Janice Simmons is a senior editor and Washington, DC, correspondent for HealthLeaders Media Online. She can be reached at jsimmons@healthleadersmedia.com.
In 11th hour negotiations last weekend with representatives from the White House and several House members who belong to the Quality Care Coalition, Health and Human Services Secretary Kathleen Sebelius presented a letter indicating that Medicare may be soon moving away from a fee-for-service system to a more quality- and value-based system.
In the letter, Sebelius promised steps to improve Medicare reimbursement rates for physicians and hospitals in regions of the country—particularly the Midwest and Pacific Northwest, where providers say they have been paid less for the delivery of care that may be more efficient—but smaller in volume.
In the letter, she called for:
An Institute of Medicine (IOM) study, beginning in April, to reform the Medicare system to address geographic disparities for doctors and hospitals; implementation of IOM recommendations would be by December 2012.
An IOM study, beginning in April, based on earlier House passed language, making recommendations to move toward high-quality, lower-cost care across the healthcare sector; implementation of the recommendations, as part of the new Independent Payment Advisory Board, would be by 2014.
Additional direction to the new Center for Medicare and Medicaid Innovation to further test innovative models to incent high-quality, low-cost care across the provider spectrum.
A commitment to convene a National Summit on Geographic Variation, Cost, Access and Value in Health Care in September of this year.
The 30-member Quality Care Coalition includes representatives primarily from Midwestern, Pacific Northwest, and rural states, who have complained that they have been strapped with low reimbursement fees over the years while often providing more efficient care.
As part of the reconciliation process, the House Rules Committee included on March 20 a new section, "Payment for Qualifying Hospitals," that would provide additional funding from the Medicare Hospital Insurance Fund for hospitals located on counties within the lowest quartiles of payment.
Marathon days are here again as the Senate met 17 hours—from mid-morning Wednesday to 2:30 a.m. Thursday—on its second day to review and vote on more amendments to the House healthcare reconciliation bill (HR 4872).
While no amendments were added to the bill on Wednesday, the reconciliation bill may still need to return to the House for another vote. Problems have risen in the bill over the formula for determining the maximum Pell grant award under an expanded program. The Senate parliamentarian is also investigating other issues with the bill. The Senate leadership hopes to complete the Senate's work by late today or Friday, at the earliest.
Until the close of business early Thursday morning, nearly two dozen amendments have been proposed by GOP senators since the Senate started meeting on the bill on Tuesday. All amendments have been defeated. The maximum discussion on a reconciliation bill is 20 hours; time is not counted when amendments are introduced.
Sen. Tom Coburn (R-OK) introduced one of the more publicized amendments, which called the new healthcare reform law "the greatest assault on liberty" this country has ever seen. The proposal, he said, was to prevent convicted child molesters, rapists and other sex offenders from getting federal drug coverage for erectile dysfunction drugs. The amendment was defeated in a 57 42.
Sen. Max Baucus (D MT) took exception to the amendment, calling it "a crass political stunt aimed at making 30 second commercials." He added that the bill was trying to help seniors pay for drugs while making healthcare affordable for more people. "This is a serious bill," he said, adding that Coburn's amendment made a "mockery of the Senate and of healthcare.
Other amendments that emerged yesterday were:
A proposal by Sen. Pat Roberts (R-KS) to exempt critical access hospitals in rural areas from cuts proposed by the Independent Payment Advisory Board, which was created by the new healthcare reform bill.
A proposal by Sen. John Thune (R-SD) to remove the Community Living Assistance Services and Support (CLASS) Act from the healthcare reform legislation because "it overpromises and underdelivers."
The Senate resumes floor debate on the healthcare reconciliation bill at 9:45 a.m. today.
While the ink was drying on the historic healthcare reform bill signed into law by President Obama on Tuesday, the latest—and possibly the last—major debate on reform was gearing up across town on the Senate floor.
Under discussion was the 153-page reconciliation bill (HR 4872) approved by the House Sunday night that contains "fixes" to provisions contained in the bill passed by the House on Sunday.
"While the Senate still has a last round of improvements to make on this historic legislation and these are improvements I'm confident they will make swiftly the bill I'm signing will set in motion reforms that generations of Americans have fought for, and marched for, and hungered to see," Obama said at the bill-signing ceremony.
With a vote of 56-40, the Senate voted on Tuesday afternoon to begin the debate. Under Senate rules, discussion of the reconciliation bill will be limited to 20 hours. However, senators are permitted to offer as many amendments as they want, which don't count on the time.
Democrats, though, will likely try to prevent any amendment from being approved because that would mean the bill would have to go back to the House for a new vote. On Tuesday, the Senate met until 10:30 p.m., using more than seven hours of debate time. Democrats are hoping to have a vote on the reconciliation measure by the week's end.
"We do not have before us the whole healthcare reform bill. We do not have to reopen every argument that we had over the last two years. We do not have to say everything that we said about healthcare, one more time," said Sen. Max Baucus (D-MT), chairman of the Senate Finance Committee, in opening floor debate.
However, Sen. Judd Gregg (R-NH), the ranking member of the Senate Budget Committee, was first to offer one of the numerous GOP reconciliation bill amendments. His amendment called for requiring that any Medicare savings from the new healthcare law and the reconciliation bill be used to "shore up the already insolvent Medicare program—not expand or create new entitlements at the expense of Medicare beneficiaries."
Gregg, the designated GOP strategist for Senate debate this week, called the reconciliation bill an "atrocity" and "an attempt to purchase votes in the House." He said most of the reconciliation bill's hospital insurance trust fund savings "would be used to pay for other spending and therefore would not enhance the ability of the government to pay for future Medicare benefits.
"Democrats are trying to have it both ways, but they can't," Gregg said. "The end result is that more money will have to be borrowed from our children to cover the difference."
Among the GOP amendments offered on Tuesday were:
From Sen. Charles Grassley (R-IA): To make sure the president, cabinet members, White House senior staff, and congressional committee and leadership staff purchase health insurance through the health insurance exchanges established by the new law.
From Sen. Charles Inhofe (R-OK): A provision to exclude devices for persons with disabilities from the medical device tax.
From Sen. John McCain (R-AZ): A measure to eliminate financial "sweetheart deals" for Tennessee, Hawaii, Louisiana, Montana, Connecticut, and frontier states.
From Sen. Tom Coburn (R-OK): An amendment that would both enact recommendations from a Government Accountability Office to stop fraudulent payments for prescription drugs prescribed by dead providers, plus prohibit coverage of Viagra and other erectile dysfunction medications to convicted child molesters, rapists, and sex offenders.
The debate on the reconciliation bill will continue on Wednesday morning.
Medical devices. Fees for medical device makers would be delayed to 2013 (from 2010). The sector earlier won a reduced industry tax of $20 billion—down from $40 billion. The bill now contains a 2.9% sales tax—rather than an overall industry fee. Certain consumer products, such as eyeglasses and contact lenses, that are found in retail and drug stores are exempt from the tax.
Physician payment expenses. The bill inserts a new section (1108) that accelerates the phase in of Medicare physician practice expense adjustment for areas "with below average practice expense payment rates."
Hospital payment increase. The bill inserts a new section (1109) that provides an additional payment under the Medicare inpatient prospective payment systems to hospitals located in counties in the bottom quartile as ranked "by risk-adjusted spending per Medicare enrollee."
Adult children. Health insurance plans will be required to offer dependent coverage for adult children through the age of 26 years; insurers are prohibited from denying coverage to children because of pre existing health problems, and can no longer put lifetime dollar limits on coverage and cancel policies—except in cases of fraud.
Tax exempt insurers. Tax-exempt insurers, such as Kaiser Permanente and Geisinger, would pay a new fee levied on insurers on half of their premiums.
Senate Bill Adjustment. Last year, to help win the vote of Sen. Ben Nelson (D-NE), the Senate reform bill included $100 million in federal Medicaid assistance only for Nebraska. The House committee removed the provision, subsequently dubbed the "Cornhusker Kickback," from the revision bill.
Many of the provisions included in the healthcare reform legislation approved Sunday—and the bill that adds fixes to that measure that was sent to the Senate—would take place not immediately, but along a 10-year timeline through 2020. Here's a glimpse of how that timeline rolls out:
2010
Adults with pre-existing conditions who have been uninsured for at least six months can enroll in a temporary high risk health insurance pool and receive subsidized premiums--beginning three months after the bill's passage. (The pools expire when exchanges are implemented in 2014.)
All health insurance plans are to offer dependent coverage for children through age 26; insurers are prohibited from denying coverage to children because of pre existing health problems.
Insurance companies can no longer put lifetime dollar limits on coverage and cancel policies--except in cases of fraud.
Tax credits will be provided to help small businesses with 25 employees or fewer to get and keep coverage for these employees.
The Medicare "doughnut hole," in which beneficiaries had to pay full cost of their prescription drugs, begins narrowing by providing a $250 rebate this year to those in the gap, which starts this year after they have spent $2,830. The doughnut hole fully closes by 2020.
Indoor tanning has a 10% sales tax.
2011
For Medicare beneficiaries reaching the Medicare doughnut hole, prescription coverage will be available with a 50% discount on brand name drugs.
A 10% Medicare bonus will be provided to primary care physicians and general surgeons practicing in underserved areas, such as inner cities and rural communities.
Medicare Advantage plans would begin to have their payments frozen—and then lowered in 2012. The plans would have to spend at least 85 cents out of every dollar on medical costs, while leaving 15 cents for plan operations, including overhead and salaries. Reductions would be phased in over the next three to seven years.
A voluntary long term care insurance program would be made available to provide a modest cash benefit for assisting disabled individuals to stay in their homes or cover nursing home costs. Benefits would start five years after people begin paying a fee for coverage.
Funding for community health centers would be increased to provide care for many low income and uninsured people.
Employers would be required to report the value of healthcare benefits on employees' W 2 tax statements.
Pharmaceutical manufacturers will have a $2.3 billion annual fee that will increase over time.
2012
Nonprofit insurance co ops would be created to compete with commercial insurers. Hospitals, physicians, and payers would be encouraged to band together in "accountable care organizations."
Hospitals with high rates of preventable readmissions would face reduced Medicare payments.
2013
Individuals making $200,000 a year or couples making $250,000 would have a higher Medicare payroll tax of 2.35%—up from the current 1.45%. A new tax of 3.8% on unearned income, such as dividends and interest, is also added.
Medical expense contributions to tax sheltered flexible spending accounts (FSAs) are limited to $2,500 a year—indexed for inflation. In addition, the thresholds for claiming itemized tax deduction for medical expenses rise from 7.5% to 10% of income. People age 65 or older can still deduct medical expenses above 7.5% of income through 2016.
Medicare device makers would have a 2.3% sales tax on medical devices; devices such as eyeglasses, contact lenses, and hearing aids would be exempt.
2014
New state health insurance exchanges would be created. Income based tax credits will be available for many consumers in the exchanges. The sliding scale credits phase out for households that are four times above the federal poverty level (about $88,000 for a family of four).
Medicaid would be expanded to cover low income individuals up to 133% of the federal poverty level—about $28,300 for a family of four.
Insurers would be prohibited from denying coverage to people with pre existing conditions, or charge higher rates to those with poor or chronic health conditions. Premiums (with limitations) can only vary by age, place of residence, family size, and tobacco use.
Insurers will be required to cover maternity care as they do other medical procedures
All legal residents would be required to have health insurance—except in cases of financial hardship—or pay a fine to the IRS. The individual penalty starts at $95 each in 2014—rising to $695 in 2016. Family penalties are capped at $2,250; penalties will be indexed for inflation after 2016.
Employers with more than 50 workers would be penalized if any of their workers get coverage through the exchange and receive a tax credit. The penalty is $2,000 times the total number of workers employed at the company. However, employers get to deduct the first 30 workers.
2018
A tax would be imposed on employer sponsored health insurance worth more than $10,200 for individual coverage, and $27,500 for a family plan. The tax is 40% of the value of the plan above the thresholds, indexed for inflation.
2020
Doughnut hole coverage gap in Medicare prescription benefit is phased out. Seniors continue to pay the standard 25% of their drug costs until they reach the threshold for Medicare catastrophic coverage.
The House on Sunday night finally passed a historic healthcare reform measure that is expected to be signed by President Obama in a day or two. The vote was largely along party lines 219-212.
But approval of the bill is hardly the end of a year-long, hard-fought, and sometimes bruising process that took place on Capitol Hill.
"Now, as momentous as this day is, it's not the end of this journey," said Obama following the Democrats' winning votes in the House.
On Tuesday, the Senate will take up the $940 billion House bill (HR 4872), which revises the Senate bill (HR 3590), that the House also passed Sunday night by a 220-211 vote.
"It's time to bring this debate to a close and begin the hard work of implementing this reform properly on behalf of the American people. This year, and in years to come, we have a solemn responsibility to do it right," the President said.
But Republicans do not want to close the debate any time soon. They are expected to continue their efforts starting this Tuesday to push back the amended bill in the Senate.
Republicans plan on using "a series of amendments on the substance of the bill" that will highlight "the massive Medicare cuts, the massive tax increases, and other deficiencies that we think are the reason the American people are against this bill," said Senate Minority Leader Mitch McConnell Sunday CBS's Face the Nation.
"It could end up going back to the House of Representatives for a second vote. They may not be through with it after today. They may get it back if it doesn't succeed in the Senate," McConnell said Sunday.
Prior to Sunday's vote, House Minority Leader John Boehner (R-OH), who remained critical of the Democrats' actions to pass a reform bill, said, "The process here is broken. ... This bill is not what the American people need or what our constituents want," he said. "Shame on each and every one of you who substitutes your will and your desires above those of your fellow countrymen."
But, for the meantime, the House Democrats chose to bask in the moment of passing the historic legislation. "We believe that the act passed here tonight is an all-American act," said House Speaker Nancy Pelosi (D-CA) in a briefing after the votes.
And Rep. John Dingell (D-MI), who was behind the gavel 45 years ago to announce to the House that Medicare was adopted, said on the House floor Sunday night, "Today is a day that is going to rank with the day we passed the civil rights bill in 1964. Today we are doing something that ranks with what we did on Social Security or Medicare."
Fasten your seat belts, it should be an interesting weekend as the House appears ready to vote on Sunday afternoon on the House healthcare reform package.
Democrats are closing in on the magic number of 216 votes, but because at least two dozen Democrats remained undecided, the total appears not to have been reached yet.
Also, whether Democrats will use the "deem and pass" method, which is a process that would let the House vote on a package of changes to the Senate healthcare reform bill, but not the Senate bill itself, has not been confirmed. But House Democrats were successful on Thursday in turning down attempts by Republicans to stop that process.
In a 222 to 203 vote, a resolution by former Democrat, Rep. Parker Griffith (R-AL), to support a bill ensuring an up-or-down vote on the healthcare reform legislation was turned down. Later, the House voted 232 to 181 to table a measure from Rep. Eric Cantor (R-VA) that said—in reference to the deem and pass strategy—that the House disapproves of the "malfeasant manner in which the Democratic leadership has thereby discharged the duties of their offices."
As to why difficulties were arising over getting the necessary 216 votes, House Speaker Nancy Pelosi (D-CA)said: "Every vote is a heavy lift. We have great diversity in our [Democratic] Caucus. We don't have a rubber stamp Congress or a rubber stamp caucus. ... Members want to see the figures, they want to see what the Senate will do. We like the dynamic in our Caucus."
GOP members remained adamant that they would not let the reform measures go through.
"Republicans in the House and Senate have worked together closely over the last year. We're going to continue to work closer together to do everything we can to make sure that this bill never, ever passes," said House Minority Leader John Boehner (R-OH) at a joint Republican House and Senate briefing.
"Our plan is for the [reform legislation] not to come to the Senate. Our plan is for it to be defeated in the House in the next few days," said Senate Minority Leader Mitch McConnell (R-KY).
After nearly three months since the passage of the Senate bill, the House Rules Committee issued its 153-page reconciliation proposal on Thursday that makes "legislative fixes" to the Senate measure.
Here's a sample of some the major changes made to the Senate bill:
Cadillac Health Plan Tax. This proposed tax, which was not included in the initial House bill approved in November, had been strongly opposed by many House members. The provision does remain in the new House measure, but with changes.
Now, the tax would apply only to the portion of healthcare plans costing more than $10,200 a year for individuals (up from $8,500 in the Senate bill), and $27,500 for families (up from $23,000). Also, the tax would start in 2018—not 2013. The changes would also reduce the projected revenue to the federal government by 80%.
Closing the Doughnut Hole. While the initial House bill closed the doughnut hole—the gap in Medicare in which beneficiaries must pay their own drug costs—the Senate bill did not. Under the new reconciliation measure, Medicare beneficiaries will receive $250 to cover expenses when they cross into the gap this year.
Next year, the beneficiaries would get a 50% discount on brand name drugs (with the cost being paid for by the pharmaceutical industry). In following years, the discounts would be expanded, with coverage extended to generic drugs. By 2020, the discounts would reach 75%.
Medicare Advantage. The federal government currently pays Medicare Advantage private health plans an average of 14% more than traditional Medicare plans. The House plan would cut those payments even more steeply than the Senate bill: $132 billion over 10 years, compared with $118 billion.
In addition, the new bill would shift the funding with some higher cost areas getting paid 5% below traditional Medicare, while some lower cost areas would be paid 15% more than traditional Medicare. Also, proposals in the Senate's plan that would have shielded various areas of the country—such as South Florida—from major reductions was largely eliminated.
Primary Care Payment Increase. Under the new House reconciliation bill, primary care physicians (internists, family physicians, and pediatricians) would get Medicaid payments starting in 2013 and 2014 that would be on par with Medicare rates, which typically are around 20% higher than Medicaid.
Individual Mandate. Similar to the Senate bill, the new bill would penalize most Americans without insurance. The first annual penalty would be $95 and start in 2014. However, in subsequent years, the penalties in the reconciliation bill are slightly different. Those without insurance would pay the greater of two alternatives: (1) a flat fee of $695, which is down from the Senate's $750; or (2) 2.5% of their income.
Medicaid Expansion: The House reconciliation measure calls for full federal funding to all states for newly eligible Medicaid recipients. The funding would last for three years. The bill also eliminates the controversial provision—nicknamed the "Cornhusker Kickback"—that would have exempted Nebraska from paying the costs of Medicaid expansion included in the Senate bill.
Disproportionate Share Hospital Payments. The House provision lowers the reduction in federal Medicaid Disproportionate Share Hospital payments from $18.1 billion to $14.1 billion over the 10-year period. The reductions would not begin until fiscal 2014.
Fraud and Abuse. Funding for fighting fraud, waste, and abuse is increased by $250 million over the next decade. Funds to fight Medicaid fraud will be indexed based on increases in the Consumer Price Index.
Premiums Tax Credits. The reconciliation bill would provide more generous credits to low and moderate income Americans, up to 400% of the poverty level.
Physician Owner Referrals. The reconciliation bill includes a date (Dec. 31, 2010) for the prohibition of physician-owned hospitals to self-refer.
Amnesty International is probably best recognized in the U.S. for its work worldwide that reports on issues such as human rights violations, discrimination, or health disparities. But for its latest report, the group turns its focus on the U.S.
While this country may have one of the most advanced healthcare systems in the world, AI said, it also has major problems with maternal mortality and pregnancy-related complications when compared with other industrialized nations.
In the U.S., women have a greater lifetime risk of dying from pregnancy related complications than women in 40 other countries, according to the report, Deadly Delivery: The Maternal Health Care Crisis in America, which was released last week.
From a comparative standpoint, the likelihood of a woman dying in childbirth in the U.S. is five times greater than in Greece, four times greater than in Germany, and three times greater than in Spain.
The Centers for Disease Control and Prevention (CDC) statistics back this up: They show that 13.3 maternal deaths now occur for every 100,000 live births—well over the target of 3.3 maternal deaths per 100,000 live births, a goal of the US Healthy People 2010 initiative.
"This country's extraordinary record of medical advancement makes its haphazard approach to maternal care all the more scandalous and disgraceful," said Larry Cox, executive director of Amnesty International USA.
"Good maternal care should not be considered a luxury available only to those who can access the best hospitals and the best doctors. Women should not die in the richest country on earth from preventable complications and emergencies," Cox added.
Maternal mortality actually doubled from a low of 6.6 deaths per 100,000 live births in 1987 to 13.3 deaths per 100,000 live births in 2006. While the increase may partially reflect improved data collection, an increase to double digits is a cause for concern, according to the report.
Similar maternal mortality rates have been recently found in California as well, where maternal mortality rates nearly tripled from 1996 2006—and are 4.5 times higher than the Healthy People 2010 benchmark, according to the California Maternal Quality Care Collaborative. No specific reason is identified for this troubling increase.
In the 1990s, California's rates ranged from 5.6 to 10.7 deaths per 100,000 live births, which is consistent with the overall U.S. rate. Beginning in 2000 the rate climbed to 10.9, then to 14.6 and in the last reported year it is nearly 17. Also concerning is a similar rise in the entire U.S. rate.
The five main causes of maternal death the U.S. are:
Embolism or blood clots, 20%.
Hemorrhage or severe blood loss, 17%.
Pre eclampsia or eclampsia, 16%.
Infection, 13%
Cardiomyopathy or heart muscle disease, 17%.
Complications associated with pregnancy are a major issue as well. In 2004 and 2005, more than 68,000 women almost died in childbirth in the US. These complications, known as "near misses," increased by 25% between 1998 and 2005.
In addition, more than a third of the women who give birth in this country—1.7 million women annually- experience at least one complication that will have adverse effect on the mother's health.
Native American and other minority women, women living in poverty, are immigrants, speak little or no English, or are living in rural or isolated areas are particularly impacted, the report noted. But, even for white women, the maternal mortality ratios are higher than for women in 24 other industrialized countries.
These disparities have not improved in more than 20 years.
Overall, the number of maternal deaths is significantly understated, Cox said, because of a lack of effective data collection nationwide.
"Reform is primarily focused on healthcare coverage and reducing healthcare costs," said Rachel Ward, one of the Deadly Delivery report authors. "It does not address discrimination, systemic failures and the lack of government accountability."
The report makes 10 suggestions for reducing maternal mortality, including the creation of an Office of Maternal Health, which would be charged with improving maternal health care and outcomes and eliminating disparities.
In addition, state governments should ensure that low-income pregnant women have temporary access to Medicaid while their permanent application for coverage is pending (presumptive eligibility) and that Medicaid provides timely access to prenatal care. In cases where a woman receives prenatal care before eligibility is confirmed, states should ensure that Medicaid reimburses retroactively for services provided.
The Joint Commission has weighed in earlier this year with a Sentinel Event Alert that suggests hospitals take a series of steps to prevent maternal death or injury, such as:
Educating physicians and other caregivers about underlying conditions such as high blood pressure, diabetes or morbid obesity that may put women at risk if they become pregnant.
Using specific protocols to treat pregnant women who have, for example, experienced a change in vital signs, hemorrhage or pre eclampsia.
Training emergency room staff to consider whether female patients may be pregnant or recently pregnant.
Referring high-risk women to experienced prenatal care providers who can direct specialized services for women.
But another answer may be that health systems should simply provide more and better prenatal care. Ron Anderson, MD, CEO of Dallas-based Parkland Hospital and Health System, which delivers over 16,000 babies per year, told the Medicare Payment Advisory Commission (MedPAC) in Washington this month that as the system increased the amount of prenatal care, it decreased the number of babies born prematurity.
"Prematurity, as you know, in the United States is going up. We actually have seen a reduction over the last 20 years," he said. Through outreach programs sponsored by the hospital, the hospital now delivers prenatal care to 98% of the women—some of whom may be undocumented women—who actually come to Parkland prior to their delivery.
"The results are a reduction by almost two thirds in stillbirth, neonatal deaths, intracranial bleeds and days in the neonatal ICU—so it saves us a lot of money," Anderson said. "When we're asked why we provide prenatal care to undocumented women, the economic argument [comes to the top], but the humane argument should [as well]."
"Deadly Delivery" is a "clarion call to action to transform our healthcare system and ensure that every woman has access to high quality maternal and newborn care within a coordinated, integrated and equitable system designed to best meet the needs of mothers and their fetuses/newborns," says Maureen Corry, executive director of the New York-based Childbirth Connection, which has closely studied how to improve and transform the maternity care system.
"Rapid gains are within our reach if we apply what we know from best evidence is optimal care for mothers and babies," she adds.
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House Democrats got some good news today with the eagerly awaited Congressional Budget Office (CBO) results on the healthcare reform bill that the House could vote on as early as this weekend.
CBO reported that over the next decade, the new bill, which makes changes or fixes in the Senate bill, would save $138 billion. This amount is $20 million more than the CBO projected for the bill that was approved by the Senate on Christmas Eve.
The clock now starts ticking for 72 hours before House Democrats can bring the legislation to the House floor. That time would be Sunday at the earliest. At least 216 votes will be needed to ensure passage in the House.
House Majority Whip James Clyburn (D-SC) said on Sunday that the House Democrats did not have the votes, but today he seemed optimistic that the votes needed would now be there.
The gross cost of the bill is $940 billion during the next decade, which includes:
$434 billion for Medicaid and Children's Health Insurance Plans
$466 billion for exchange subsidies and related spending
$40 billion for small employer tax credits
CBO does caution, as with its other projections, that the figures are preliminary.
Relative to HR 3590 (the Senate bill approved in December), the House reconciliation proposal would make a number of changes to affect its longer term impact on the budget, CBO said. In particular, it would increase the subsidies offered in the new insurance exchanges and would reduce the impact of an excise tax on health insurance plans with premiums above certain thresholds.
The net cost of coverage now ($794 billion over 10 years) would come from penalty payments from uninsured individuals ($17 billion); penalty payments by employers that do not purchase insurance ($52 million); excise tax on high-premium insurance plans or "Cadillac plans" ($32 billion); and other effects on tax revenues and outlays ($44 billion).
This morning, President Obama called the reform effort the "most significant effort to reduce the deficit" in more than a decade.
"This is but one virtue of a reform that will bring new accountability to the insurance industry and greater economic security for all Americans, so I urge every member of Congress to consider this as they prepare for their important vote this weekend."
House leaders are continuing to consider use of the controversial process that would "deem" the initial Senate bill as having been passed without an actual roll call vote completed. House Republicans, however, have indicated that they will be seeking a measure that would force and up-to-down vote.
