Consumer Directed Healthcare

Experts Disagree Over Legislation’s Fate

By JOSEPH BROWNSTEIN
ABC News Medical Unit
Jan. 21, 2010—

With Republican Scott Brown’s victory in Massachusetts on Tuesday, Republicans in the Senate captured a seat long held by Democrats, and, perhaps more importantly, the possible 41st vote necessary to filibuster any new health care bill.

But while the future of a health care overhaul remains unclear, experts are divided as to how to read the tea leaves in public opinion on the issue following a vote from a state that already has universal health care. Brown, then a state senator, voted in favor of the measure when the Massachusetts legislature passed it in 2006.

Brown has vowed to halt the current version of health care reform, passed by the Senate on Dec. 24, saying he did not think the current plan was a good one for the country — or Massachusetts.

“We already have 98 percent of our people insured here,” Brown said Wednesday afternoon, repeating one of his campaign themes. “We know what we need to do to fix it. But to have the one-size-fits-all plan that is being pushed nationally — it doesn’t work.”

Experts were split on whether health care overhaul could continue forward at this point.

“President Obama’s already unpopular health plan didn’t lose just one vote in the Senate. It lost maybe a handful of votes in the Senate and perhaps a dozen or more in the House,” said Michael Cannon, director of health policy studies at the Cato Institute.

“Antipathy toward the Obama plan was the number one reason for Brown’s victory, and that has vulnerable Democrats in Congress running scared,” he said. “They are now far more likely to vote against the Obama plan, particularly since the elections in New Jersey and Massachusetts show that Obama can’t help them on the campaign trail.”

But others disagree.

“Health reform is not doomed. It just depends who does it,” said Uwe Reinhardt, a professor of economics and public affairs at Princeton University. “The task will always be much, much more difficult for Democrats, because they are suspected of plotting government hegemony just breathing. It is much simpler for Republicans to do the same thing.”
State of Opposition
To be sure, nationwide numbers have shown the public to be divided on the issue, with a slight majority opposed to the measure.

But it remains unclear how those numbers translate to Massachusetts, traditionally one of the most Democratic-leaning states in the union, but one that has some unusual circumstances when it comes to health care overhaul.

During his campaign, Brown said the health-care bill passed by the Senate would force Massachusetts to subsidize care in other states.

“It is a good point that Massachusetts residents didn’t ‘need’ national reform,” said David Dranove, a professor of health industry management at the Kellogg School of Management at Northwestern University. “But they must have been furious about having to pay for healthcare in Nebraska and Louisiana on top of paying for their own healthcare.”

He also noted that Massachusetts voters “could see that the national reform effort was a badly compromised version of their own reforms,” noting that Democrats in Congress struck some deals that he feels voters found unpalatable.

But some also noted the fact that Massachusetts has had some level of health care reform may be a sign that voters did not cast their votes based on that issue — and perhaps politicians shouldn’t interpret it to mean that.

“I do find it ironic that many people outside of Massachusetts are interpreting this vote as a message that those living in the state oppose health care reform, when a very similar system is very popular inside that state,” said Dr. Aaron Carroll, director of the center for health policy and professionalism research at the Indiana University School of Medicine. “If they were truly opposed, you should have seen at least one campaign running on a platform of scrapping their system. None did.”
Second Life Or Dead On Arrival?
While some may see health care overhaul as a lost opportunity, others see the vote as a setback that can be overcome.

Reinhardt noted that in the past, Republican administrations have pushed bills through Congress that brought price controls set by the federal government. Under Ronald Reagan the target was the hospital sector, and under George H.W. Bush it was doctors.

“Both times it went without a huge public outcry. But now imagine if a Democratic president — e.g., Bill Clinton or Obama — had done the same thing. He would swiftly be denounced as trying to impose Soviet-style pricing on American hospitals which, in effect Reagan’s [pricing systems] were,” he said.

“Moral of the story: There is a double standard here,” Reinhardt said. “Perhaps only Republicans can get health reform done, because only they can get away with doing even Soviet-style policies.”

Other ideas for a bill passage have been floated.

Some proponents of health reform have held out hope of persuading Maine Sen. Olympia Snowe, a Republican, to vote for a bill, and others wanted to speed through health care reform before Brown was seated, although Obama has nixed that idea.

“Here is one thing I know, and I just want to make sure this is off the table,” he told ABC News’ George Stephanopoulos on Wednesday. “The senate certainly shouldn’t try to jam anything through until Scott Brown is seated. People in Massachusetts spoke. He’s got to be part of that process.”

Leadership Unclear
Even Democrats in the Senate do not appear to have a clear plan for how to proceed right now.

In response to a question from ABC News correspondent Jonathan Karl about whether he was committed to finishing the health care bill and confident he could pass it on to the president, Senate Majority Leader Harry Reid replied, “I am confident that health care is an issue in this country. We are going to do everything we can to alleviate the pain and suffering of people who cannot afford health care and who want to maintain what they have.”

He then noted that the House had until Dec. 24, 2010 to pass the bill the Senate had passed at the end of last year and send it to the President.

His representative clarified afterward.

“We are still committed to getting health care done,” Reid spokesman Jim Manley said.

But Brown himself has given some hints that even if the current incarnation of health care reform is not something he will vote for, it does not mean he will oppose any proposal.

“I think it’s important for everyone to get some kind of health care,” he said Wednesday. “It’s just a question of whether we’re going to raise taxes, cut a trillion from Medicare, we’re going affect veterans’ care — I think we can do it better.”

ABC News’ Political Unit in Washington contributed reporting. The ABC News Medical Unit is based in Needham, Mass.

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From Dana Bash and Ed Henry, CNN

(CNN) — Faced with the once-unthinkable prospect of losing the Massachusetts Senate race, Democratic officials on Capitol Hill are quietly talking about options for passing health care reform without that critical 60th Senate vote.

Top White House aides insist they are not engaging in any talk of contingency plans, because they believe Democrat Martha Coakley will beat Republican Scott Brown in Tuesday’s crucial Senate battle.

“We are not having any discussions like that,” White House spokesman Bill Burton told CNN. “We believe she is going to win.”

Asked about potential contingency plans as Air Force One returned to the Washington area after President Obama’s Sunday campaign rally for Coakley in Boston, White House Press Secretary Robert Gibbs insisted to reporters the plan is to still pass health care reform with 60 votes. “We think Coakley will win this race,” Gibbs said.

But Democratic sources on Capitol Hill say “what-if” discussions are taking place about how they could proceed with health care if Coakley is defeated, and they privately admit none of their alternatives is very good. According to senior Democratic congressional officials, here are options under discussion:

Pass health care reform before Scott Brown is seated.

But multiple Democratic sources say this is unlikely. Even if House and Senate Democrats could reach a deal to meld their bills and pass them in the next couple of weeks — a big if — there would be a huge outcry from not only Republicans, but also an increasingly distrustful public.

For that reason, one senior Democratic source says some Democratic lawmakers who voted yes last time have already warned they would vote no if health care is voted on in advance of any swearing in of Brown.

The House passes the Senate health care bill.

Democratic sources also call this extremely unlikely, because House Speaker Nancy Pelosi likely wouldn’t have the votes to pass it. Many House Democrats have major differences with several provisions in the Senate bill, especially the way the Senate structured a tax on high-cost insurance plans.

Revisit the idea of trying to push health care through the Senate with only 51 votes, a simple majority.

But to do that, Democrats would have to use a process known as reconciliation, which presents technical and procedural issues that would delay the process for a long time, and Democrats are eager to put the health care debate behind them and move onto economic issues such as job creation as soon as possible this election year.

Try once again to get moderate Maine Republican Olympia Snowe’s vote. They could try for a compromise health reform plan with the independent-minded Republican, but multiple Democratic sources say they believe that is unlikely now.

Their health care overhaul dies.

Although some Democrats are not ruling out this possibility, numerous top Democrats say not passing a health care bill for the president to sign is unthinkable after he put so much political capital into passing a reform bill, and congressional Democrats spent much of last year working on it.

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Advocate Groups Say Incentives For Wellness May Hurt The Poor and Elderly
By EMILY P. WALKER MedPage TodayWashington Correspondent
WASHINGTON, Jan. 10, 2010—
Incentives within the U.S. Senate health care bill designed to encourage healthy lifestyles unfairly target the poor, elderly, overweight and disabled, and could be exploited by insurance companies for financial gain, advocacy groups claim.

Dozens of health, justice, and disability organizations have signed a letter urging senators to remove a provision in the health care reform bill that would allow insurers to provide reimbursements or incentives to workers who meet certain fitness goals laid out in workplace wellness programs.

In rewarding healthy people for making good choices, those who don’t meet fitness goals would be unfairly penalized, the groups said.

“It’s indistinguishable from medical underwriting,” Sue Nelson, vice president for federal advocacy of the American Heart Association (AHA), told reporters during a Thursday call.

“This is a loophole that [insurance companies] will drive right through on day one,” added Andrew Kurz, former chief financial officer of Wisconsin Blue Cross-Blue Shield. “This can lead to huge differences in premiums.”

Under the existing Health Insurance Portability and Accountability Act, group health insurance plans can’t discriminate based on an individual’s health status by varying insurance premiums.

But the law does allow insurers to provide incentives tied to voluntary “wellness programs,” either solely for participating in a workplace wellness program, or for meeting certain health and fitness benchmarks, such as reaching a certain body mass index target.

Those incentives can take the form of extra reimbursements, but they can’t top more than 20 percent of the employer’s cost of covering the employee.

The Senate bill would raise that figure to 30 percent, so an individual who doesn’t meet the wellness goals could hypothetically be paying up to $1,410 more in annual premiums than an employee who met wellness goals.

The amount could be raised to 50 percent, with government approval. People with medical conditions that preclude participation would be offered an alternative program, the bill says.

“Such exorbitant penalties undermine a fundamental goal of healthcare reform — the creation of a system in which no one can be charged more based on their health status,” said the letter, signed by representatives of groups including the American Heart Association, AARP, the American Diabetes Association, and the National Disability Rights Network.

The basic idea sounds intuitive and hardly controversial: Reward people for being healthy.

“Weight gain and unhealthy lifestyles that focus on smoking and lack of exercise have sky-rocketed our healthcare costs,” said the sponsor of the provision, Sen. John Ensign (R-Nev.), in a statement when the Finance Committee adopted his amendment in a bipartisan vote.

“These costs could be lowered by focusing on what makes us healthy — through weight loss programs, smoking cessation, and preventive care. Voluntary employee participation in these areas should naturally be reflected in lower healthcare costs,” he said.

However, it’s not so cut-and-dry, advocacy groups contend. Employers could first raise premiums for workers across-the-board, and then lower premiums for employees that meet certain goals, such as having low cholesterol or reaching a certain body mass index.

Those who are unable to meet such goals would be forced to pay a high premium that could well be unaffordable.

“Attainment incentives provide welcome rewards for employees who manage to comply but may be unfair for those who struggle, particularly if they fail,” wrote Harald Schmidt of the Harvard School of Public Health in a recent “Perspective” published in the New England Journal of Medicine. “In some cases, the incentives are really sticks dressed up as carrots.”

“This is not workplace wellness, this is cost-shifting,” added AHA’s Nelson, arguing that costs would likely move from healthy employees to sick employees, and from employers to employees.

Schmidt said the incentive programs would unfairly penalize lower-paid workers, who are more likely to be unhealthy.

Advocates say it’s unfair to expect the same level of exercise and diet from a law school graduate who has a gym in his condo and a single mother who works two jobs, can’t afford a gym membership, and lives in an area with a limited supply of healthy foods.

“It’s really important to ask what is the motivation behind these programs,” Schmidt told reporters. “Is it really to make people more healthy or to reduce costs? Or to do both? In the end, there is nothing wrong if we can achieve both, but we do have a problem if … it leads to unfairness and inequity.”

Sen. Tom Carper (D-Del.), a co-sponsor of the amendment said the provision contains “strong protections against discrimination” for employees.

“Companies using similar incentives have not only seen their employees’ health improve, but they have seen a significant decrease in healthcare costs,” Carper said in an e-mail.

During the health care reform debate, the grocery store chain Safeway was referenced countless times as a company that implemented a successful employee wellness program that helped workers quit smoking, lose weight, and eat healthily while saving the company money.

But critics say that because the Senate bill doesn’t include guidelines on what a workplace wellness program should look like, one might involve nothing more than testing cholesterol levels while ignoring fitness and motivational components, said Nelson.

Employers would have little incentive to spend money to install a workplace gym or hire smoking cessation counselors, she said.

Nelson said the AHA and other groups are working with congressional staff to remove the provision and instead have the final bill include the House language, which would merely set up pilot programs to test the idea.

A spokesperson for Senate Majority Leader Harry Reid declined to comment on whether the provision would be eliminated during conference, but said “differences will be negotiated with the House.”
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