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As health care reform evolves, many options being discussed
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Health care reform is moving forward on a fast track. There is little possibility of derailment but there will be course changes as the principles and legislation are debated in the House and Senate.
The Senate Finance Committee, Senate HELP Committee, and the House Tri-Committee (House Committees on Ways and Means, Energy and Commerce, and Education and Labor) have all released legislative documents. The proposed legislation is currently undergoing markup by the committee and scoring for cost and effectiveness by the Congressional Budget Office (CBO). The President and Congress have said that Americans can keep their current coverage if they like it and can preserve their choice of doctors, hospitals and health plans.
Health care proposals
Both the House and Senate have considered an exchange or gateway structure. These will work as a transparent marketplace for individuals and small businesses to compare insurance plans that guarantee a basic set of benefits as recommended by an independent advisory council. The most controversial part of this strategy is whether there should be an added public plan that competes with commercial products. This has raised concerns that a public plan would be the forerunner of a single-payer system. Republicans on the committee have labeled the public insurance choice as a non-starter.
Affordability is a common theme, and there are proposals of sliding scale credits depending on income status. Subsidies up to 500% of the federal poverty level (FPL) have been considered (that is up to an income of $110,000 for a family of four). Individuals must buy insurance or pay a 2% penalty of gross income if they fail to do so. Employers are also responsible to provide coverage for their employees or they would pay a tax as a percent of payroll to the public plan.
Controlling costs has been another major part of discussion. President Obama has stated that cost controls must be in place, not only for insurance to be affordable for the individual but also for the fact that the country cannot continue to bear the rapidly increasing cost of health care. The White House has said that it will only support a plan that is deficit-neutral over 10 years including the 10th year.
Many strategies for improving care coordination through the patient-centered medical home are being reviewed. Integrated health care delivery is viewed as a method for increasing coordination, decreasing cost and improving quality. Only 15% of current health care is delivered in integrated systems. This will require changing the health care delivery for 85% of clinicians and patients. This is an enormous restructuring of health care delivery and the mechanisms of implementing those changes are uncertain. Federal Trade Commission anti-trust laws and STARK regulations will need changing. Health information technology and interoperability are key components of the infrastructure necessary to coordinate the care. The White House and Congress believe the CBO estimated projected costs will be less as accountable care organizations develop and they become more efficient with bundling of payments to encourage provider coordination and best care.
Prevention and wellness are a significant part of the HELP Committee legislation. The legislation proposes setting up a national preventive health and public health council to evaluate community health services as well as population-based strategies. Community health teams would be set up that could promote wellness, prevention, decrease hospital readmissions, improve adherence to medications and coordinate the care among clinicians. A community living assistance program would be optional for citizens to buy into with the intent of providing support to those who are unable to perform at least two or more activities of daily living. The intent would be to make it easier for them to stay in their home environment. Dollars paid into this plan would be placed in a lockbox for use for these services.
The House plan deals with changes in the sustainable growth rate (SGR) by resetting the baseline and has proposed eliminating the SGR when other payment methods are in place. Medical liability reform is notably absent in these proposals.
The CBO placed a price of $1.6 trillion over 10 years on the Senate Finance Committee’s plan. That plan will either need to scale back benefits or find added sources of revenue, such as taxation on employer-paid insurance premiums. CBO looked at the Senate HELP Committee plan and calculated that it would only cover 16 million of the current 46 million uninsured and cost $1.2 trillion over 10 years.
The current Medicare D-Prescription Drug Plan donut hole is also under consideration for change. Pharmaceutical Research and Manufacturers of America (PhRMA) has pledged to give seniors a 50% discount on brand name drugs when they enter the Medicare D donut hole. This totals $80 billion over 10 years and clearly reduces the direct cost to seniors but does not do anything to the overall costs of insurance coverage.
President Obama had conversations with the American Medical Association and other industry representatives at the White House and stated that they volunteered to save $2 trillion over 10 years. The next day, however, those organizations involved in the discussion claimed that was not their commitment. They were willing to make efforts to control costs but not at a specific dollar figure.
The horse-trading has started. Many amendments have been added and program proposals have been scaled back as the reality of costs becomes obvious. Patients and clinicians should make their concerns about health care legislation known to their Congressional delegation.
James Dove, MD, is President Emeritus, Prairie Cardiovascular Consultants and Clinical Professor of Medicine, Southern Illinois University School of Medicine.