On Leavitt

I found out yesterday Michael Leavitt has a blog. I feel like I should have known this sooner, but alas, I found out about it from an article in USA Today. I don't even like USA Today.

Nonetheless, it turns out Leavitt has used it recently to defend President Bush's veto of S-chip. Not a huge surprise, but I thought it'd be fun to see what exactly he's saying. Here's some clips of a post from Oct. 9:

Some months ago, the Democratic leadership in Congress made clear they were going to send the President an SCHIP bill he would have to veto.

Hmm. I find this argument interesting. "Congress sent something to the president they knew he would HAVE to veto." As if someone is forcing his hand to sign that veto.

During that period we will hear a lot of political rhetoric but in the end the veto will be sustained. When that occurs we can get down to the business of solving this problem. ... [Democrats] have chosen to proceed as though the President’s opinion isn’t important.

Here's my other problem with the administration's political tactic. Why didn't they attempt to compromise BEFORE the bill's signing? President Bush didn't have a reasonable opinion prior to the bill's passage. What makes his opinion important now? Is it really any wonder the Dems aren't open to additional compromise?

It's not really any surprise how Leavitt's blog reads. I mean, he's the White House mouthpiece, this is how it should go. Doesn't stop me from thinking he's wrong.

****

Despite his party line belief in the inherent evil-ness of S-chip, I don't actually dislike a lot of Leavitt's policy ideas. David Broder of the Washington Post wrote an opinion piece on Sunday about Leavitt, which I think highlights some of the good that he can do for the health care system. Leavitt last week at a conference of insurers and health care providers described what he sees as the "coming revolution in health care in this country," according to Broder, which "is a story that, while less publicized than the SCHIP fight, holds promise of a better day not just for children but for all Americans." Broder writes

What I learned about Leavitt in his years as governor is that he is blessed with vision that sees future policy challenges and developments more clearly than most politicians. In this case, he is visualizing a radically different kind of medical marketplace, in which families armed with specific information about the treatment success and prices of hospitals and doctors can shop at will for the best quality and most affordable care.

...

Leavitt's view is that the government should not own health care; instead, it should organize the health-care marketplace and then let competition based on full information proceed.

Broder notes ("do not faint," he says) that Leavitt's plan is consistent with Hillary's health care plan. Leavitt's view that the health care marketplace needs to be organized is an important one, one that I think is often ignored. Government has organized other fields -- technology is a great example of this. Radio and the switch to digital cable, for example. When the government doesn't set standards, innovation flounders a bit, i.e. electronic health records. It's important that they all work together, but no one has stepped up to say how exactly those systems should work. I have to add that a bit of regulation is necessary, and I would imagine that Leavitt would not agree with that.

That's all for now, but look forward to more clips from Leavitt's blog, now that I've discovered it exists.

An embarassment to bloggers everywhere

Yep, that's me. It's been almost a month since my past entry, which is so sad. I'm going to blame it on my work load, which has become out of control as S-chip has spiraled out of control (perhaps the increase in news is actually MORE reason to blog, but still) and has left completely exhausted and unable to write another sentence about anything related to health care. Today, though, I am feeling energetic. And plus, you may have heard that just two hours ago, the House failed to override President Bush's veto.

Surprise, surprise, I know. Doesn't mean I wasn't rooting for some rogue Republicans to heroically stand up when voting and say, "I vote for children!" ... alas, no luck there.

So what's next? Dems have a couple of options when it comes down to it.

Change the bill slightly, so it becomes more difficult for Republicans to lie to the American people about why they should hate the bill (but can't ... a recent CBS poll found that even 70% of Republicans wanted to reauthorize S-chip). If Dems put in language that prohibits states from enrolling children in families with annual incomes of over 300% of the federal poverty level -- which the vetoed bill does in essence anyway -- then Republicans will be unable to break out their "Familes earning $83,000 a year will be on the public dole!" line.

The small revisions will have the effect of either a) persuading enough Republicans to switch their vote and vote to override, or b) make Republicans look sooooo bad that they won't be able to get reelected. It's 10 million children or the president, as Rahm Emanuel, Pelosi and Reid are so fond of saying. Who are they going to choose?

Another alternative: actually work with the president and Republicans to craft a different bill. I don't personally think this will ever happen. There's a pretty big differences between $5 billion and $35 billion and they'll never be able to bridge that gap. I don't think the president seriously thinks they'll be able to compromise either. In my head, I envision Bush as a whiny little child throwing a tantrum over S-chip. He was invited to the party, but thought no one was going ... now that it turned out to be a big deal, he wants in -- and he'll cry, and cajole and veto until he gets his way.

Here's some preliminary coverage from the New York Times and CNN.

I heart Chuck Grassley.

I know, I know, I shouldn't say such things about a Republican, but really I can't help myself in this case. Grassley is just so into S-Chip, it makes my heart all aflutter.

Here's why: President Bush apparently got a little misinformation (probably was intentional, who knows) about what the compromise S-Chip bill would do. Someone told Bush the bill would cover children in families with annual incomes of $83,000 (400% of the federal poverty level). However, this is patently untrue. The compromise bill, finalized over the weekend with final text expected today, limits S-Chip enrollment to 300% of the poverty level (maybe 350%, I'm not sure). The $83,000 that Bush refers to in his little rant on Thursday was about New York. NY petitioned to cover children in families at 400% of the poverty level ... and was denied, as Bush should know since his right hand man, HHS Secretary Mike Leavitt, did it.

So Grassley comes out Friday and says flat out, Bush, you don't know what you're talking about. Some highlights of Grassley comments:

• From CongressDaily: Bush's comments indicate a "miserable lack of understanding of what we're doing and even what his own administration has done;"
• From LA Times: Bush's proposal for SCHIP is insufficient "to accomplish what he said he wants to do, and that's cover more kids;"
• From USA Today: "The White House must recognize that bipartisan compromise is necessary" to continue the program; and
• From NY Times: "Drawing lines in the sand at this stage isn't constructive. I wish he'd engage Congress in a bill that he could sign instead of threatening a veto, and I hope he'll still do that."

"Miserable lack of understanding" is my favorite. I think it's just so rare that a Republican comes out and says it. You're wrong, Bush, and you suck (okay, maybe the "you suck" part is just my own personal view).

Runner up for favorite Republican on S-Chip is Orrin Hatch. When asked if he would vote to overturn Bush's veto, Hatch said, "You bet your sweet bippy I will." Aw, shucks, Orrin, you're just too adorable.

I started this post originally on Friday, and obviously more things have happened than my expression of adoration for two senior Republican senators. No, indeed, you may have heard that the compromise bill has been released. Here's the details, ala a Senate Finance Committee press release.

Grassley and Baucus, 1, Stark, 0

To be honest, I almost can't even stand to blog about S-chip anymore, I am so sick of hearing about it. But since it is my life and I love it, and I am a mere 10 days away from seeing SOMETHING actually happen with it, here's yet another post about S-chip.

The House gave in. The "compromise" bill (hopefully) is being released tomorrow and word on the Hill is that Stark lost his oh-so-precious cuts to Medicare Advantage. Baucus and Grassley must be thrilled. Sure, it's not really much of a compromise (considering it is so closely worded to the Senate bill they might not even have to re-vote on it, depending on whether the House can force some concessions). But still. At least it's something. That can pass in the Senate at least -- all bets are off in the House. Today I read that 17 House GOPers have said they will vote in favor of the new bill. Another Republican member (I forget who, but he's working along with Rahm Emanuel) predicted 30. The question becomes: Will it be enough to override a veto? I've heard some mixed predictions -- some say that there's these limited number of Republicans volunteering to support it, while others have said (over and over, I would say), Republican or not, you simply cannot vote against children.

Only 10 days before we find out. I'm going to fucking go into S-Chip withdrawl when this is over.

Who knew you could do this?

Reporting on S-chip has taught me so much about procedural tactics, it's kind of scary.

This week was no exception. Bush decided on Friday, after business hours, while Congress is in recess, that he is going to make it virtually impossible for any state to enroll children in S-chip if their families earn more than 250% of the federal poverty level. Under his news rules, if states want to insure children in families earning above 250%, they must:

• Enroll 95% of eligible children in families under 200% of the poverty level (This is impossible. No state does it.);
• Ensure that children in families over 250% are uninsured for a year before enrolling them;
• Charge kids in families over 250% premiums and copays at the same rates as private insurance;
• Ensure that the percentage of children enrolled in private insurance plans doesn't drop by more than 2% (to make sure that employees aren't dropping their private insurance left-and-right to run on over to public assistance, the Republicans' anti-Christ); and
• Create mechanisms to ensure that employers don't create policies that encourage employees to switch to public programs.

While it probably goes without saying, I think this new policy is stupid. Yes, I suppose Bush is technically within his rights to create it ... it just seems unnecessarily cruel to set states up for failure, and in turn, children. It really bugs me in its hypocrisies. Bush expects (or maybe he doesn't?) states to now strive for enrolling 95% of all eligible children at 200%, the law's "original intent" or whatever, but under Bush's SCHIP proposal, there wouldn't be enough money to pay for them long-term. What's the point of bringing children into the program, if two years down the line, you are going to have to kick them out when the program runs out of funding? In essence, he basically set up that rule to prevent states from covering children above 250%. Someone never told Bush "honesty is the best policy."

Obviously he can't tell the truth about what he's doing, though. He would sound like an asshole. Which I think perfectly describes what he just did, denying care to children and putting more burdens on states. He is being so incredibly inflexible about everything that is S-chip.

Real reporters' coverage available here and here and here.

Now what?

With both the House and the Senate having passed substantially different versions of health care legislation, I'm intrigued to see how the conference committee is going to find some sort of viable solution. Both sides are saying, "here's this provision of our bill that can't change" and they seem completely at odds with each other.

In the House, both Dems and Republicans are saying that the tobacco tax increase can't go above 45 cents. Dems already lost 10 votes because of the tax in the first round, who knows how many more they'd lose if they increased the tax to the Senate level of 61 cents.

Meanwhile, Republican senators do not seem willing to even consider cuts to Medicare Advantage (complete bullshit if you ask me...). But the Senate already has the smaller expansion -- if you were to just collect funds from a 45 cent tax increase, it wouldn't even be enough to fund the $35 billion expansion. So basically senators have to find a completely different, non-controversial source of funding. I hope they're creative, because I'm not sure that exists.

My prediction: $35 billion expansion, with some of the House's Medicare provisions (definitely the reversal of scheduled physicians cuts, to be funded perhaps by the cuts to nursing and inpatient rehabilitation centers?), without the MA cuts. All to be funded with a 45-cent tax increase and "unidentified non-controversial tax" (I've heard that perhaps they could better collect back taxes, and that would get lawmakers the needed money).

What makes it even more tricky is the impending presidential veto. I wish Bush would get off his ideological high horse already. Leavitt is quoted in the NY Times as saying

Congress was jeopardizing health care for millions of needy children by passing bills that “the president will have no choice but to veto.”

Seriously, what an ass. So not only does the conference committee have to come up with something that most of the lawmakers can agree on, it also has to be veto-proof. That, or millions of children go without health insurance. No pressure Congress. No pressure at all.

On S-Chip ... and Medicare Advantage ... and Physician Reimbursements ...

Finally back from vacation, and almost caught up at work.

Dominating my work life these days is S-Chip, both the House and the Senate versions. I gotta say, the House version bugs me. It just seems so utterly unrealistic. The bill does so much ... from a major expansion of S-Chip, to a 45-cent tobacco tax, to major revisions in Medicare (i.e. physician reimbursement levels, nursing home and inpatient rehabilitation reimbursements ... and let's not forget everyone's favorite -- Medicare Advantage).

Reimbursed on average 12% higher than traditional Medicare, and sometimes as high as 19% more, Medicare Advantage is House Dems' favorite source of S-Chip funding to meet their own pay/go guidelines. And no wonder why, the latest CBO scoring finds equalizing the payments will save $50.4 billion over five years and $157.1 billion over the next decade. Dems argue that there's no reason these plans should get more, just because they're private. It's a big Republican scheme to make insurance companies richer, they say.

Republicans, along with AHIP, HATE the idea of equalizing the reimbursement rates. Some reasons they give why the rates shouldn't be equalized:

1. The lower reimbursement rates will make the plans unprofitable and cause the insurance companies to drop them, which could hurt seniors in rural areas, who have limited options to begin with.
2. If companies drop the MA plans, minorities will be adversely affected because they enroll in higher numbers in the private plans. (This is a contentious assertion. Rep. Pete Stark, and other supporters of an equalization, say this is simply not true -- that minorities are equally enrolled in both the traditional plans and private plans.)
3. Reducing the reimbursement will cause physicians to stop accepting patients enrolled in the plans, which would obviously be bad for everyone.

So who to believe?

MedPAC, which advises Medicare, issued recommendations (PDF) in June saying that MA rates should be equalized. It writes that

MedPAC has a long history of supporting private plans in the Medicare program. The Commission believes that Medicare beneficiaries should be able to choose between the [traditional] Medicare program and the alternative delivery systems that private plans can provide. Private plans may have greater flexibility in developing innovative approaches to care, and these plans can more readily use tools such as negotiated prices, provider networks, care coordination and other health care management techniques to improve the efficiency and quality of health care services.

However, the recommendations continue:

The Commission believes that payment policy in the MA program should be built on a foundation of financial neutrality between payments in the traditional ... program and payments to private plans. Financial neutrality means that the Medicare program should pay the same amount, adjusting for the risk status of each beneficiary, regardless of which Medicare option a beneficiary chooses.

I'm going with MedPAC. I think overall reimbursement rates are too low and the access to care for Medicare beneficiaries is a problem, but I don't think continuing to give private plans more money is the solution. I'm all about an overhaul of the reimbursement system.

So go ahead and equalize 'em, Stark, you've been waiting for this moment all session. (Now if only you could get enough support in the Senate to actually make it happen...).

More on S-Chip in the days to come.