By Emily Ethridge, CQ Roll Call

December 12, 2013 -- Even as Congress makes important progress in replacing how Medicare pays physicians, many hurdles large and small remain to be negotiated next year.

The House passed, 332-94, a bipartisan budget deal last week (H J Res 59) that was coupled with a short-term fix to avert a scheduled 24 percent cuts in physicians' reimbursements that would begin Jan. 1 under the current formula.

The budget deal now goes to the Senate for final passage. Stakeholders hope the three-month doctor patch, which would give providers a 0.5 percent update, will buy more time for finishing work on a replacement measure.

The short-term patch also would continue various Medicare and Medicaid "extender" provisions, and would save $300 million over 10 years, according to the Congressional Budget Office (CBO).

In more sweeping action on a long-term replacement, the House Ways and Means Committee and Senate Finance Committee recently approved measures that would permanently repeal Medicare's flawed physician payment formula, based on the sustainable growth rate (SGR). Although the committees were considering similar measures, the markups were very different.

The House panel moved much more quickly. Ways and Means considered only a chairman's substitute amendment to an existing bill (HR 2810), and approved, 39–0, the amended bill by the time the Senate committee was done with members' opening statements.

The Senate Finance Committee approved its measure by voice vote after five hours of work, often interrupted by votes on the Senate floor. Lawmakers withdrew most of the 140 amendments that had been filed to the legislation, which is based off a draft framework the committee crafted with Ways and Means.

The committee adopted seven amendments by voice vote, including one that would create a demonstration project version of bipartisan mental health legislation (S 264) sponsored by Debbie Stabenow, D-Mich.

But even though lawmakers and stakeholders are encouraged about the prospects for a replacement bill, many obstacles remain ahead—including the major question of how to pay for it. No offsets are included in the long-term fix. Lawmakers insist that they will find a way to offset any measure's cost, but are saving that discussion for the floor.

"Let me say it in no uncertain terms: This bill will be offset. Period," said Senate Finance Ranking Republican Orrin G. Hatch of Utah at the markup. He said he has had "extensive discussions" with Committee Chairman Max Baucus, D-Mont., and House committee leaders, and that they have agreed that "once the bill is out of committee, we will sit down to find suitable offsets."

The CBO found that simply repealing the SGR for 10 years would cost $116.5 billion over 10 years. It found the Senate Finance Committee legislation would cost $148.6 billion over that time period, and a replacement bill approved by the Energy and Commerce Committee in July (HR 2810) would cost $153.2 billion.

House Ways and Means Committee Chairman Dave Camp, R-Mich., said that the lower CBO score allowed him to give providers a 0.5 percent increase for three years in his amendment.

Still, he added, "Though the score is the lowest ever, it still must be paid for. And I am under no illusion that finding pay-fors will be an easy task."

Many House Democrats said that they would not support an offset that undermines the 2010 health care law (PL 111-148, PL 111-152) or puts more financial burden on Medicare beneficiaries.

Several Ways and Means panel members noted issues they had with the legislation and changes they would like to make—but they held off on offering amendments.

After citing several items that troubled him, including expanding the authority of the Centers for Medicare and Medicaid Services and interfering with Medicare's fee-for-service system, Georgia Republican Tom Price said he had "a lot of other concerns, but this day is a real opportunity," and voted for the bill.

Another big difference between the bills that remains to be worked out is the matter of the health care "extenders," which Congress typically renews each year for short periods of time. Neither of the House measures would address those payment policies, but the Finance Committee bill would renew some of them permanently and extend others for several years.

Hatch said the committee had taken "a thorough and complete look" at those provisions. "For those we believe are still justified, we will make them permanent. For others, we will extend for a period of time so we can continue to assess them," he said.

Several Democrats on the House panel called for the final legislation to include language addressing those extenders.

Some of the amendments adopted by the Finance Committee dealt with those extenders, including one that would extend a program that allows certain Medicaid beneficiaries to continue receiving benefits as they work more hours or increase their income. The amendment, from Democrats Sherrod Brown of Ohio and Jay Rockefeller of West Virginia, would extend the program for five years but give states additional flexibility to opt out.

The panel also adopted an amendment from Iowa Republican Charles E. Grassley that would make permanent the existing floor for the physician work index, based on three geographic factors, under Medicare's physician fee schedule.

In addition, it adopted an amendment from Grassley and New York Democrat Charles E. Schumer that would make permanent a program that gives additional payments to small rural hospitals and certain low-volume hospitals.

By Melissa Attias, CQ Roll Call

December 12, 2013 -- The Obama administration announced last week that it is extending a temporary high-risk pool program created in the health care law for one month for some individuals.

The extension appears to acknowledge concerns that those patients would not have enough time to enroll in coverage through the new insurance exchanges by the program's Jan. 1 expiration date, particularly with the rocky rollout of healthcare.gov.

According to the Centers for Medicare and Medicaid Services (CMS), those who are currently enrolled in the Pre-Existing Condition Insurance Plan (PCIP) but do not yet have other coverage will now have the option of staying in the high-risk pool plan for the month of January.

The program was intended to serve as a bridge to provide coverage for individuals who faced difficulties securing health insurance due to pre-existing conditions until certain provisions of the health care law (PL 111-148, PL 111-52) took effect in 2014. Starting Jan. 1, the law prohibits insurers from denying coverage or charging higher premiums due to health status.

But House Energy and Commerce Committee Chairman Fred Upton said that Health and Human Services (HHS) Secretary Kathleen Sebelius did not mention this change or any others announced last week when asked about upcoming delays at a recent hearing.

"Unfortunately, withholding information from the public has become the norm," the Michigan Republican said in a statement.

"The administration has known for many months that this law was not ready for prime time, and Americans who depend on high-risk pools would have been better served by the administration admitting their failures sooner and working with the Congress to protect these and other Americans being harmed by the health care law," he added.

The program has served more than 135,000 people, CMS said, and offers security to some of the nation's sickest patients.

"Today, as part of our efforts to smooth the transition to the Marketplaces for those seeking coverage that begins in January, we are taking steps to ensure that Americans enrolled in the federal PCIP insurance plan will not face a lapse when the new year begins," said CMS spokesman Aaron Albright, in an email. "We are committed to providing consumers additional flexibilities while they evaluate and select a quality, affordable, health plan that meets their needs."

But Senate Minority Leader Mitch McConnell pounced on the announcement as "a clear admission that Obamacare is failing Americans with preexisting conditions who are losing the plans they already had." He said that millions of people were kicked off of their plans, but that "only a fraction of that number" have successfully signed up on the exchanges.

"How many extensions and waivers is it going to take for the administration to admit the consequences of Obamacare that are hitting millions of Americans they promised it would help?" the Kentucky Republican said in a statement.

Although the 2010 overhaul says that the program will end on Jan. 1, 2014, CMS noted that it also gave federal officials the authority to extend the coverage beyond 2013 in order to avoid a lapse in coverage for those who are transitioning to plans on the exchanges. Avoiding that lapse is important, CMS said, because many enrollees are receiving regular treatments for cancer, diabetes and other diseases.

Chris Hansen, president of the American Cancer Society Cancer Action Network, echoed that sentiment in a statement praising the decision.

"Extending the PCIP will give tens of thousands of people with a history of cancer or another serious disease the security of knowing they will not face a costly gap in coverage on Jan. 1 if they cannot enroll in a marketplace plan by Dec. 23," Hansen said. "People living with a chronic disease such as cancer must carefully weigh several factors when choosing a health plan, including premiums and other out-of-pocket costs, coverage of necessary care including prescription drugs, and available financial assistance options. Extending coverage under PCIP gives patients valuable additional time to select the marketplace plan that best meets their unique needs."

The National Association of State Comprehensive Health Insurance Plans (NASCHIP), which had previously urged an extension through March, also applauded the move in a statement. The group represents state high risk pools, including some that were administering the federal program.

"The challenges with healthcare.gov have been particularly troubling for those high risk members who may be premium subsidy eligible but would have been forced to enroll by December 23rd to avoid a lapse in coverage," said NASCHIP President Tanya Case. "Many of these members are medically fragile and high utilizers of medical care and some are in the midst of critical treatment that cannot and should not be interrupted."

Case also noted that her group plans to work with HHS to closely monitor the situation and will once again call for a longer extension if problems continue.

CMS said it will continue to look for other ways to make the transition to the exchanges easier for all consumers, including those in the federal high-risk pool program. The agency also noted that some state programs are considering a similar extension.

Although Republicans have been working to repeal the health care law, House GOP leaders sent a letter to President Barack Obama in March asking him to support moving funds within the overhaul to cover continued enrollment in the federal high-risk pool program. The letter came after the administration announced in February that it was halting enrollment, citing cost concerns.

House Republicans went on to try to advance legislation (HR 1549) that would have taken about $3.7 billion from the health care law's prevention fund and funneled that money toward continued enrollment. But some Republicans and conservative groups expressed opposition to the legislation, arguing that it would extend and not repeal the president's signature law, and it was pulled from the House floor in April.

Although the legislation was later reworked in an attempt to address those concerns, sponsor Joe Pitts, R-Pa., said in July that the revised version also lacked the necessary votes and it was never brought back to the floor. The updated language would have completely repealed the prevention fund and provided funding for state-run high-risk pools rather than the health care law's program.

By Kerry Young, CQ HealthBeat Associate Editor

December 12, 2013 -- The top U.S. health official has asked for a list of concessions from insurers to aid consumers trying to sign up for coverage through the new federal exchange—including making coverage retroactive if consumers miss deadlines.

The announcement aims to avoid gaps in coverage stemming from missteps in the startup of the healthcare.gov website.

One of the recently announced steps is to continue the Pre-Existing Condition Insurance Plan through January. It had been scheduled to end this month.

The steps announced by Health and Human Services Secretary Kathleen Sebelius in an interim final rule include formally requiring insurers to provide coverage beginning on January 1 if a person pays by Dec. 31. That takes away the companies' right to set earlier deadlines.

HHS also said that it was formalizing an earlier decision to move back the deadline for signing up through the marketplaces to Dec. 23 from an earlier cutoff date of Dec. 15.

But Sebelius also called on insurers to make other accommodations that would cover consumers if they miss these deadlines.

"We will consider moving this deadline to a later date should exceptional circumstances pose barriers to consumers enrolling on or before December 23," HHS said in a fact sheet. "This includes allowing issuers to offer retroactive coverage for people who sign up after Jan. 1. For example, if a person signs up and pays on January 5, they can have coverage with a start date of January 1," qualifying them for an advance premium tax credit, the fact sheet said.

Aetna Inc. already has agreed to allow people to make their first payments for coverage through exchange plans as late as Jan . 8 for coverage retroactive to Jan. 1, said Cynthia Michener, a company spokeswoman, in an e-mail. There was no immediate comment from America's Health Insurance Plans, the trade group for the industry. The office of the No. 2 House Republican, though, quickly offered up its assessment of the HHS announcement. "It's clear the administration knows Obamacare's problems are only going to get worse, and patients will be the ones who suffer," said Rory Cooper, a spokesman for Majority Leader Eric Cantor, R-Va. "What's not clear is whether they understand the confusion and chaos they continue to cause."

On a call with reporters, Sebelius said HHS is also urging insurance companies to make some voluntary concessions to ease the transition in the marketplace for consumers.

"We're encouraging insurers to allow consumers who pay portions of their premiums, such as a down payment, to be able to start their coverage on time," she said.

In addition, HHS said it was "strongly encouraging" insurance companies to treat out-of-network providers as in-network to ensure continuity of care for some services. It also wants insurers to treat out-of-network providers as in-network if they are listed incorrectly in a plan's provider directory as participating in the plan.

HHS also is "strongly encouraging insurers to refill prescriptions covered under previous plans during January."

By Kerry Young, CQ HealthBeat Associate Editor

December 11, 2013 -- Medicare's providers face an added two years of automatic spending cuts under the budget agreement recently announced by the leaders of the House and Senate budget committees.

That would help offset the costs of temporarily easing the impact of sequester provisions of the budget control law on operating budgets of federal agencies.

The unexpected development drew a mixed reaction from health lobbyists. A top hospital official said the move will threaten access to critical services. But medical research advocates said they'd back the agreement, which may lead to some lessening of the cuts to the National Institutes of Health.

Doctors also stand to get some benefit from the agreement in that it is being paired with a House proposal that shifts the timing of some sequester cuts to pay for a near term three-month payment patch.

The agreement announced last week by Sen. Patty Murray, D-Wash., and Rep. Paul D. Ryan, R-Wis., would lessen for 21 months the impact of the sequester provisions of the budget control law (PL 112-25).

But the automatic two percent yearly cut providers including hospitals, skilled nursing facilities, and doctors take under that law would be extended to include fiscal years 2022 and 2023. It now runs through fiscal 2021.

The lobbying group for for-profit hospital chains asked lawmakers to reject the deal.

"The budget agreement threatens access to critical health care services for seniors by trading off Medicare cuts for increases in government and defense spending today," said Chip Kahn, president of the Federation of American Hospitals. "It sustains bad budget policy under the guise of solving real mandatory spending issues facing this country."

The House may vote soon on the agreement, which would raise the cap on the federal government's operating expenses by $63 billion for the next two fiscal years. To do this, the bill would change the terms of the sequester now demanded by the budget control law. The cap for fiscal 2014 would rise to $1.012 trillion from the current $967 billion limit on regular discretionary spending.

Democrats and Republicans in both parties and both chambers have long derided the sequester as a dumb way to do budgeting. Cuts are made indiscriminately to both effective and ineffective programs, they note.

Help for Docs, But Risks Too

The Murray–Ryan deal is being paired with a House measure that includes language to prevent for three months a January 1, 24 percent cut in Medicare payments to physicians. To pay for the temporary patch, the House language tweaks the timing of when sequester cuts to providers occur a decade from now.

The way the 2 percent reduction would be applied in fiscal 2023 would be shifted. The reduction would be 2.9 percent in the first six months, and then 1.1 percent reduction in the last six months.

With the Murray–Ryan deal, it may appear a somewhat easy trade for lawmakers to swap future cuts to Medicare payments to gain an immediate boost for the budgets of federal agencies. Congress after all sometimes later softens the blows called for by budget deals when faced with lobbying by constituents and affected groups. But there are risks to the way Murray and Ryan are using Medicare as an offset mechanism.

Ed Lorenzen, a senior adviser for the Committee for a Responsible Federal Budget and former budget aide to Minority Whip Steny H. Hoyer, D-Md., pointed out that extending the sequester on nondefense mandatory spending—a category that under by the 2011 budget law largely boils down to Medicare—would increase the odds of these automatic cuts becoming permanent.

"When we start on the budget next year with the ten year-budget window of FY '15-FY '24, anyone looking for offsets can get roughly $15 billion savings in the budget window by extending the sequester another year," Lorenzen said in an email. "Simply extending an existing policy for one more year ten years out to pay for costs of legislation with benefits now will be a very tempting option, especially compared to the alternative of doing something new and painful now."

Debt Ceiling Fight Too?

Medicare also could be the target for a more deliberative approach to cost savings in the next big budget fight, which will start next month.

"Remember that we have got the debt ceiling coming up in February. It is more likely that you would see a larger kind of deal that gets into mandatory spending reform on the debt ceiling," said John Hoeven, R-N.D., who serves on the Senate Agriculture and Appropriations committees, in a recent interview.

Hoeven said that he would like to see changes made to Social Security, Medicare and Medicaid in such a deal on the scale that's being contemplated for mandatory-spending programs in the farm bill negotiations. Conferees have been working this week to iron out the final details in that legislation.

"We're showing that in the farm bill we are going to get on the order of $30 billion in savings" said Hoeven, a conferee on the measure. ¨I think that is exactly the kind of thing that we can do" with entitlements in a larger deal.

Hoeven said that any major changes to Medicare would likely exempt people who are within 10 years of traditional retirement age, so those who are 55 and older.

"Paul Ryan has talked about that," Hoeven said.

Hoeven said that he would like to see lawmakers do more to shift Medicare away from its current system, in which the agency has been paying more for the volume of care rather than focusing on quality.

"That's an incentive for abuse and so you change some of those things, and you would see more savings," Hoeven said.

By Rebecca Adams, CQ HealthBeat Associate Editor

December 10, 2013 -- The Centers for Medicare and Medicaid Services (CMS) approved a Medicaid expansion waiver requests by the state of Iowa last week. CMS officials made few changes to the state's plan, although they will not let the state charge monthly premiums to very low-income people.

The approval shows how eager federal officials are to encourage states to expand the program for low-income Americans under the health law (PL 111-148, PL 111-152).

The Iowa plan is similar to one for Arkansas that CMS officials approved in September. Both states will use Medicaid dollars to buy coverage offered through the new marketplaces.

In Iowa, the state will buy marketplace insurance plans for people with income between 100 and 138 percent of the federal poverty line who are between the ages of 19 and 64.

The approvals for Arkansas and now Iowa could encourage officials in other states to consider offering benefits in the same way.

In both states, people in the new population with income at or below 100 percent of the federal poverty line and medically frail people will receive coverage under the traditional Medicaid program. This helps ensure that a few high-cost people will not drive up costs for other people in the marketplaces and allows vulnerable people to use a system that is more familiar to them, officials said.

In 2013, the federal poverty line is $11,490 for a single person.

In Iowa, state officials will be allowed by CMS officials to charge a monthly premium to people with income above the federal poverty line. Some consumer advocates worry that could discourage people from enrolling.

Federal officials did not approve Iowa's request to charge premiums to people with incomes between 50 and 100 percent of the federal poverty line. An administration official said that CMS does not believe requiring the payment of premiums at income levels that low without safeguards will further the objectives of the Medicaid program, which is the legal standard for granting state demonstration requests.

About 40 states charge premiums to some Medicaid enrollees, but no state charges premiums to people with income below the poverty line.

Iowa officials also will be allowed to create an incentive program to encourage people who are gaining coverage through the Medicaid expansion to adopt healthy behavior. The state also will be permitted to test payment ideas that promote care coordination, lower costs, and higher-quality care.

"Iowa has pioneered innovative, state-based solutions for Medicaid expansion, and we are pleased to grant this waiver," said CMS Administrator Marilyn Tavenner. "CMS stands ready to work with other states to explore options that aim to improve care and lower costs in the Medicaid program."

The Iowa waivers will extend Medicaid coverage to more than 100,000 additional Iowans, said administration officials.

By John Reichard, CQ HealthBeat Editor

December 13, 2013 -- The opportunity to spend time looking over and comparing products in detail before taking the plunge to buy is certainly no less important in insurance shopping as it is in buying a new car.

Thanks to the tinkering of a retired 73-year-old techie in San Francisco who likes to do things on his own that others do by committee, there’s a quick way to do comparison shopping for individual plans in the state and federal health insurance exchanges, health care law boosters say.

The ability to easily window shop for health insurance plans has become critical with time running out to buy Jan. 1 coverage on healthcare.gov, the federal site serving insurance shoppers in 36 states.

A fast, easy way to compare plans also has become more important as insurers seek to directly enroll consumers under the health care law, consumer advocates say.

While “direct enrollment” means consumers won’t have to spend as much time trying to figure out the enrollment process themselves, it could leave people too vulnerable to the pitch of a single company.

And while window shopping has become easier on healthcare.gov, the site developed by computer industry veteran Stephen Morse (http://stevemorse.org/obamacare/obamacare.html) allows visitors to compare more features of plans and puts them all on one screen in a single grid that speeds the process.

And unlike healthcare.gov, it covers all 50 states in the United States and gives quality ratings for plans.

An Example

Take, for example, a 28-year-old smoker buying insurance in Montgomery County, Md. Click on an “all plans” link on Morse’s site and 33 plans are displayed in a grid on a single page that compares monthly and annual premiums (or, select a metal tier such as “silver plans,” and only those plans display).

Click on a “show details” button and all 33 plans appear in a grid on a single screen with added details for each plan. They include yearly deductibles, out-of-pocket maximums, and copays for doctors, hospitals and prescriptions.

Identify a plan of interest and click on the insurer’s name and a Consumer Reports rating of the quality of the plan pops up. It’s based on ratings of health plans by the National Committee for Quality Assurance. The numerical rating on a scale from 1 to 100 is based on consumer satisfaction, the performance of the plan in preventing and treating disease, and its accreditation status.

Each plan has a “provider link” with a search function to see if a given doctor or hospital participates.

Also on the page is a subsidy calculator. Enter “one person” under household size and $20,000 under annual income. The page says: “Your income is 174.1 percent of the federal poverty level.”

It explains, “You therefore qualify for a subsidy of $1,170.00 per year (97.50 per month) that you can apply to any non-catastrophic plan.”
It adds: “The most you’ll need to pay for a silver plan is 5.1 percent of income, or $1,021.39 per year ($85.12 per month).”

It notes that “the actuarial value of any silver plan you purchase will be 87 percent instead of the normal 70 percent.” It explains that “you qualify for cost-sharing reductions that improve the actuarial value from 70 percent to 87 percent on any silver plan you purchase.

“The actuarial value is the percentage of your healthcare costs that the insurance company will pay, on average, after considering such things as copays, deductibles, coinsurance, and maximum out-of-pocket limit.”

As soon as the subsidy is calculated, the grid fills in instantly to include the cost of monthly premiums for each plan after subtracting the subsidy.

By unclicking the check mark in the “uses tobacco” box, the 28-year-old smoker instantly finds out how much money can be saved in the future on plan premiums if the smoker kicks the tobacco habit.

The tobacco feature notes that there is no tobacco surcharge in California, the District of Columbia, Massachusetts, New Jersey, New York, Rhode Island and Vermont.

Try the same search on healthcare.gov and a visitor is directed to the Maryland state-run exchange site. That marketplace gives detailed information on plans but doesn’t set them up on one page in a way that quickly concentrates in a relatively small screen space such a wide range of comparative information on such a large number of plans.

Neither does healthcare.gov. And neither site gives speedy access to quality ratings or allows one to quickly compare premiums after subtracting subsidies.

Healthcare.gov does not have quality ratings. It requires going to a separate page to estimate one’s subsidy if one qualifies. The visitor must then go back and subtract that sum from premium amounts.

A Mechanism to Unleash Market Forces

Easy “window shopping” was supposed to be one of the big breakthroughs of the new insurance exchanges created under the health care law—a huge time saver for anyone who has attempted to go through thick insurance booklets to find and compare plan features.

It also is supposed to be the mechanism to unleash market forces as never before in the insurance market by making it easy for consumers to find the best values, forcing plans offering lesser values to innovate to keep pace.

But when healthcare.gov launched on Oct. 1, visitors couldn’t check out one plan against another without first creating an account, a step that required verification of one’s identity. Account creation worked so poorly that millions were unable to compare plans online for weeks.

To be sure, healthcare.gov’s window shopping feature has been greatly improved. A big “See Plans Before I Apply” button was added Dec. 1 and drew millions of hits right away. A number of other sites also exist that let people get a better idea of what’s out there fairly quickly and what they would have to pay. They include Sherpa and Valuepenguin, for example.

The Morse site is unpolished in appearance compared to some of the other sites and is still relatively unknown, but has strong devotees. Tony Hausner, a retired Centers for Medicare and Medicaid Services official now heavily involved in efforts to enroll the uninsured in Maryland, gives it the best ratings.

Former White House official Ezekiel Emanuel co-wrote an opinion piece in Politico on Nov. 15 in which he gave the Morse site a strong recommendation. “He built a simple, user-friendly anonymous shopping tool that compiles pricing information from all of the plans on the state and federal health insurance exchanges and provides custom, premium readouts according to age, location, tobacco use and income,” wrote Emanuel.

But can the sites be trusted? Lynn Quincy, a health policy analyst with Consumers Union, the publisher of Consumer Reports, says her organization has not evaluated the various window shopping sites. One area in which consumers must be cautious in using such sites is in considering whether they might have a bias toward particular insurers, she says.

‘Scraping Data Sets’

For his part, Morse asserted in an interview that his site has no such bias, and he does what he does for free.

His career in the computer industry was a distinguished one. The publication PC World says Morse was the electrical engineer who was most responsible for Intel’s 8086 chip, which in a 2008 article it called “the microprocessor that set the standard that all PCs and new Macs use today.”

After career stops that included Bell Labs, IBM, Intel, and Netscape, Morse said, he has a hobby in retirement of tinkering with data sets that support websites. He said he likes to see if he can make the websites work better in ways that help people. “I have all the tools for scraping data sets,” he said.

Morse has used those tools to make genealogy searches much quicker and easier and has said his genealogy site gets 100,000 hits a day. When he heard about healthcare.gov’s problems shortly after its launch, he wondered about applying his expertise to make that site work better.

But he figured that the problems would be fixed and didn’t bother. When the site remained mired in glitches moving into late October, Morse decided to act.

He said he put up his health plan site within a day, and now spends time refining it to weed out any errors he finds or that users report.

How is it possible that Morse by himself could act so quickly when healthcare.gov struggled with its window shopping feature? “I’m fast,” he said.

Asked whether he has ever contacted CMS about his work, Morse said no. “I have never contacted them. I didn’t feel that it was my place to do so,” he said.