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January 12, 2009

Washington Health Policy Week in Review Archive 8ad6de31-1e19-4638-95e1-bc333d8a5d4a

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Commission Broods over Payments for Primary Care

By John Reichard, CQ HealthBeat Editor

JANUARY 8, 2008 -- Medicare Payment Advisory Commission Chairman Glenn Hackbarth wasn't having it. A change in the wording of a proposed recommendation to Congress that, if followed, would seemingly drive up Medicare premiums paid by seniors for doctor care–to say nothing of the already big price tag for erasing a scheduled 21 percent in Medicare payments to physicians next year.

Hackbarth let it be known Thursday–the first day of the panel's two-day meeting dealing primarily with 2010 payment updates — that though he might lose, he would vote against anything higher than a 1.1 percent fiscal 2010 increase for doctors.

In the end, the panel voted Thursday to go along with Hackbarth on the 1.1 percent hike, along with payment updates averaging 2.7 percent for hospitals, an 0.6 percent increase for ambulatory surgery centers, and other payment updates. But the commission did not reach closure on the issue underlying the proposed wording change that made the usually placid Hackbarth dig in his heels — how to remedy shortages in primary care physicians seen as the key to improving the efficiency of health care at a time when rising health costs looming as a major threat to an already troubled economy.

The MedPAC style is collegial, not confrontational, but commissioner Nancy M. Kane made her feelings known to her colleagues that they had not done enough on primary care. "I really feel that primary care is in a state of crisis," said Kane, a professor of management at the Harvard School of Public Health. Kane lives in a state that has expanded health coverage, only to leave many newly insured Massachusetts residents with long waits to see primary care doctors.

She said MedPAC recommendations on the issue are tantamount to "a drop in the pond" when what is really needed is to "move a whole ocean." Kane expressed impatience with the idea of waiting many years for the results of an upcoming Medicare demonstration program testing whether assigning patients to primary care practice-based "medical homes" leads to cost savings and quality improvements. The demo involves paying primary care doctors $50 per member per month to coordinate treatment needs of the chronically ill, improve their preventive care, and to give them easier access to treatment through e-mail communication and expanded hours.

"Do we really have to wait for a demonstration? Let's get moving on this," Kane said. "It's time to fix it. And it's time to fix it at the same level of urgency" that policy makers showed several years ago in adding prescription drug coverage to Medicare, she said. "I would love to see this commission take a stand at that level of urgency, rather than say that there's something that might happen some day in the future once we know all the facts. That's just not the right standard of evidence on this kind of problem."

Commissioner Francis J. Crosson, a physician-executive with the Kaiser Permanente Medical Group, agreed with Kane that the measures recommended thus far by MedPAC fall short of addressing the magnitude of the problem. Crosson also challenged the wording of a recommendation proposed by Hackbarth that "the Congress should update payments for physician services in 2010 by the projected change in input prices less the Commission's productivity goal."

MedPAC's forecast of input price inflation for 2010 is 2.4 percent and the commission's goal for improvements in productivity is 1.3 percent — in other words, MedPAC is pushing doctors to lower their costs through productivity gains and so recommends subtracting the 1.3 percent from the 2.4 percent to yield a payment update of 1.1 percent.

Crosson argued that the productivity adjustment makes no sense for primary care doctors whose work is their "hands, and time, and mind" used in trying to diagnose and manage medical conditions. Crosson called for rewording the proposed recommendation to make the payment update to doctors concurrent with a payment adjustment for doctors mainly involved in primary care. The change would entail dropping the productivity adjustment, Crosson said.

That elicited Hackbarth's comment that he wouldn't support anything above 1.1 percent, noting that increases in payments to doctors drive Part B premiums higher for beneficiaries already struggling to pay for health care and alluding to doctors as a "well-compensated part of the population." Hackbarth reminded commissioners that the productivity adjustment is a prod to make care more efficient in a society in which the elderly are increasingly facing financial difficulty.

Unmentioned was the enormous pressure MedPAC faces from Congress to avoid payment recommendations that worsen the fiscal crisis Medicare faces with the arrival in the program of the baby boomers. Even an added percentage point for doctors means billions in added Medicare spending.

Hackbarth noted earlier in the session that policy changes completed or in progress have increased payments to primary care physicians by 10.6 percent and that two newer MedPAC recommendations relating to primary care that the commission approved on Thursday would boost the rates another 10 percent to about 20 percent. Program-wide adoption of the medical home concept would mean payments on top of that, he said.

"It's not a totally bleak picture," he said. "It's not as rosy as I'd like it to be," but "things are happening."

In addition to voting to recommend the 1.1 percent increase for doctors generally, the commission voted to recommend anew a not-yet-adopted June 2008 recommendation that payments be increased for selected primary care services furnished by doctors and others in medical practices focused mainly on primary care. The adjustment would be made on a budget-neutral basis, meaning it would be paid for by paying less for other types of services.

The second recommendation related to primary care urges Congress to direct the Medicare program to "increase the equipment use standard for expensive imaging machines from 25 hours to 45 hours per week." That shift in effect would pay doctors less for imaging services in practices that use expensive machines such as CT, MRI and PET scanners less than 45 hours a week. The savings — an estimated $900 million in 2010 — would be shifted to payments for other physician services including primary care.

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Coverage Now Nearly Universal in Massachusetts

By John Reichard, CQ HealthBeat Editor

JANUARY 5, 2009 -- Looking at the state as a whole, health insurance coverage is now nearly universal in Massachusetts, with the uninsured rate dropping from just over 5 percent in 2007 to 2.6 percent in 2008, according to a new survey. However, some sub-groups of the population had considerably high uninsured rates, notably Hispanics and residents with household incomes below 300 percent of the federal poverty level.

Released Dec. 26 by the Washington, D.C.-based Urban Institute, the survey last summer of 4,910 Massachusetts households found that 7.2 percent of Hispanic residents were uninsured, compared to less than 3 percent of non-Hispanic residents. About 5 percent of residents with family income below 300 percent of the federal poverty level were uninsured, compared to about 2 percent of those with family incomes between 300 percent and 500 percent of the federal poverty line. Less than one percent of those with family incomes five times or higher than the poverty line lacked health benefits.

Massachusetts adopted a law in 2006 requiring individual residents to carry health insurance and employers to provide coverage or pay a fee if they failed to do so. The law provides subsidies to low-income residents to buy coverage if they are not covered by public programs, which were expanded under the overhaul. The state's Division of Health Care Finance and Policy estimated in August that some 439,000 people have enrolled in private or subsidized coverage since the law was passed. About 8.6 percent of the state's population were uninsured before Massachusetts adopted the law.

According to the latest U.S. Census Bureau figures, which are based on 2007 data, 15.3 percent of the nation's population is uninsured. The uninsurance rate nationally for Hispanics was 32.1 percent, according to the Census figures. Although the Massachusetts plan is viewed widely as a reform model, the state is atypical in that its uninsured population was relatively low before the law was passed and it had access to a relatively large number of federal dollars. In addition, costs associated with the overhaul law have raised questions about its long-term sustainability.

However, the Urban Institute survey found strong support for the law, with three out of four households backing it in 2008, up from 64 percent in September of 2006. Of Massachusetts residents with insurance coverage, 68 percent obtain their benefits through their employers, 15 percent through Medicare, and 17 percent through other publicly funded programs including Medicaid.

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Health Spending Growth Slows -- For Now

By John Reichard, CQ HealthBeat Editor

JANUARY 6, 2009 -- Braked by the smallest increase in prescription drug spending since 1963, health spending in the U.S. grew at the slowest pace in a decade in 2007, rising 6.1 percent in 2007, according to new figures released by the Office of the Actuary at the Centers for Medicare and Medicaid Services.

"We're happy about that," Richard Foster, the head of the office, said at a press briefing Monday. But "I wouldn't expect the good news to continue," he added. Health spending grew at a 6.7 percent rate in 2006.

Foster noted that the 6.1 percent growth rate, although relatively low, still outpaced the nation's economic growth rate of 4.8 percent in 2007. As a result, health care's share of the Gross Domestic Product rose to 16.2 percent in 2007, up from 16 percent in 2006. "So we still have this affordability problem," Foster said. U.S. health spending in 2007 totaled $2.2 trillion, or $7,421 per person.

CMS economists did not tie the spending growth slowdown to the nation's economic woes. They said that the current recession began in Dec. 2007 and so overlapped with the period of the study by only one month. In prior recessions, health care spending held steady while economic growth rates declined, a trend that suggests the current downturn will contribute to sizeable future increase in health care's share of GDP, according to one of the economists.

The most striking finding from the analysis, posted Tuesday by the academic journal Health Affairs, was that retail prescription drug spending grew 4.9 percent in 2007 to $227.5 billion, down from 8.6 percent in 2006. The drug spending slowdown accounted for more than half of the overall slowdown in national health expenditures.

But other types of health outlays grew in 2007 at the same rate or at a faster clip than in 2006. And the more modest increase in drug spending may not last. Foster said it may continue for "a little while," but added that there's a limit to one of the main factors driving down drug spending growth—the rate at which generic drugs are substituted for more costly brand-name drugs.

The substitution rate increased from 63 percent in 2006 to 67 percent in 2007, but at some point that growth rate has to stop, Foster said.

The loss of patent exclusivity for various drugs helped drive the lower drug spending growth rate. In 2006, blockbusters that lost exclusive marketing rights included Flonase, Pravachol, Zocor and Zoloft. The loss of patent exclusivity for other blockbusters in 2007 also contributed to the increased use of generic drugs. They included Norvasc, Ambien, Lotrel, Coreg and Toprol-XL. But expiring patents were only part of the story; the increasing use of lower co-payment charges rewarding the use of generics and discouraging the use of brand-name drugs also was a significant factor.

Slower growth in prescription drug prices also contributed to the slowdown. Prices grew 1.4 percent in 2007, compared to 3.5 percent in 2006. The introduction of generic drug discount programs by large retail chains were one factor in the price moderation, although the rate of brand-name drug price growth fell as well.

"Increased safety concerns for certain prescription drugs in 2007 also likely influenced the drug spending trend, as the Food and Drug Administration issued sixty-eight 'black box' warnings, compared to fifty-eight in 2006 and twenty-one in 2003," the analysis by CMS actuaries in Health Affairs said.

The other main factor causing a slowdown in health spending overall was a decline in the growth of spending to administer Medicare benefits. That type of spending grew 62.5 percent in 2006 with the start of the Medicare prescription drug benefit. In 2007, spending to administer Medicare benefits grew 10.7 percent to $21.6 billion.

In the first part of the 1990s, some analysts attributed a slowdown in health spending growth at the time to industry fears about how a health care overhaul might affect the health care sector. Is the same thing happening now with another health overhaul debate in the offing? "Possibly," Foster said, but added that he wouldn't expect to see such an impact reflected in 2007 data.

No Slowdown in Many Other Sectors

Unlike the drug sector, spending growth for hospital, nursing home and home health services accelerated in 2007. Hospital spending, which accounts for about 30 cents of the U.S. health care dollar, grew 7.3 percent to $697 billion, compared to 6.9 percent in 2006. The gain was driven partly by strong growth in Medicaid spending on hospital care. Hospital price growth, however, moderated from 4.4 percent in 2006 to 3.5 percent in 2007.

Spending on freestanding nursing homes grew 4.8 percent to $131 billion compared to 4.0 percent in 2005. In that sector, price growth increased from 3.0 percent in 2006 to 4.7 percent in 2007. Spending for freestanding home health care services grew 11.3 percent in 2007 compared to 10.3 percent in 2006. Part of the increase stemmed from higher prices but "use and intensity" gains also drove the increase. Shady billing drove some of that increased "use"; Foster said of home health billing that "some of it if not outright fraudulent is abusive and questionable."

On the other hand, spending on physician services slowed, partly because of legislation that took effect in 2007 reducing Medicare payments to doctors for imaging services. The rate of price growth increased for physician services to 3.9 percent in 2007 compared to 1.8 percent in 2006, but not utilization. "This acceleration in price, combined with relatively stable overall spending growth, indicates a sharp decrease in non-price factors such as the use or intensity of services paid for in 2007," the Health Affairs analysis said. “Recent survey data indicate that the number of physician office visits declined from the end of 2006 through 2007."

Medicare and Medicaid Growth Back to Normal

Medicare spending grew 7.2 percent in 2007 to $431 billion, down from the big 18.5 percent increase that occurred in 2006 with the advent of the prescription drug benefit. Medicaid spending rose 6.4 percent to $329 billion following its first-ever decrease in 2006 — 0.7 percent. That drop was attributed to the fact that people eligible for both Medicare and Medicaid were switched to Medicare in 2006 for their drug coverage.

In the traditional part of the Medicare program, spending growth slowed considerably to 3.6 percent in 2007. The figure reflected the growing enrollment in the private plan side of Medicare Advantage (MA). MA spending grew 23 percent in 2007 and this increase accounted for almost 60 percent of the total change in Medicare spending in 2007, "largely because of the shift in enrollment," the Health Affairs analysis said.

Medicare spending for physician and clinical services grew at a slower rate of 4.6 percent in 2007 compared to 6.3 percent in 2006, partly because of reduced payments to doctors for imaging services.

However, Medicare retail prescription drug spending increased at a "robust" rate of 19 percent, in large part reflecting increasing enrollment in plans delivering the drug benefit.

In Medicaid, spending on hospital services grew 8.9 percent in 2007, up from 4.9 percent in 2006. "This acceleration was largely attributable to increases in inpatient and outpatient payments as states provided additional supplemental payments to hospitals," the analysis said. Medicaid spending for dental care jumped, rising 13.9 percent in 2007 compared to an increase of 2.7 percent in 2006. But Medicaid payments to providers are now at risk as states face big shortfalls in their budgets because of recession.

Premium Growth Flat

Private health insurance premiums increased 6 percent, the same rate of increase as in 2006. Benefit payments accounted for 87.8 percent of premiums in 2007. The relatively low rate of premium growth can be explained by fewer small employers offering coverage, a decline in the share of the U.S. population covered by private insurance, and the growing rate of Americans with high-deductible health plans, CMS analysts said.

Out-of-pocket spending rose 5.3 percent in 2007 compared to 3.3 percent in 2006. Consumers had to shell out more for prescription drugs, nursing home services and certain medical supplies.

Champagne Bottles Remain Corked

Emphasizing that 2007 had the lowest rate of overall health spending growth since 1998 creates the wrong picture, Paul Ginsburg, president of the Center for Studying Health System Change, said of the Health Affairs article. That's "a highly misleading headline," he said. "Literally it is the lowest but if you look at the details it's continuing as it has been," he said of the health spending trend.

"If not for this sharp drop in drug spending growth the increase would have been the same," Ginsburg said. While a few more big blockbusters will be coming off patent in the next few years, specialty drugs made by biotech firms will have a bigger and bigger impact on drug spending totals. Twenty percent a year increases in spending on specialty drugs off a bigger and bigger base "is our future," he said. "The insurers don't know what to do about it. It's one of their biggest concerns."

Ginsburg said it's possible that the recession could bring a smaller rate of yearly increase in health spending than the 2007 figure but taxpayers "the picture for consumers and taxpayers is likely dismal" because income and revenues available for health care spending will suffer in a sharp economic downturn.

There was little immediate Capitol Hill reaction to the health spending data, but an aide to Senate Finance Committee Chairman Max Baucus, D-Mont., suggested that it would have no impact on the timing of action on health care. "Health care reform is an absolutely urgent need for America's 46 million uninsured, and for those who are not getting sufficient coverage or value for what they do spend on health insurance," the aide said.

Mark Merritt, president of the Pharmaceutical Care Management Association, said lawmakers have an opportunity to keep a lid on prescription drug spending growth because of the nation's dire economic straits. "This is a unique time in history when policy makers can roll special interests," he said. With a trillion dollar deficit looming "we've got to cut spending," he said.

"Pharmacy benefit managers could provide even greater savings and access if policy makers work to accelerate physician adoption of electronic prescribing, support greater use of mail-service pharmacies in federal programs and empower the FDA to approve follow-on biologics and process applications for traditional generics in a timely manner."

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House Democrats Scaling Back Duration of Children's Health Bill

By Drew Armstrong, CQ Staff

JANUARY 8, 2009--House Democrats are scaling back plans to reauthorize the State Children's Health Insurance Program, as budget scoring problems and rising costs make a five-year reauthorization unlikely.

Instead, they likely will pursue a shorter reauthorization, leaving states that depend on SCHIP money less certain about future funding. House Democrats say they are still planning to base the core of the shorter SCHIP bill on legislation from the last Congress.

Majority Leader Steny H. Hoyer, D-Md., told the House Friday that the SCHIP legislation will be considered on the floor under a rule either Jan. 14 or 15, and that the bill probably will be available online Monday, Jan. 12.

Minority Whip Eric Cantor, R-Va., said that the Republican leadership planned to release a letter late Friday outlining its ideas for the program. He also said he hoped that whatever rule is set for the bill will allow amendments. "We hope we will have an opportunity to offer our ideas," Cantor said.

President Bush twice vetoed SCHIP reauthorization bills in the 110th Congress that would have expanded the program by $35 billion over five years, to $60 billion.

Since then, however, the costs of the program have grown and the revenue-raising power of the 61-cents-per-pack tobacco tax that would have funded it has shrunk.

"The budget window has changed and with it the numbers," said a senior aide to the House Democratic leadership.

"The [reauthorization] length may or may not be five years, depending on what [the Congressional Budget Office] gives us."

It will almost certainly be shorter if the CBO assigns a lower cost "baseline" to the bill, limiting how much money lawmakers can assign to it.

"Since the baseline has changed and the costs have gone up since we passed the bill last year, we are heading towards something under five years," said an aide to a senior House Democrat who worked on the SCHIP legislation.

The SCHIP program covered 7.1 million people — mostly children — in 2007 and is projected to cost the federal government $6.1 billion in 2009, according to the Centers for Medicare and Medicaid Services.

"We are waiting on numbers from CBO, which will tell us both costs and coverage and determine the scope of possibilities," said the Democratic leadership aide. "A final decision will be made once that is known."

Democrats are seeking to pass the bill as a quick way to give President-elect Barack Obama a victory on health policy. It is likely to be considerably later in the year before Congress is ready to start work on a comprehensive health care overhaul.

Initially, at least, the reduced duration for the legislation did not seem to upset some key House advocates.

"Although a five-year reauthorization would be great, it's more important to have a stronger bill," said the Democratic House aide. "The length of the bill isn't as vital since we will be able to come back and look at some of these issues when we tackle health reform," said the aide.

Edward Epstein contributed to this story.

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Obama Will Seek Health Care Overhaul Through Regular Order

By Alex Wayne, CQ Staff

JANUARY 8, 2008 -- Tom Daschle, President-elect Barack Obama's nominee to run the Department of Health and Human Services, promised Republicans Thursday that the new administration will not try to ram a health care overhaul through Congress under expedited budget procedures.

Daschle, a former Senate Democratic leader from South Dakota, faced no hostile questions during a hearing on his nomination before the Health, Education, Labor and Pensions Committee. He had clearly done spade work with Republicans beforehand; several mentioned that they had spoken privately with Daschle in recent days and enjoyed the conversations, which focused on health policy. One Republican, Orrin G. Hatch of Utah, said upfront that he would support Daschle's confirmation, indicating that the eventual Senate vote is a fait accompli.

The hearing's only real drama arose when the committee's senior Republican, Michael B. Enzi of Wyoming, asked Daschle if he "would discourage" the Senate from using a process called "budget reconciliation" to pass a health reform plan. "Yes," Daschle replied.

Reconciliation is an expedited procedure that bars filibusters and requires only a simply majority to pass legislation.

The exchange was polite, and only experts on congressional procedure who had also read a book Daschle published earlier this year on health reform likely grasped the tension behind Enzi's question.

In his book, called "Critical," Daschle suggested that Congress should consider addressing a health care overhaul in its annual budget resolution in order to speed its passage through the Senate. But that would effectively limit Republican input, because majority Democrats could push the bill through without support from GOP senators.

Obama has repeatedly said he wants to involve Republicans in drafting major legislation and to operate in a more bipartisan fashion than has been the norm in recent years.

"Our goal, our hope, our desire, is to use — as you referred to it — the 'regular order,'" Daschle said, meaning the traditional route for legislation, which entails consideration by subcommittees and committees and amendments on the Senate floor. "I'm determined to use regular order to produce the best product we can."

No Tough Questions

Daschle is a familiar figure on Capitol Hill. He served four terms in the House and three in the Senate before losing his seat in 2004 to Republican John Thune.

Republicans did not ask Daschle any questions about his personal qualifications for the job or issues that might present a conflict of interest, such as his work since leaving the Senate in 2005 for a Washington lobbying firm. Daschle was not a registered lobbyist for the firm, Alston & Bird, but the company lobbies Congress and HHS on behalf of many different health companies.

It is not clear if Daschle worked with any of those companies. Obama has said that people who join his administration from lobbying firms will not be allowed to work on issues that were the subject of their lobbying work. Spokespeople for Obama's incoming administration have said Daschle will recuse himself from working on such subjects when appropriate.

Republicans also did not ask Daschle about the work of his wife, Linda Daschle, an aviation expert and formerly a registered lobbyist who has focused on transportation issues. She sat behind Daschle at the hearing, along with his children and their spouses.

Obama also has named Daschle to lead a new White House Office of Health Reform; together with his position in charge of HHS, Daschle is indisputably Obama's point man on health policy.

"If confirmed, I will use these dual roles to marshal the talent and energy necessary to at last succeed in making health care affordable and accessible for all Americans," Daschle said.

In his book, Daschle proposed expanding Medicaid, the State Children's Health Insurance Program and Medicare to cover more Americans who are poor, old or young, while opening the Federal Employee Health Benefits Program — which provides private health insurance to federal employees and members of Congress — to everyone in the country. He also proposed a new "Federal Health Board" that would set policy on the technical aspects of health care and insurance coverage, relieving Congress of politically sensitive decisions that Daschle believes are best left to health experts and economists.

Many Republicans are concerned about a big expansion of government-run health care programs under Obama, but those concerns weren't especially evident on Thursday.

Sen. Tom Coburn, R-Okla., whom Daschle spoke with privately Wednesday evening, is considered one of the most conservative Republicans in Congress and doubtless will be a major obstacle to Obama's health reform plans. But his questions Thursday focused on whether Daschle would adopt good-government practices at HHS, such as reporting contracts to Congress and reviewing HHS programs for waste and inefficiency. Daschle promised that he would.

Democrats spent much of their allotted time asking Daschle if he would support their favorite health causes; in every case, Daschle promised that he would. Sen. Barbara A. Mikulski, D-Md., whose constituents include many HHS employees, asked Daschle if he would end what she sees as the politicization of HHS science agencies, such as the National Institutes of Health and the FDA.

"I want to reinstate a science-driven environment," Daschle said.

Sen. Bernard Sanders, I-Vt., asked Daschle if he would support a huge expansion of community health centers, which provide care to many people without insurance or with little access to doctors. Did Daschle agree that quadrupling the number of health centers, currently at about 1,100, would save money by diverting people from emergency rooms and reducing the need for hospitalizations? Sanders asked.

"No question," Daschle said.

The committee did not vote on Daschle's nomination. The Finance Committee, which oversees Medicare, has jurisdiction over his appointment and will hold its own confirmation hearing and vote to advance his nomination to the full Senate. No date has been set for the Finance hearing.

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Study: COBRA Insurance Too Expensive for Unemployed

By Leah Nylen, CQ Staff

JANUARY 9, 2009 -- Most unemployed families cannot afford to retain their former employer's health insurance through the COBRA program because the premiums eat up more than three-quarters of the typical unemployment insurance benefit, according to a Families USA study released on Friday.

Created in 1985, the COBRA program (PL 99-272) allows employees who are laid off or voluntary leave their jobs to keep their health insurance for up to 18 months.

While unemployment insurance benefits vary according to state, the report found that the national average unemployment insurance benefit is $1,278, but the average COBRA premium for family coverage absorbs about 84 percent of those funds, or $1,069.

"COBRA health coverage is great in theory and lousy in reality," said Ron Pollack, executive director for Families USA. "For the vast majority of workers who are laid off, they and th"

Because of the rising number of individuals losing their jobs — and health insurance — during the current economic downturn, combined with the high cost of COBRA, congressional Democrats are considering including some form of health insurance assistance for laid-off employees in the recovery package, Pollack said.

On Tuesday, Senate Finance Chairman Max Baucus, D-Mont., said the package might include subsidies to help the unemployed with COBRA premiums.

The Families USA study analyzed state by state the average unemployment insurance payments, based on Department of Labor statistics, compared to the average COBRA premiums compiled by the Agency for Healthcare Research and Quality of the Department of Health and Human Services.

In nine states, the cost of COBRA premiums equaled or exceeded the unemployment insurance payment. In Alaska, the state with the largest disparity, the average COBRA premiums for family coverage consume 132 percent of unemployment income.

According to Pollack, there are two major approaches under consideration. The first would provide some form of subsidy to the uninsured to help with purchasing health insurance, such as COBRA.

The COBRA subsidy under discussion for the stimulus package could take the form of a refundable tax credit, similar to the health coverage tax credit offered for workers who lost their health coverage because of trade agreements, said Cheryl Fish-Parcham, deputy director of health policy for Families USA. The federal government also could directly pay for coverage by increasing unemployment payments or paying insurers directly, Fish-Parcham said.

The other approach under discussion would allow unemployed workers to be temporarily eligible for Medicaid, Pollack said. Under this scenario, the federal government would pay for 100 percent of the costs rather than the sharing costs with the states on a percentage basis.

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