Will 2010 be the year of health reform? Many members of Congress hope it will be, but they will have a fight on their hands from some of their colleagues.
In a speech to a joint session Congress last February—almost a year ago—President Obama told legislators he wanted a health reform bill on his desk soon.
“I suffer no illusions that this will be an easy process,” he said. “It will be hard. But I also know that nearly a century after Teddy Roosevelt first called for reform, the cost of our health care has weighed down our economy and the conscience of our nation long enough. So let there be no doubt: Health care reform cannot wait, it must not wait, and it will not wait another year.”
Democratic lawmakers did their best to deliver a bill by the end of 2009, but they fell a little short. The House passed its health reform bill in early November, while the Senate got the job done—with much turmoil—on Christmas Eve.
The result was not exactly bipartisan: Of the 220 House members who voted in favor of the bill, only 1 was a Republican; no Republicans voted for the Senate bill. Republicans have vowed since then to fight against passage of the final measure that will emerge. Normally a final bill would be crafted in a House-Senate conference committee, but at press time Democrats were considering using a more informal process under which changes would be made and then “ping-ponged” back and forth between the two chambers until a final bill was agreed on.
The House and Senate bills contain some of the same basic elements, including:
▸ A ban on discrimination by insurers against people with pre-existing medical conditions;
▸ A requirement that all Americans purchase health insurance coverage, with penalties for those who do not;
▸ The creation of health insurance exchanges through which uninsured people could purchase policies, with subsidies to help low-income people pay premiums;
▸ An expansion of Medicaid to include people with incomes greater than 100% of the federal poverty level (how much greater differs between the two bills); and
▸ A prohibition on federal funding of abortions, although the specifics of this provision differ between the two versions.
One thing the two bills vary greatly on is a public option for health insurance—a government-funded insurance program designed to compete with private plans. The House bill includes a public option, but the Senate bill does not, and several senators have said they would not vote for a bill that contains a public option. The Senate briefly considered an expansion of Medicare to persons aged 55–64 years in lieu of a public option, but quickly abandoned that idea after several key senators expressed opposition.
The bills also differ slightly on cost—the Senate measure would cost $871 billion over 10 years, while the House bill would cost $894 billion over the same period, according to estimates from the Congressional Budget Office.
Both bills offset some of the cost by cutting payments to Medicare Advantage plans—private health plans that contract with the government to care for Medicare beneficiaries.
Physician groups have plenty to chew on in the bills, each of which numbers around 2,000 pages. The American Academy of Neurology did not take a position on either bill, but has some concerns about provisions that were left out, according to Michael Amery, AAN legislative counsel.
“We have two key elements, neither of which was fulfilled to date,” he explained. One provision was a permanent fix for the sustainable growth rate formula used to determine physician pay under the Medicare program. Instead of a permanent fix, Congress gave physicians a 2-month reprieve from next year's impending pay cut.
The other measure the AAN hoped to see included was to add neurologists to the list of providers eligible for primary care bonuses under the health reform bill. Under the incentive plan, certain providers who claim at least 60% of their billable charges as evaluation and management codes are eligible for a 10% bonus. The list of eligible physicians includes family physicians, internists, geriatricians, pediatricians, and—in the House version of the bill—ob.gyns.
“Neurologists don't necessarily want to be known as primary care doctors, but the reality is that they provide a lot of primary care to patients,” said Mr. Amery. “If you ask patients with amyotrophic lateral sclerosis or Parkinson's disease who is their primary care physician, they would almost all say, ‘My neurologist.'”
Mr. Amery noted that a lot of subspecialists are included under the “internal medicine” category of the provision, but because neurologists are not board-certified through the American Board of Internal Medicine, they are not included.
The academy is still working to get the two provisions included in the final bill.
The American Association of Neurological Surgeons expressed its displeasure with both the House and Senate bills.
“We're not very happy,” said Katie Orrico, director of the association's Washington office. “Since the release of the original [House bill] this [past] July, we've consistently opposed every iteration that's come out since then.”
The association's major concern with the bills, Ms. Orrico said, “really is the significant increase in federal involvement in health care determinations across the board—of quality, including developing and identifying outcomes measures, and various potential concerns we have regarding coverage and payment policies.” That includes a provision in the Senate bill calling for an independent Medicare advisory board which would make recommendations on cutting Medicare costs.
Regarding the quality measurement provisions, “Neurosurgery—as I suspect is true of other specialties—is really at the beginning of trying to develop outcomes measures,” Ms. Orrico said. In addition to launching a portal for neurosurgeons to participate in Medicare's Physician Quality Reporting Initiative program, “we're also doing some pilot programs on quality measurement and we are about to embark on a venture with Blue Cross Blue Shield. But we believe that's something the profession should be doing with the encouragement and support of the federal government—it shouldn't be taken over by the federal government.”
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