s failed health overhaul attempt.

A recession in the economically sensitive American health care system, with market-based treatment costs and employer-provided insurance, would raise the stakes for national overhaul, said Brian Biles, a George Washington University health policy professor and former assistant secretary of Health and Human Services under President Clinton. Biles spoke as part of the forum held Friday by the non-partisan Alliance for Health Reform and Robert Wood Johnson Foundation.

In contrast to the golden economy surrounding 1993–1994 overhaul efforts, Biles said "in the U.S., where health care is employment-based and when people lose jobs they lose health care, with a recession … could come the commitment to do something about it."

The cautious panelists also warned that comprehensive overhaul would also require robust public support and delicate political conditions.

"Health care reform is not done in a vacuum" said Chris Jennings, a senior health care advisor to President Clinton in 1993 and 1994. "It has a lot to do with timing, implementation, and people."

Panelists said health care advocates would face more acute challenges in 2009: costs are higher, partisanship is deeper, media scrutiny is more intense, and access to insurance will have deteriorated since the last comprehensive overhaul attempt failed in 1994. Proponents of changing the health care system would still have to vie with the many stakeholders and myriad interests invested in the health care debate, which plagued overhaul efforts nearly 15 years ago, they said.

"This issue is the one issue in our lives that touches every single thing: tax, spending, welfare…. It is life and death; you have to expect it'll be bloody," said Christine Ferguson, former chief of staff to the late Sen. John H. Chafee, R-R.I., who was a key player in the centrists' effort to create a bipartisan overhaul plan.

Experts said that the overhaul would have to top the congressional agenda and require a singular dedication from the president. Lawmakers should also aim to simplify proposals, allowing details to be resolved after enactment, and propel legislation in the beginning of the congressional session, ideally in the year after the presidential election, when political capital is highest.

"The [Clinton] administration took too long to send legislation to Congress; by January, the clocking was ticking," Biles said. He attributed the Clinton proposal's floundering to "not taking the momentum of the one-year congressional cycle … [and] the failure to use the budget reconciliation process."

By Reed Cooley, CQ Staff

January 23, 2008 -- The Blue Cross and Blue Shield Association, whose members provide health care coverage to nearly one in three of all Americans, unveiled a new proposal Wednesday that aims to cover a large chunk of 47 million uninsured Americans.

The Blue Cross Blue Shield Association (BCBSA) plan emphasizes private and public cooperation, incentives rather than mandates, and an improvement of the existing system rather than looking for new modes of coverage. The association hopes that the five-point proposal will extend coverage to two-thirds of America's uninsured, or about 35 million people, as well as improve the quality of care.

"We believe the best approach is to build upon the current employer-based system—a system which is working today," said Scott P. Serota, president and CEO.

The plan is a second attempt by BSBCA to tackle the problem of the uninsured. In 2007 the group, as part of a larger coalition, released a proposal to cover more Americans, but the plan never came to fruition. BCBSA acknowledged at a Wednesday news conference that a portion of its new proposal, which focuses on public and private cooperation, shares many similarities with the 2007 plan.

However, the key difference is that the new plan looks at changing the delivery system rather than just expanding access, said Mary Nell Lehnhard, senior vice president, Office of Policy and Representation at BCBSA.

Specifically, the new proposal promises to reimburse providers based on quality standards designed by third party evaluators, to help providers and consumers adopt and make use of electronic and personal health records, and to create a new nationwide database to record the claims experiences of 80 million BCBS costumers.

Each of the five points also contains recommendations on what state and federal governments should do in cooperation with the proposal. Suggestions include tax credits, health education programs and the creation of an independent entity—a Comparative Effectiveness Research Institute—to evaluate cost and clinical effectiveness of various procedures, drugs, and technologies. BCBSA also recommends expanding public programs to cover all individuals living below the Federal Poverty Line ($10,210 annually for individuals and $20,650 annually for a family of four in 2007).

Serota did not put a price tag on the proposal and said that BCBSA had not yet identified revenue sources to back the tax credits. He said that the Association was suggesting that all private and public payers fund the proposed institute.

The Association has enlisted the help of Sens. Kent Conrad, D-N.D., and Max Baucus, D-Mont, in drawing up language for a bill to support the plan, but Serota and his colleagues expressed some concern that the legislative progress would be slow in a contentious election year.

Serota said BCBSA has touched base with each viable presidential candidate for the 2008 election, in hopes of building a foundation for cooperation in the new term.

By John Reichard, CQ HealthBeat Editor

January 25, 2008 -- Senate Finance Committee members who met Friday morning to lay out the options for an economic stimulus package discussed the possibility of temporarily boosting federal Medicaid spending to help jump-start the economy, but there were no immediate signs they would push hard for such a provision at a markup next week.

Committee Chairman Max Baucus, D-Mont., was mum after the meeting about Medicaid or any other specific provisions that might go into the Senate version of the stimulus package, saying only that he sees an opportunity to build on the agreement announced Thursday by House leaders and the Bush administration.

Meanwhile, advocates of the increase are pinning their hopes on the Senate version of the package. Labor, provider, and patient advocacy groups scrambled to join state governors in urging the Senate to add Medicaid increases, sending a letter to congressional leaders Thursday signed by 87 organizations saying that in the last recession, Medicaid cuts "caused one million families and children to be cut off or denied Medicaid."

"Local government revenues are plummeting in many areas, due to falling property tax revenues that reflect the decline in home values," said the letter signed by the AFL-CIO, the American Federation of State, County, and Municipal Employees, the American Hospital Association, the Children's Defense Fund, the American Health Care Association, and the National Conference of State Legislatures, among other groups. "To avert slashing fire, police, and education in response to falling property tax revenues, many local governments are now beseeching their states to help fill that gap. But that puts even greater pressure at the state level on programs like SCHIP [the State Children's Health Insurance Program] and Medicaid."

The National Governors Association (NGA) said this week that temporarily increasing the percentage the federal government pays of Medicaid costs—the "federal medical assistance percentage" (FMAP)—is a top priority for governors on a bipartisan basis in the economic stimulus package. The NGA said in a statement Wednesday that "the nation's governors strongly support a combination of a $6 billion block grant and $6 billion in increased Medicaid funding to be included in any stimulus package enacted into law during the economic downturn of 2008.

"As a condition of receiving the enhanced FMAP, states should be barred from reducing Medicaid eligibility as was the case in 2003" when states received fiscal relief, the coalition letter said. "Fiscal assistance to states and localities, as a growing number of states confront budget deficits, constitutes an effective stimulus, shoring up budgets while preserving essential services for millions of low- and middle-income families."

Oregon Republican Senator Gordon H. Smith said that Finance Committee members who attended the meeting Friday morning—about half of the panel's members attended—had "a good discussion" about a temporary increase in federal Medicaid spending. "I think there's general support for it, but an unwillingness to scuttle the package over it," Smith said.

"At this point, it's one of the items on the table," said Debbie Stabenow, D-Mich. "There have been no decisions."

"One of the issues that was raised was where the White House would be," Stabenow said. "The extent to which the president would support it obviously becomes key if we're going to get it done." President Bush agreed to a temporary increase in FMAP rates in 2003 legislation that included major tax cuts, but Medicaid provisions are not a part of the agreement announced Thursday negotiated by the administration and House leaders.

"We're not going to comment on every idea that's floating out there," said White House Spokesman Tony Fratto when asked about the administration's reaction to including Medicaid provisions. "But I think we've made it very clear that we got to a very good bipartisan agreement with the House." He added that the Senate "runs the risk of getting bogged down" and of upending the deal if it begins considering a wide variety of provisions.

Medicaid is competing with extending unemployment insurance and improving food stamp benefits among the provisions the Senate might try to add to the stimulus package. The latter two provisions may be higher priorities on the Finance panel. Unemployment insurance "is very important" to Michigan, Stabenow said.

Unemployment insurance and food stamp provisions also were discussed at the meeting, Smith said. "I think there's an openness to it, again with the idea to not jeopardize this bipartisan opportunity to actually do something to be helpful," he said. "And so it's a balancing act that we'll have next week, and so we'll have a markup next Wednesday or Thursday."

House Speaker Nancy Pelosi, D-Calif., suggested Thursday that Medicaid and unemployment insurance might be handled in follow-up legislation, and lobbyists are speculating about the possibility of a second stimulus package later this year. But New Hampshire Republican Sen. John E. Sununu, a newcomer to the Finance panel, said "my sense from the discussions is that we'll have a good opportunity to get a bipartisan package here, to get something signed into law in the next couple of weeks. But any subsequent package in May or June or July of of this year is going to run into presidential politics, and I think realistically that means we'll have one opportunity to put together an economic growth package."

By Alex Wayne, CQ Staff

January 23, 2008 -- The House failed Wednesday to override President Bush's second veto of a children's health insurance bill, again confounding Democrats' plans to expand government-sponsored health coverage to include an additional four million low-income kids.

The override failed 260–152, 15 votes short of the two-thirds majority required. Democrats wound up no closer to enacting their signature health policy proposal than they were in October, when their attempt to override Bush's first veto failed by 13 votes. In fact, Democrats lost ground since they passed the second bill Oct. 25 by 265–142, because three Democrats and two Republicans who supported that bill were absent for Wednesday's vote.

The bill (HR 3963) would expand the State Children's Health Insurance Program, or SCHIP, by $35 billion over five years, to $60 billion. The expansion would be financed by an increase in tobacco taxes, including a 61-cent hike of the cigarette tax to $1.00 per pack. Democrats said the money would be enough for SCHIP to cover 10 million children, about 4 million more than it covers now.

Since last week, Democrats have been making a new argument in support of the bill, describing it as part of a plan to jump-start the flagging economy.

"Here we have a Republican administration making it more difficult for states to cover children at the same time as the need becomes greater every day," said Rep. Frank Pallone Jr., D-N.J., chairman of the Energy and Commerce subcommittee on Health. "It's an absolute disgrace in my opinion that this bill was vetoed."

Most Republicans oppose the bill—as well as a previous, very similar measure (HR 976) —because they say, variously, that the bills would cost too much, or raise tobacco taxes too much, or would draw too many middle-income families out of private insurance, or would allow SCHIP to continue covering adults, or would allow illegal immigrants to enroll in the program.

A statement from the White House called the legislation "misguided" because it "would have expanded SCHIP to higher income households while increasing taxes."

Democrats claimed they responded to those concerns in this latest version of the measure, chiefly by including language in the second bill that would cap eligibility for SCHIP at three times the poverty level, or about $64,000 for a family of four.

"Republicans' position is: continue the existing program, perhaps expand coverage somewhat for families above 200 percent of poverty, and cover every child in the country under 200 percent of poverty," said Rep. Joe Barton of Louisiana, the senior Republican on the Energy and Commerce Committee.

Republican leaders have dismissed the idea that the bill is part of an economic stimulus package, saying that expanding a government program will not help the economy.

The failed override does not jeopardize the existing program. Bush signed a law late last year (PL 110-273) that keeps SCHIP running through the end of March 2009 with enough money to maintain coverage at current enrollment levels.

But Democrats consider SCHIP's expansion a powerful political issue, and may seek to force Republicans to vote on it again before the November elections.

By Emily P. Walker, CQ Staff

January 24, 2008 -- Congress should direct the Department of Health and Human Services (HHS) to designate a program that determines which health care services work best, an Institute of Medicine (IOM) report released Thursday recommends.

Specifically, IOM recommends an entity—a public group or one that is public–private—"with the authority, expertise, and funding necessary to set priorities for evaluating clinical services, to conduct systematic reviews of the evidence available on these priorities, and to promote the development and use of standards-based clinical practice guidelines," according to a brief on the report.

Currently, hundreds of studies, recommendations, and guidelines exist that contain a dizzying amount of information on any given medical service, drug, device, or program.

The IOM report lays out a blueprint for a private or private–public group to reach a meaningful clinical conclusion on the effectiveness of any given health care product: such as hip-replacement surgery or a blood pressure medication.

According to one of the report authors, organizations that set clinical practice guidelines would be encouraged to adhere to the group's guideline standards, and use the group's vetted data for their recommendations.

Medical societies, patient groups, government agencies, and others already do aspects of what the IOM report says a new organization should be formed to do—synthesize existing clinical studies.

But, according to one of the report's authors, there is currently no standard for synthesizing studies and producing guidelines from the results.

"There needs to be one group that says these are the standards for systematic review," said Barbara McNeill, head of the department of health care policy at Harvard School of Medicine.

The report argues that a single entity that provides "credible, unbiased, and understandable syntheses" of all available studies "could help minimize the use of questionable services and target services to the patients most likely to benefit."

Health plans also could use information provided by the group to learn how policyholders might benefit from newly available health services, the report said.

The group's findings—which would perhaps be viewable on a Web site—also could serve as a resource for medical professionals who do not have time to read dozens of studies and reviews, or who do not want to make their clinical decisions based on manufacturer-sponsored recommendations.

The group also would be responsible for setting priorities for about what clinical services need to be evaluated through systematic reviews of clinical effectiveness.

To cut down on potential bias, the IOM recommends that HHS appoint a board that represents "diverse public and private sector expertise and interests" to oversee the program.

Grace-Marie Turner, president of the Galen Institute, a free-market health care reform think-tank, said she worries that such a group might either oversimplify conclusions, or not be able to keep up with study results that change because of the availability of new data.

However, she said does see value in ensuring that the public has results from all reputable studies on a particular issue.

Karen Ignagni, president and CEO of America's Health Insurance Plans, issued a statement on the report that said, "With new treatments and technologies introduced each day, providers need a dependable and trusted source of information that provides useful guidance on treatment options available. A national entity to compare the effectiveness of new technologies will help the nation evaluate what works, what doesn't and how best to allocate resources.

By CQ Staff

January 25, 2008 -- The leaders of the Senate Finance Committee are urging the Centers for Medicare and Medicaid Services (CMS) to work with a variety of groups to implement provisions of a new law that expands a Medicare physician reporting initiative.

In a letter sent Wednesday to Acting CMS Administrator Kerry Weems, Finance Chairman Max Baucus, D-Mont., and the panel's ranking Republican, Charles E. Grassley of Iowa, said it is important for CMS to work with the National Quality Forum, the American Medical Association's Physician Consortium for Performance Improvement, specialty societies, and other stakeholders "to ensure the most meaningful measures are available" for use in the Medicare physician quality reporting initiative.

In December, President Bush signed into law legislation (PL 110-173) that stopped a scheduled cut in Medicare physician payments and extended federal funding for the State Children's Health Insurance Program (SCHIP) through March 2009. Provisions of that legislation extended the 1.5 percent incentive payments for physicians who successfully report measures during 2008, and the law removes the application of the cap on calculation of incentive payments for reporting in 2008 and 2009.

In their letter, Baucus and Grassley indicated they intend to "move legislation that would extend incentive payments for 2009 and future years in order to continue making progress toward aligning Medicare payments more closely with the quality of care provided."

The physician reporting provisions, the lawmakers wrote, "are designed to address existing shortcomings" in the current Medicare physician quality reporting program as well as "encourage broader participation by physicians and other eligible professionals, and move toward our long-term vision for a valid, consumer-friendly mechanism for measuring and rewarding the quality of care that clinicians provide."

In their letter, Baucus and Grassley indicated they intend to "move legislation that would extend incentive payments for 2009 and future years in order to continue making progress toward aligning Medicare payments more closely with the quality of care provided."

Bush Administration officials and many lawmakers have expressed support for the idea of linking Medicare reimbursement to the quality of care provided. While many physician groups say they support quality measures and pay for performance—which links payment to the quality of care provided—they say Congress must move cautiously because one set of quality measures will not work for all medical specialties.