Medicaid Battle: Congress vs. The Veto

A battle over proposed cost saving measure proposed by the Bush administration is brewing in the U.S. House of Representatives. With a veto threat already on the table, things are looking interesting as another face-off between the two branches of government begins.

Jim Abrams gives us the scoop in his article for Time Magazine:

Passage of the legislation in a vote scheduled for later Wednesday would send it to the Senate Finance Committee, where Chairman Max Baucus, D-Mont., is reviewing options for suspending the regulations, his press officer said.

The governors of all 50 states, state Medicaid directors and others oppose the rules, Energy and Commerce Committee Chairman John Dingell, D-Mich., told the House. "They know the devastating effects these rules would have on local communities, upon hospitals, and upon vulnerable beneficiaries." Dingell's committee approved the bill earlier this month on a 46-0 vote. [Emphasis added. -GW]

So far during the current administration Congress has only been able to successfully override one veto from the President: a water projects bill last November. While this does not bode well for Congress in the coming conflict, this issue is far from dead in the water. Legislators, state governors, health care providers and more are coming together in favor of the moratorium because they fear the administrations plans will simply cost shift the burden to the poor and the state governments.

Once again, the Executive branch and Legislative branch of our government are locking horns, this time on one of the top issues of the current electoral season.

The White House, in a statement Tuesday warning of a veto threat, said the bill would "thwart these efforts of the federal government to regain fiscal accountability and integrity in Medicaid." Health and Human Services Secretary Mike Leavitt, in a letter to lawmakers, said it "puts billions of dollars of federal funds at risk, and may turn back progress that has already been made to stop abusive state practices."

But the proposed changes have met opposition from states, health care providers and advocates for poor who say they will shift costs from the federal government to the states and create new hardships for the needy. "Some of these regulations already have become effective and current state estimates of the impact could be as high as four times the administration's $13 billion estimate," National Governors Association chairman Tim Pawlenty, D-Minn., and other governors wrote lawmakers this month. Timely action to impose the one-year moratorium was "critical to avert significant disruptions in coverage for vulnerable populations," they wrote.

So it looks like the fiscal side of American health care rears its head once again. With 48 million people participating in Medicaid over 2007 the impact of this legislation will be felt far and wide. The Time article paints the cost of Medicaid programs at $352 billion, $200 of which was supplied by the federal government, an amount guaranteed to make the public sit up and take notice.

When was the last time you can recall the governors of all 50 states in the U.S. agreeing on something?

SOURCE: "House Challenging Medicaid Rules" 04/23/08
photo courtesy of euthman, used according to its Creative Commons license

The New Bush Budget: Cutting Health Care for 9/11 Responders, Medicare, and Veteran's Health Programs

The buzz is everywhere now that U.S. President George W. Bush has unveiled his budget plan for the coming fiscal year. Huge cuts in health care spending are part of the package, and the prevalent attitude across the media seems to one of shock.

Let's begin in New York with The Queens Gazette where John Toscana addresses the massive reduction in health care funds for 9/11 survivors:

New York lawmakers in Washington who have been persistently pressing the White House for increased funding for healthcare programs for ailing 9/11 World Trade Center workers were jolted last week when President George W. Bush's proposed budget slashed those programs by 77 percent. [...]

"This dramatic and unwarranted cut flies in the face of common sense, compassion and just plain fairness," Senator Charles Schumer declared as he promised to "fight these cuts tooth and nail to ensure these heroes receive the health care they need and clearly deserve".

An editorial yesterday in the San Jose Mercury News lists some of the extensive health care cuts:

The single most damaging portion of the Bush budget is his proposal to cut an additional $200 billion from Medicare and Medicaid programs. That will cause irreparable harm to public hospitals that are required by law to provide medical care to uninsured residents. And it will further reduce the number of doctors willing to treat a growing senior population, let alone the poor on Medicaid.

[...] Cutting Medicare and Medicaid isn't the only ill-advised health care proposal. Incredibly, Bush calls for a decrease in veterans' medical programs, despite the toll of war and revelations of inadequate care.

He calls for a freeze in the National Institutes of Health budget, which will result in fewer research grants to find better treatments for cancer and other diseases. His proposed funding for the State Children's Health Insurance program falls far short of the bipartisan agreement that has the approval of Congress, including Republicans such as Sen. Orrin Hatch of Utah. One out of every eight children in the nation now has no health insurance, a national embarrassment.

The proposed cuts in veterans' health care come at a time when the Veteran's Administration is facing litigation for arbitrary denial of care and benefits to wounded veterans, an issue that will be joined in a hearing March 7th.

Next stop on the tour is Oregon's Portland Business Journal, where Republican Sen. Gordon Smith's reception of this news is frosty:

"Good policy should drive the budget, not arbitrary cuts to programs that protect our seniors, our children and the most vulnerable," Smith said in a statement. "Cuts to Medicare and Medicaid start an unwelcomed ripple effect in state budgets and doctors offices.... We should strengthen, not bring down the programs that keep America healthy."

In upstate New York hospitals are looking at a loss of $2.4 billion in funding over the next five years if the proposed budget gets passed. Christian Livermore of the Hudson Valley Times-Herald-Record brings us that perspective along with more commentary by Senator Schumer:

Sen. Chuck Schumer yesterday called the proposed cuts -- the largest, he said, since he has been in the Senate -- "a punch to the gut of upstate New York hospitals."

"Our hospitals are already struggling to get by," Schumer said in a conference call with reporters. "Many are in red ink. You put these cuts in and you're pulling the rug out from under them, not just the hospitals themselves, but the doctors, the nurses, the technicians and the people who sweep the floors at night, who depend on these hospitals for their livelihood."

Bush's cuts to New York hospitals and health systems could total $10 billion statewide, much of it from rate freezes and reductions in reimbursements for indigent care, and would cut Medicare and Medicaid by $200 billion nationwide over the next five years.

It will be interesting to see what happens when this reaches Congress. Senators Smith and Schumer are far from the only critics on Capitol Hill.

SOURCE: "NY Lawmakers Shocked At Bush's 77% Cut In 9/11 Health Funding" 02/06/08
SOURCE: "Editorial: Bush's budget takes money away from health care" 02/06/08
SOURCE: "Veterans not entitled to mental health care, U.S. lawyers argue" 02/05/08
SOURCE: "Smith criticizes proposed health care cuts" 02/04/08
SOURCE: "Proposed cuts could sting: Local hospitals face decisions they'd rather not have to make" 02/07/08

photo courtesy of U.S. State department (Official Portrait, Public Domain)

One Third of Americans Call for Health System Rebuild While SCHIP Faces New Veto

Thursday the SCHIP legislation cleared the senate by a vote of 64-30, still not enough to override the promised veto from the executive branch. This would be President Bush's second veto of this legislation.

The Associated Press analysis of the situation yields the following:

In a situation of bewildering political complexity, Republicans dictated the decision to pass the legislation speedily. It appeared their goal was to short-circuit attempts by supporters of the bill to reach a compromise that could attract enough votes in the House to override Bush's veto.

Attempts by [U.S. Senator Harry] Reid to delay final passage of the bill until next week or longer drew objections from the Republicans.

This new round in the ongoing SCHIP battle comes as Science News brings us the results of a new seven nation study by the Commonwealth Fund, showing that over one third of Americans want a total rebuild of our health care system from the ground up. This is the highest rate of any of the countries surveyed, and cites medical errors, costs, and long waits for treatment as major contributing factors.

As in previous surveys, U.S. adults were most likely to have gone without care because of cost and to have high out-of-pocket costs. In the U.S., nearly two of five (37%) of all adults and 42% of those with chronic conditions had skipped medications, not seen a doctor when sick, or foregone recommended care in the past year because of costs -- rates well above all other countries. In contrast to the U.S., patients in Canada, the Netherlands, and the U.K. rarely report having to forgo needed medical care because of costs.

In addition, one-fifth of U.S. adults report serious problems paying medical bills--more than double the rate in the next highest country. And nearly one third (30%) in the U.S. spent more than $1,000 in the past year out-of-pocket -- a level rare in most of the other countries.

Some additional statistics provided from the report include:

• 1 in 5 report doctors advising treatment perceived as having little to no benefit


• Only in the Netherlands do people spend more time on paperwork and medical bill/insurance disputes


• The U.S. has the second highest percentage of adult visits to the emergency room (36%) out of nations surveyed, exceeded only by Canada.

SOURCE: "Congress Passes New Child Health Care Bill, Setting Up Another Veto Fight With Bush" 11/02/07
SOURCE: "One Third of U.S. Adults call For Completely Rebuilding Health Care System" 11/04/07
remixed photo courtesy of James and Vilija, used under this Creative Commons license

Veto II: The Sequel?

On Thursday the U.S. House of Representatives passed a revised version of the SCHIP legislation that President Bush vetoed the last time it came through Congress. The final tally was 256-142, enough to pass but shy of the two thirds majority needed to override another veto. (Ten members of the California delegation did not vote due to the wildfires in their home districts.)

While the Democrats refuse to alter the scope of the proposed plan (covering 10 million children at a cost of $35 billion over five years), there are a number of alterations when compared to the previously vetoed attempt. Matt Canham at the Salt Lake Tribune enumerates some of the changes:

The latest bill would:

• Cap income eligibility at three times the poverty level or about $60,000 a year for a family of four. The old bill would allow the president to agree to waivers to cover those making more than that.


• Phase out the adults covered by CHIP in one year instead of two.


• Require the Social Security Administration to verify that all participants are citizens, bolstering provisions barring undocumented immigrants.


• Require the Government Accountability Office to create a report detailing the best ways to avoid "crowd out," where those with private insurance drop it in favor of this government program.

The White House and House Republicans were not impressed by the concessions, calling them "cosmetic."

Depending on how long it takes for this revised bill to negotiate the Senate it could be on the President's desk as early as next week. Several media sources report administration officials as saying President Bush is solidly opposed to the stiff increases in tobacco taxes which would fund the program. Most of these sources agree that a second veto is highly likely once this reaches the executive branch. If that occurs an override vote is likely to occur near November 16, the date on which temporary funding for the program expires.

Stay tuned.


SOURCE: "CHIP Revision Passes House" 10/26/07
photo courtesy of Superturtle on Flickr, used and remixed under this Creative Commons license. Image Remix by George Williams

Digital Medicine

While the pros and cons of SCHIP dominate the news and the blogosphere, a quiet little press release snuck onto the web this morning offering news of advances in the field of electronic medical records (EMRs).

CNNMoney reprints the original Siemens press release:

Siemens Medical Solutions is fulfilling the demand for a workflow-oriented, patient-centric approach to healthcare with its Enterprise Document Management (EDM) and Soarian(R) Healthcare Information Management (HIM) solutions, which are helping healthcare institutions enhance patient care, improve patient safety initiatives, and reduce healthcare costs.

Why would this drive the costs of health care down?

Accessible from any location, EDM and Soarian HIM coordinate processes within and between departments, as well as tasks between users. With their Web-based intuitive user interfaces, the solutions host concurrent and multi- user access, helping to eliminate multiple trips by clinicians and patient financial services staff to the HIM department to access patient data. When patient charts are virtual, costs and time associated with chart storage and retrieval are reduced. Many EDM and Soarian HIM customers are seeing positive outcomes as a result of use at their facilities.

So....

Transparent and portable medical information, eh? Good idea, sounds familiar. According to the release the implementation of these digital sstems has driven down costs while improving efficiency and accessibility. Photocopying costs are a good example. The cost of making copies of medical records was reduced by $100,000 annually for CaroMont Health of North Carolina. and $45,000 for the Mountain States Health Alliance after the implementation of HIM solutions.

The release presents some specific examples on a case by case basis:

CaroMont Health has reduced the number of record requests by 30 percent, its record analysis by 50 percent, its medical records delinquency rate by 84 percent, unbilled accounts receivables by 50 percent and photocopying costs by $100,000 annually.

You can rest assured that we will be returning to this story when there is more to report.


SOURCE: "
Siemens Soarian Health Information Management is Widely Adopted by Leading Healthcare Institutions in 2007: Leading Healthcare Institutions Embrace Technology That Enables Free Flow of Patient Documentation Throughout the Enterprise
" 10/08/07
Image by George Williams

The Veto Heard Round The World

President George W. Bush on Wednesday issued his expected veto of $35 Billion in children's health care funding. In short order the commentary and criticism of this move have rippled through not only our own national news, but across the the global media as well. Here is a quick World Tour of reactions to this fourth veto of President Bush's career:

The first stop on our world tour is Korea, where we pick up a copy of The Korea Times and read about the SCHIP legislation:

The bill has problems. It is expensive, $35 billion over five years; the use of a cigarette tax to finance it is questionable; and it may indeed cover some families who could afford private insurance.

But it is not, as some overheated opponents charge, socialized medicine or anything like it. Some Republicans charge that SCHIP is the first step toward "HillaryCare," but even if that were in the back of the Democratic candidate's mind, it would be beside the point.

Then we head over to nearby China to see what The Xinhua News Agency has to say:

The veto of Bush was seen by analysts as a high-risk gamble that might impair his party's efforts to compete with democrats for the next presidency and the dominance in Congress.

Lets shift perspective to Western Europe, how are they viewing this? A quick glance at The Economist (UK Edition) unearths the following:

Up with children, down with smokers: it was, in other words, an easy sell. But Mr Bush balked for several reasons. He said that expansion would mean shifting the programme's focus away from poor children. Better off parents might be tempted to drop their private coverage in lieu of the government option, nudging the country down the dangerous road to nationalised care. Mr Bush objected to the tax increase. And although this White House is not known for fiscal restraint, it thought the expansion would cost too much. Mr Bush had previously said that a $5 billion spending increase would be about right.

Getting a bit closer to home we find the Dominican Republic rejoicing at the veto. Why? As Dominican Today reports, it has saved their industry:

Tobacco farmers of the country's north region (Cibao) yesterday heard with joy the news that U.S. president George Bush's vetoed a bill passed by Congress, which threatened to decimate the Dominican and Central American tobacco industries.

The president of the Cibao Tobacco Harvesters Federation, Jorge Mercado, said the U.S. president's decision would reactivate the north zone's tobacco industry, mainly in Santiago province. "The veto of the law represents hope and relief for more than 300 harvesters in this region who have lived off the production of tobacco for centuries."

Agriculture minister Salvador Jiménez, quoted by the newspaper Diario Libre, said if the bill had been signed into law the country would've lost some 54,000 jobs.

Stay tuned.

SOURCE: "Veto of Child Health Bill" 10/04/07
SOURCE: "Bipartisan Tension Tightens as Bush Vetoes Program" 10/04/07
SOURCE: "Why Did George Bush Veto a Popular Health Care Bill?" 10/04/07
SOURCE: "Bush Veto Saves The Dominican Tobacco Industry" 10/04/07
photo courtesy of Bluedharma used under this Creative Commons license

Lilly CEO Calls for Reform and EMRs

While the health care reform community is focused on President George W. Bush’s imminent veto of the children's health insurance bill, a major announcement about Electronic Medical Records (EMRs) has evaded the spotlight.

Sidney Taurel, CEO of pharmaceutical giant Eli Lilly put forth a call for development of a health information technology system. His proposed system would be a collaborative effort of both public and private sectors and would involve the U.S. government, the health care industry and the medical community as active participants.

The aim is tracking both actual effectiveness and side effects of drugs that have been released into the market. This "real world" data will enhance the safety profile of drugs first established through standard drug trials.

CNNMoney reports on Taurel's address at the Cleveland Clinic:

Although traditional drug trials will continue to test new hypotheses about medicines after they have reached the market, Taurel outlined how a well-functioning health IT system could serve not only to frame hypotheses for so-called "Phase IV" clinical research, but also become the practical equivalent of massive, real-world trials. Such a system would collect detailed data from day-to-day medical practices and feed insights quickly, seamlessly and at a lower cost to doctors, regulators, and drug manufacturers. The result would be a more accurate picture of a drug's safety and efficacy than exists today.

Once again we see the importance of developing portable, transparent records as Kaiser-Permanente CEO George Halvorson outlines in his book, Health Care Reform Now!

The CNNMoney article goes on to describe the current collaboration along these lines:

Taurel explained that as EMR systems build out, they provide what amounts to a 'commons' in which organizations can collaborate to share health information.

For example, Lilly, Pfizer, and Johnson & Johnson are collaborating with 'e-Health Initiative' - a not-for-profit health information technology group - as well as with the Indiana Health Information Exchange and the Partners Healthcare System in Boston. The goal is to test how safety signals can be located and understood using existing data, potentially leading to a better understanding of the risk and benefits of medicines.

SOURCE: "Lilly’s CEO Calls For Reform of Nation’s Drug Safety System" 10/02/07
photo courtesy of Uh…Bob

Eight States to Sue Administration Over Child Health Care

As the time approaches for President Bush to veto the current SCHIP legislation, as he has repeatedly promised, the adversarial nature of the debate is turning litigious. Tom Hester at Newsday reports:

New Jersey on Monday joined seven states in filing separate lawsuits against the Bush administration's challenge of proposed federal rules the states say will force poor children to lose health coverage.

The lawsuit for New Jersey was filed Monday morning in federal court in Trenton, state Attorney General Anne Milgram said. New Jersey joins Maryland, Arizona, California, Illinois, New Hampshire, New York and Washington in filing similar litigation.

"The Bush administration has gone beyond its regulatory rights," New Jersey Gov. Jon S. Corzine said as he announced the lawsuit at an East Orange health center.

At the core of the conflict are rules issued by the Center for Medicare and Medicaid Services which the suits claim exceed the statutory authority set forth in Title XXI of the Social Security Act. The SCHIP legislation currently facing veto would remove these new strictures. What new strictures, you ask? Ralph Thomas at the Seattle Times brings us the following clarification:

Under the restrictions, before states can start enrolling kids above 250 percent of the poverty level, they must make sure they are covering at least 95 percent of kids at or below 200 percent of the poverty level.

[Washington State Governor] Gregoire said no state has been able to reach that mark. She said Washington has one of the nation's highest coverage rates, at about 91 percent.

"We just do not believe that is achievable and in fact was put in place to guarantee that we couldn't go above 250 percent of poverty," she said.

The restrictions also require new enrollees above 250 percent of the poverty level to go a year without insurance before they could enroll in SCHIP.

These strictures are being cast as beyond the legal limitations on federal power, and more states continue to bring suit agaisnt them.

"The federal government lacks the authority to do what it is trying to do," [NJ Attorney General] Milgram said, adding that New Jersey's plan has been approved eight times, including five times by the Bush administration.

[New Jersey Gov. Jon S.] Corzine has said the rules could risk health insurance coverage for 10,000 New Jersey poor children.

SOURCE: "8 States Sue Bush Over Children's Health Insurance" 10/01/07
SOURCE: "State to Sue Feds Over Childrens Health Insurance" 10/02/07
photo courtesy of Scott Ableman

Deadlines Loom for Health Care Legislation

In Washington D.C., where the fiscal year ends on Sunday, September 30, President George W. Bush continues to threaten a veto of the State Children’s Health Insurance Program (SCHIP), while Democrats line up votes. Passage is expected in the U.S. House of Representatives early this week and in the U.S. Senate by the end of the week.

In an article for the Monday The New York Times blog, "The Caucus," journalist Carl Hulse explains why Democrats are not backing away from a showdown with the President:

Democrats like their position on this issue. They believe that the public supports making health insurance more affordable and that many families with middle-class incomes are struggling to provide coverage and care for their children. Some Republicans in both the House and Senate are expected to support the plan.

In California, compromise -- not confrontation -- is the top story. The San Francisco Chronicle reports that Governor Arnold Schwarzenegger is close to a compromise with Democratic leaders on a health care reform bill. Schwarzenegger wants to pass the bill before the end of the special legislative session. In a Sunday article outlining the financial interests of a dozen key players, Chronicle journalist Tom Chorneau comments on the surprising civility of the public debate at this late stage:

Absent from the airwaves are the attack ads from insurance companies and doctor groups that many feared would have materialized by now. Massive protests from labor unions or consumer groups intended to push the talks one direction or another have also been largely put on hold.

This should be an exciting week of twists and turns in the effort to pass health care reform legislation. Do you think the California bill or the federal SCHIP program will pass? Do you think President Bush will really veto SCHIP? Do you think the U.S. Congress will have the votes to override a presidential veto? We'd love to hear your comments.


SOURCE: "Democratic Leaders Close to Deal on Health Care Reform," Tom Chorneau, San Francisco Chronicle, 09/23/07
SOURCE: "Congress Tackles Child Health Care," by Carl Hulse, The Caucus, Political Blogging from The New York Times, 09/24/07
photo courtesy of U.S. White House

Let The SCHIPs Fall Where They May

The State Child Health Care Insurance Program (SCHIP) is a major bone of contention between President Bush and the United States Senate. There is never a lack of strident debate when it comes to issues as polarizing as health care has become. Sources large and small are weighing in on the subject everywhere from major networks to the blogosphere.

Political correspondent John Fout talks about SCHIP and examines the brewing confrontation for The Street in his Market Features column:

The program provides coverage to poor children who are ineligible for coverage under Medicare and who lack private health insurance, and according to a Senate report, it's been a big success. According to the report, the number of uninsured children has decreased from 14% in 1997 to about 9% in 2005, bucking the opposite trend for adults.

Fout then proceeds to examine both the funding source for the new expansion and the President's rationale for his threatened veto:

The expansion of the SCHIP program would be funded by a small tax increase on cigarettes. A recent poll by the American Medical Association found that 70% of Americans support a tax hike to pay for children's health care. In addition, incremental increases in cigarette prices are thought to have played a role in decreases in smoking. This sounds like a win-win situation for public health.

Bush, however, prefers to fight expansion of the program. He favors funding care for poor children only -- rather than the lower- or middle-class families who'd be covered under the Senate bill -- and suggested that expansion would cause middle-class families to cancel private policies in favor of public policies. The expansion only affects people presently lacking coverage.

President Bush went on to characterize the bill as "federalization" of health care and to accuse Democrats of using the issue "to score political points." He has also promised to veto the bill once it reaches his desk. (As pointed out in our Aug. 3 post, it passed the Senate with a 68-31 margin -- sufficient to override a veto.)

SOURCE: "Bush Fights Losing Battle Over Kids' Health Care" 09/20/07
photo courtesy of Tenuda on Flickr

SCHIP