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Health On The Hill – April 12, 2010

Physicians face a 21 percent cut in their Medicare payments unless the Senate approves legislation this week to stop the scheduled reduction. Meanwhile, education efforts about elements of the health care overhaul package are continuing, with the Department of Health and Human Services and other federal agencies and outside groups working to give the public more specifics about the measure.

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LAURIE MCGINLEY: Hello. I’m Laurie McGinley with Kaiser Health News. Thank you for joining us for Health on the Hill, our weekly discussion of health care policy and politics. With us today are Mary Agnes Carey from Kaiser Health News and Julie Rovner with National Public Radio. Thank you for joining us.

Well, Mary Agnes, let’s start with you. Congress is back and it’s facing a possible showdown over legislation that is designed to block a 21 percent cut in physician payments under Medicare. Could you tell us a little bit about that and where we are headed on this?

MARY AGNES CAREY: Right. This effort to block the cut is part of a bigger bill that would extend COBRA benefits for unemployed workers to help them with their health insurance and also unemployment insurance. Democrats are arguing this is emergency spending; it doesn’t have to be fully offset and it would prevent this cut in Medicare physician payments until the end of the month.

Now the cut went into effect on the 1st of April, but the Centers for Medicare and Medicaid Services, also known as CMS, has been holding those claims at the desk. So, Democrats hope they can move on this bill, but it is unclear because it isn’t fully financed. Again, Democrats say it is emergency spending. Republicans say no, it needs to be offset, so that is where the showdown is going to come.

LAURIE MCGINLEY: Julie, this seems like a hearty perennial or even more than perennially. Tell us a little bit about this problem. Why is it that we are constantly hearing about this Medicare physician doc cut problem?

JULIE ROVNER: Well, it is a problem that actually dates back to 1997 when there was actually a bipartisan bill that balanced the budget, but they set up this formula that for the first couple of year’s actually overpaid doctors, but since 2001 has been requiring cuts in physician fees under Medicare. And the first year they let the cuts go into effect and then ever since then Congress has been basically erasing the cuts.

Now for the first several years when Republican were in fact in charge, they did not pay for the cuts, and every year made it more expensive to actually offset them. And now we have gotten to the situation where actually to make the cuts go away would cost hundreds of billions of dollars, which neither side really wants to be able to come up with, neither Republicans or Democrats want to come up with.

That’s the main reason it wasn’t part of the health law that just went into effect because that would have been an extra really $250 billion or so that would have added to the tab of how much that law cost. So, they left this out to be resolved later.

So, now we have gotten to the point where there is this 21 percent cut that neither Republicans nor Democrats say is tenable, that nobody wants to cut physician pay by 21 percent, because doctors will simply stop taking Medicare patients. But, no one really knows how to pay for it. Democrats are saying we should not pay for it at all. This was really a mistake that goes back now 13 years. We should just call it even and start over again. And in the House they have actually gotten fiscal conservatives to go along with that. But, in the Senate, actually even some of the fiscally conservative Democrats say no we really should pay for it, so it is just a matter of where the money is going to come from.

So, we have been doing this a month at a time. The House passed a bill that would extend the really sort of the moratorium on these cuts until October, but the Senate has not been able to get that through. So, now we have got this sort of cliffhanger every month about how will we do this or will we do this? And in the meantime you have got doctors wondering if they are going to get paid or how much they are going to get paid, and it’s a real problem.

LAURIE MCGINLEY: Are we going to face this all year, month by month?

JULIE ROVNER: It certainly looks that way. Eventually Congress is going to have to come to grips and deal with this problem. You cannot expect doctors to continue to treat Medicare patients if they do not know when or how much they are going to get paid.

LAURIE MCGINLEY: Mary Agnes, you mentioned the COBRA subsidies – now that is a very important issue to many, many people. Could you explain a little bit more about it and how that fits into this current battle?

MARY AGNES CAREY: Well, if you lose your job and you lose your health insurance, that is a big problem. And so COBRA allows you to extend it, but it is a very expensive program for a lot of people to pay that COBRA benefit, and so that has been in place for awhile to give additional money to help people cover the health insurance. And of course, if those subsidies stopped, then you are going to have more uninsured people, which no one really wants.

LAURIE MCGINLEY: You reported this week that consumers are just dying for information about this new law that is so mind boggling in its complexity. Tell us a little bit about what questions consumers are asking, who they are asking, and what some of the groups and government agencies are doing to try to take care of that demand.

MARY AGNES CAREY: The Department of Health and Human Services has been having weekly web chats. They had their second in a series last week. Before the web session started, they had something like 700 questions that came in. You would expect, of course, a lot of things geared to Medicare. “I am on Medicare Advantage, how will this affect me?” “Will I be able to get a physical every year now as a Medicare beneficiary?” All those sorts of things, people want to know how it affects them.

Other groups, AARP for example, Families USA, have set up their own information centers. There is a lot of interest in the immediate benefits. The high risk pool for coverage, if you have lost your health insurance, or how do you keep your adult child up to age 26 on your health insurance policy?
The regulations for these are now being written and as more of that becomes clear from the Federal Government, then more will become clear to these groups and to the public, but there is just a lot of interest in the immediate benefits and the long-term benefits and people are going everywhere they can to get information.

LAURIE MCGINLEY: Julie, do you get the impression that the Department of Health and Human Services is able to answer all these questions? Do they have the structure set up at this point or is that still sometime away?

JULIE ROVNER: Well, a lot of questions, there are no answers yet. As Mary Agnes said, there are regulations that need to be written. I think at this point they are very basic questions to answer. When do things take effect? Some things take effect in three months. Some things take effect in six months. Some things take effect in 2014. So, a lot of things can be answered fairly simply. A lot of things, though, a lot of questions that people really want to know, as I mentioned, will not be answered until there are regulations.

But there is still a lot of misinformation that is out there. Some of it is just mistaken. Some of it is being put out purposely by critics of the new law. So, I think the Department is doing a pretty good job at being very proactive, getting out there, doing these web chats, doing conference calls.
One big problem, of course, is that there is still no administrator for the Centers for Medicare or Medicaid Services. We now have a name, Don Berwick, that has been leaked by the Administration, but he has still not been even officially nominated, so he will need to be nominated and there will need to be hearings.

LAURIE MCGINLEY: When do you think that will move ahead?

JULIE ROVNER: I would assume in the next couple of months. We knew that they weren’t going to nominate anyone until the bill became law, because there would be no way that such an important post – this is basically three-quarters of a trillion dollars that person is in charge of – they knew they couldn’t get anyone through during the fight over the bill. So, they knew that until that was over, one way or the other, they could not even nominate anyone. Now that that is through, they need to get someone in place, but I expect that to be a fairly heated confirmation battle because you will be able to refight some of the fights over the law and certainly how it will be implemented.
So, I expect now what we know who it will be that he will be named in the next certainly week or two and then however long it takes for that confirmation battle, but remember in the Senate, the Republicans who are angry still and trying to stop many nominees, I imagine he will be at the top of the list that someone will try to stop.

LAURIE MCGINLEY: As the Administration moves forward in trying to explain the new law, what lessons do you think people have learned, or learned from the experience that the Bush Administration had in explaining the Medicare Part D drug benefit that I know both of you were very involved in covering. Some of that went well. Some of it didn’t go well. Do you think that the Obama Administration is incorporating some of the lessons in what they are doing?

JULIE ROVNER: Well, I think they did a really good job in terms of their public campaign, their public awareness campaign. They used the Surgeon General. They used the head of the Food and Drug Administration. Actually, they were chastised for sort of over politicizing it, but they really did an excellent job at getting around the country.

LAURIE MCGINLEY: The bus tour.

JULIE ROVNER: Yes, they did a very good job at answering questions. I think where they kind of fell down, and I do not think you can really blame anybody for doing this, it was a very difficult job to get that up and running with so many private plans on one day to turn over everybody’s prescription drug, the way people got prescription drugs, and there were obviously going to be flaws and there were. I don’t think you can really blame that on the Administration. I think they did about as good a job as one could do. I mean, I think if this Administration can do as good a job as the Bush Administration did with Part D, they probably can consider that a job well done. But I think in terms of the public relations job that they did with Part D, that would be something that they would want to go back and emulate.

LAURIE MCGINLEY: Mary Agnes, it is interesting that HHS Secretary, Kathleen Sebelius, who by her own account was not a major factor in the negotiations over the health care law, is now one of the most important people in Washington. She has definitely moved to the forefront in trying to implement this law. She is everywhere.


LAURIE MCGINLEY: What do you think about her change in status, in position?

MARY AGNES CAREY: Well, I think she is kind of a great saleswoman and chief, if you can give her that title. I mean, she is out, she is very clear when she speaks, she is eloquent, she has got a lot of experience in her home state of Kansas, and she is out there and she is talking in very clear terms to people about the health care bill and what it means for them. And so I think that they will continue to use her as much as they can. She is certainly playing a big role in these weekly web chats, and I think you will just see, we have seen a lot of public appearances so far. She has made it very clear if you have questions, we will have answers. I think she will be at the forefront of this education campaign.

JULIE ROVNER: And she is not only a former governor. She was a former insurance commissioner in Kansas, so she really understands this stuff at a granular level and she is really able to explain it in very clear terms and I think that really helps.

LAURIE MCGINLEY: Julie, what was your take on another recent development, which was Bart Stupak’s decision to retire – the Democrat from Michigan who was so involved in trying to get stringent anti-abortion clauses into the law.

JULIE ROVNER: Well, poor Bart Stupak really got it coming and going. He, of course, got the language, the very strict abortion language in the bill when it left the House, became a hero to the anti-abortion movement and kind of the goat to the abortion rights movement, and when the bill came back to the House, of course, he really wanted to vote for the bill.

When he ran in 1992, health care was one of the main points of his platform. He wanted health care for all. He was one of those true anti-abortion Democrats, and I put as much emphasis on the anti-abortion as the Democrat part, so he really wanted there to be a health care bill, but he really wanted to keep to his anti-abortion pledge. And in the end, remember that the bill, as it came out of the Senate, was strong enough on the anti-abortion language to win the votes of people like Ben Nelson of Nebraska.
So even though there were anti-abortion groups who say that it was not very strong, it was strong enough to have the opposition of most of the abortion rights groups, too, so this was not so much of a big sellout. And what Bart Stupak and his band of anti-abortion Democrats in the House were able to win was that they would take the Senate bill, mostly because they knew they could not change it. There was no way structurally to get it changed, and they got President Obama basically to promise through an executive order that he wouldn’t interpret it to allow any further abortion funding.

And remember going in, the object of this whole thing was to keep the status quo, to not extend any more abortion restrictions and not extend any fewer abortion restrictions. So basically from what the anti-abortion groups had said going in, they got what they wanted, but for some reason the anti-abortion groups decided that this was a loss, and they branded Stupak a traitor to the cause.

So now, he not only is being opposed by the abortion rights groups, he is being opposed from his own flank by abortion opponents and he is getting hate mail and hate calls and threatening calls from the anti-abortion cause, and he has got it looking at a primary challenge from an abortion rights Democrat, and I think after 18 years he said he just finally had enough.

He has got this vast, huge district in Northern Michigan, the entire Upper Peninsula, 600 miles back and forth, it takes him eight hours to get home, and he said he just finally had enough. He had gotten this bill through, the health bill. He got to vote for it, which was important to him, and I am taking him at his word when he says that it was just enough of the fight.

LAURIE MCGINLEY: Well, Julie thank you very much, Mary Agnes thank you very much. This has been Health on the Hill. Thank you for joining us. I am Laurie McGinley with Kaiser Health News.

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