I think it’s fair to say, nobody knows how this health care reform process is going to come out after last week's disturbingly ambiguous week. Both the House tri-committee bill (at 838 pages and a CBO estimated cost of $1.6 trillion over 10 years) and the Senate Finance bill (also $1.6 trillion over 10 years) have gone back to the drawing boards, tails between legs, to try to cut a half trillion out of their perceived grandiosity. The Senate HELP bill was estimated to cost less at a little more than a trillion, but, at 600+ pages, only a few folks really read it. The HELP bill isn’t that much of a bargain because it doesn’t include the costs of Medicaid expansion to cover an additional 15% of the uninsured. The Medicaid expansion is included in the Senate Finance and House proposals.

Finance says they will soon have trimmed the $600 billion over their target out by reducing the benefits and cutting some hospital costs in their revised strategy. The details are not yet available. They still plan to include a cap on deductibility of employer sponsored health insurance; and they will tax employers up to 8% of wage to help fund the new insurance “exchanges” and to subsidize low income uninsured coverage if they do not insure their workers directly.

Does size matter?  Is 800 pages better law than 600? Or are there more things to dislike in the growing complexity of the discussion? Probably the latter. Skepticism has increased. And,  when the public -- seemingly polled to death -- was asked whether they wanted government to completely take over health care, contribute to a rising deficit, and take away their choice, they said, “duh, no.”

Polling Overload
Of course, when that same seeming deer-in-the-headlights public was asked in a different way whether they were supportive of a ‘public option’ insurance plan to compete with private insurance this week, they answered overwhelmingly YES. Since 100% of Republican members of Congress are opposed to the public option, they must have been both scarily surprised by this alleged public option support from their constituency, and are likely ready to re-poll the beleaguered and confused registered voters yet again with some better polling questions, like “would you still favor a public option if it was to cause flesh eating bacteria (MRSA) to become a greater risk to your family? It’s hard to trust these polls -- the questions can lead us to the responses we seek.

There were far too many editorials and op-eds on health reform this week to summarize here. Even reading them was tough. Common threads are hard to find, but there is at least one: people still think the status quo is not good, and some kind of reform is necessary. Phew!  Of course, that could change next week.

House Bill Details
House members this week were getting pretty bent out of shape at doctors who weren’t supportive of their bill, and unable to see that the House had been kind to the profession. They expected big physician support. The House proposes a LOT of new money into health care that would benefit doctors and patients in the aggregate. They eliminate the SGRrrr (at least for the ten year window they can reach to), and that’s worth $300 billion! They take more federal control of Medicaid to assure consistent and better pay across all states, adding millions of uninsured poor men to coverage, and adding billions of $$$ to take Medicaid payments for doctors up toward Medicare levels for most services. They allow cognitive (E & M and consult) payments to increase by GDP+2%, and procedures by GDP+1%. They gave primary care docs a 5% special pay bonus; and they put some money into GME. They also put a lot of new money into prevention. That IS impressive.

Of course, they have some cuts we don’t like and will fight in imaging equipment utilization. And, they strongly support the ‘public option,’ which remains controversial to some folks (like the insurers!).

Insurance Exchange: A Regional FEHBP
The overlooked insurance exchange is actually the big positive in the House plan -- this is a regional FEHBP (federal employee health benefits plan) model that would increase choices of private insurers at mass-purchased lower costs of coverage for uninsured, small business, and self employed persons. This is a positive thing that is getting very little play -- I guess because it isn’t divisive. Quite frankly, the exchange idea is more significant than the public option. The House would allow employed persons to shift their employer’s insurance and join the exchange and/or sign up for the public option if they so choose. That irks the Republicans as an overt move toward a single payer. Of course traditional Medicare already IS a single payer.

House vs. Senate Bills
It would be naïve and short-sighted of us not to see that the House proposal to cut Medicare Advantage insurance subsidies big time, to regulate insurers more intensely; to tax employers who don’t offer coverage, and to cut some hospital reimbursement. Meanwhile, they are adding a lot of dollars to access, and not really cutting doctors in the aggregate. The profession fares well in the House proposal, all in all (given fiscal realities). Since the ‘public option’ may likely get traded away in the end, in favor of perhaps the Sen. Conrad’s public-private co-op model concept, it’s important not to complain too much here.

Remember the Senate versions don’t do anywhere near as much for us in terms of getting rid of the SGR, or guaranteeing higher physician payments in Medicaid, and/or for E & M and consult visits payment increases. But the Senate, with Sen. Kennedy out of town, is much more willing to trade off the public option. Of medical societies, the only one that has gone on record supporting the public option that I know of is AAFP (family docs). They’ll get a lot of credit from the Dems for doing that. But it isn’t clear how their Medical Home idea will fare in terms of actual capitated reimbursement.

Advocacy SVP Jim Fasules, M.D., F.A.C.C., and I visited Speaker Pelosi’s office last week to thank them for their help and talk about why they also need more action on responsible payment reform in their plan. Janet Wright also testified before the Energy and Commerce Committee for us last week, praising the House plan with a few suggestions about tweaking the imaging issues, and also thanking Republican ranking member Barton for adding language that would require insurers and hospitals to publicly publish prices and co-pays for all services (along with quality ratings) to enable patients/consumers to better shop around for value in the future.

The Bottom Line
Bottom line: Obama and the Democrats have staked their reputation and clout on getting some kind of historic health reform bill passed, and on getting it done this year. So I believe some kind of bill is going to eventually pass in 2009. How comprehensive and effective it is remains to be determined. And, whatever it is, it will most certainly not have all the necessary and important details really worked out in it, meaning that we will definitely need to spend the next several years fleshing in all-important details through regulations, legislative tweaks, pilot projects, and experimentation.

But change is a’coming, because it has to.  

*** Image from Flickr (s0litude). ***