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.

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.