Health system reform continues to march forward while we’re struggling with this aforementioned nightmare Medicare Rule. We once were fully engaged in reform -- until we were diverted. Nonetheless, we’re still keeping our voice at the table in the reform process. WE MUST. There’s more damage possible if we’re not engaged.

The first big item of importance relates to the SGR. The House has pulled the SGR 10-year fix provision out of their now unified bill to allow it to be merged eventually with a unified Senate bill. The SGR is in a parallel vehicle that can be potentially conferenced with the Senate bill (S 1776), which at this point lacks the 60 votes needed to move forward.

Both Chambers need to make sure the $245 billion SGR fix is not included in the cost of reform -- the President can’t sign that bill if it contributes to the deficit, which it would if it contained the SGR. However, Zeke Emanuel made clear that the White House does support the separate and parallel approach of fixing the SGR by adding the $245 billion to the $10 trillion national debt. That said, I think the SGR 10-year fix effort will nonetheless fail unless there is a way to get it approved by a simple majority in the U.S. Senate. That looks difficult. So, we might not want to tie our Medicare Rule fix to that wagon. One way or the other, however, the SGR 21% cut will not occur in January -- if the fix effort fails (which I predict it will), they will put a one- or two-year patch on as usual. 

Other Actions
In other reform actions, Sen. Reid made big news by insisting that a public option be in the Senate bill that merges the Finance and Health, Education, Labor and Pensions Committee proposals. The Majority Leader does not have 60 votes to support that decision, which he clearly made in defense of his own threatened Senate re-election race in Nevada. You see, he comes from a heavily union-dominated district, and he is facing stiff primary opposition supported by labor. So he needed to do this, even though he knows it can’t pass as crafted. Sen. Snowe could always bring back her trigger mechanism in the final bill in the Senate if need be, but I don’t see this version of a public option in what they ultimately produce.

The House will have a public option, but even Speaker Pelosi is having to accommodate the Democratic moderates and Blue Dogs in the provisions she ultimately will include. Only the Senate thus far is committed to an Independent Medicare Advisory Commission (IMAC) to replace MedPAC, but the all-important details of the IMAC -- if it proceeds -- will relate to who is on it, how they get appointed and how broad the powers of cost containment will be. 

One of the big controversies looming relates to the extent to which young healthy people should have to subsidize the costs of care for older and sicker people in reform. AARP of course wants to see a ratio of not greater than 2:1 between insurance costs for young, healthy people as compared with premium costs for older people in federal coverage programs. The insurance industry (and those concerned that young people won’t buy into mandated insurance if they’re up-front premiums are too high) want to see a 4:1 ratio between premium costs of seniors and the young-immortals.

And finally, we’re still stuck between a rock and a hard place in the House and Senate regarding whether we will tax the rich to pay for reform (the House choice), or we will tax Cadillac insurance coverage (the Senate choice) to pay. 

The House has completed their bill and the president has praised them for getting a proposal ready to go to the floor soon, but their bill is really far from done. There will still be a lot of debate, attempts at amendment and horse trading behind the scenes with the Senate before we get to a House and Senate conference committee to produce one unified bill. It will be a busy and politically crazy November and December.

*** Image from Flickr (Cedric). ***