Janice Simmons is a senior editor and Washington, DC, correspondent for HealthLeaders Media Online. She can be reached at jsimmons@healthleadersmedia.com.
Almost as important as the items included in President Obama's proposed healthcare reform summary released Monday are those items that were excluded.
Many of these items initially were included in the House bill (HR 3962) passed in early November. As the President prepares to meet with congressional leaders on Thursday, here's a list of topics that appear excluded from the current discussion.
Public insurance option: One of the most hotly debated issues during the summer and fall was the inclusion of the public insurance option. Last fall, House Speaker Nancy Pelosi (D-CA) reaffirmed her support for a public option, calling it "the strongest lever one can use to get the best possible outcomes."
The public option proposal in the House bill would have required the Health and Human Services (HHS) secretary to negotiate rates with healthcare providers as private insurers currently do.
Surtax: Initially, the House Ways and Means Committee considered a surtax on annual incomes at $250,000 for individuals to $500,000 for families. In the bill finally approved by the House in November, this was increased: a 5.4% tax was called for amounts more than $500,000 for individuals annually or $1 million for families annually.
Antitrust legislation. Earlier this month, while healthcare reform legislation waited on the sidelines, the House moved toward repealing health insurer antitrust regulations found in the decades old McCarran Ferguson Act.
While the proposed summary mentions improving insurance protections for consumers and improving oversight in the states, no mention is made specifically of repealing antitrust legislation.
Abortion. While the topic is likely to be discussion in the Feb. 25 meeting, it is not discussed in the President's summary.
Missing from the bill is a public insurance option, but taking on new significance is a section that calls for protection from rising health premium costs. Approximately 31 million would be covered under the proposal, which will be discussed this Thursday at the healthcare summit.
Obama's plan touches upon numerous areas:
Health premiums. New in the proposed bill are efforts to hold down high premium spikes—an issue that received prominence last week. The proposal would create a new Health Insurance Rate Authority, which would provide federal assistance and oversight for states to conduct reviews of "unreasonable rate increases and other unfair practices" of insurance plans.
Consumer protections. The President's proposal calls for covering adult dependents up to age 26, prohibits rescissions, mandates that plans have a stronger appeals process, and requires state insurance authorities to conduct annual rate reviews. When the exchanges would be implemented in 2014, additional protections would be added that would prohibit all annual and lifetime limits, ban pre-existing condition exclusions, and prohibit discrimination in favor of highly compensated individuals. Beginning in 2018, the President's proposal would require grandfathered plans to cover proven preventive services with no cost sharing.
Financing. The excise tax, or the so-called "Cadillac tax," remains. The President's proposal changes the effective date of the Senate policy from 2013 to 2018 to provide additional transition time for high cost plans to become more efficient. The amount of premiums that are exempt from the assessment would rise from $8,500 to $10,200 for individuals and from $23,000 to $27,500 for families.
The President's proposal, similar to the Senate approach, would add a 2.9% assessment on income from interest, dividends, annuities, royalties, and rents.
For fees on pharmaceuticals, the President's proposal calls for increasing the revenue from the assessment on the industry from $23 billion (in the Senate bill) by another $10 billion over 10 years.
Employer mandate. The President's proposal follows the Senate bill in that it does not impose a mandate on employers to offer or provide health insurance. However, it would require employers (with more than 50 workers) to cover costs if taxpayer dollars cover their workers.
But to defray costs, the assessment would provide a transition: employers with 50 or more employees would be able to subtract the first 30 workers in the payment calculation. This new factor would be multiplied by $2,000 per employee—an amount the White House says is "one third less than the average House assessment for a typical firm and less than half of the average employer contribution to health insurance in 2009."
In line with the Senate bill, small businesses with fewer than 50 workers would be exempt from any employer responsibility policies. In addition, small businesses would be eligible to receive $40 billion in tax credits supporting coverage for their workers.
Individual responsibility. All individuals would be required to obtain insurance coverage. For those who don't, the President's proposal follows in part the Senate approach, but lowers the flat dollar amount that individuals would pay—from $495 (in the Senate bill)—to $325 in 2015; and from $750 to $695 in 2016. Subsequent years would be indexed to $695.
Exceptions are made for those who can't afford to pay. The President's proposal would change the payment exemption from the Senate policy (individuals with income below the poverty threshold) to individuals with income below the tax-filing threshold (the House policy). This means that a married couple with income below $18,700 would not have to pay the assessment.
Tax credits. The President's proposal changes the cost-sharing assistance for individuals and families relative to the Senate bill: Families with income below $55,000 would get extra assistance, with additional funding to insurers to cover between 73% and 94% of their healthcare costs. It provides the same cost-sharing assistance as the Senate bill for higher income families and the same assistance as the House bill for families with income from $77,000 to $88,000.
Fraud, waste, and abuse. Obama emphasizes aggressive policies to tamp down on fraud, waste, and abuse. The President's proposal would establish a comprehensive Medicare and Medicaid sanctions database that the Department of Health and Human Services' Inspector General would oversee.
Registration and background checks of billing agencies and individuals would be increased to hold down dishonest billing practices in the Medicare program.
Donut hole. The President's proposal calls for filling the Medicare prescription drug donut hole entirely. It begins by replacing the $500 increase in the initial coverage limit, with a $250 rebate to Medicare beneficiaries who hit the donut hole in 2010. The hole would be closed completely by 2020.
Medicare Advantage. The President's proposal would create a new set of benchmark payments that would be gradually phased in to avoid disruption to beneficiaries. It would also provide bonuses for quality and enrollee satisfaction.
In President Obama's healthcare proposal released today, three days before the bipartisan summit for congressional leaders called at Blair House, many similarities are appearing in the new bill such as ways to close the a donut hole in Medicare and fighting fraud and abuse.
A new twist, in light of recent days, is a proposal to create a Health Insurance Rate Authority to provide oversight and assistance that will help states conduct reviews of "unreasonable rate increases."
President Obama used his weekly radio address Saturday to encourage Democratic and Republican leaders to attend Thursday's meeting in Washington to discuss a healthcare reform package. But, at the same time, he signaled that he will be taking a hard line against health insurance companies that implement steep hikes in their premiums.
The targets include Anthem Blue Cross, which has since agreed to delay its proposed rate hike two months until the state of California reviews the request. In addition, he cited insurers in Kansas, Michigan, and Maine for asking to raise rates from 10% to 30%.
"The bottom line is that the status quo is good for the insurance industry and bad for America," Obama said in his address. "And as bad as things are today, they'll only get worse if we fail to act . . . We'll see exploding premiums and out of pocket costs burn through more and more family budgets.
"We'll see more and more small businesses scale back benefits, drop coverage, or close down because they can't keep up with rising rates. And in time, we'll see these skyrocketing healthcare costs become the single largest driver of our federal deficits," he added. "That's what the future is on track to look like. But it's not what the future has to look like."
Likely to attend the meeting to discuss a healthcare reform is Senate Minority Leader Mitch McConnell (R-KY), who told Fox News on Sunday that he "in all likelihood” will be there." However, he will ask the president to "shelve this bill and start over."
Rep. Mike Pence (R-IN), chairman of the House Republican Conference, said on NBC's Meet the Press on Sunday that House Republicans would "welcome a good faith effort to start over on healthcare reform."
"If we were talking about really starting over with a clean piece of paper—scrapping bills that passed the House and the Senate and also renouncing...reconciliation, Republicans are ready to work," he said. "But what we can't help but feel like here is that the Democrats spell summit 's-e-t-u-p.' And all this is going to be is some media event used as a preamble to shove through Obamacare 2.0, and we're not going to have any of it."
The National Governors Association (NGA), meeting in Washington this past weekend, took an inward and instructive look at how healthcare reform actions worked—and sometimes failed to work—in their states. But one underlying idea threaded through their comments: Healthcare costs need to be controlled.
"There's a lot of debate in Washington and the state capitals about how we structure paying for healthcare in American—whether it's publicly funded plans or a privately funded system," said NGA Chairman James Douglas (R-VT) on Sunday. "But in the end, I'm not sure that matters, because if we don't get costs under control and we don't bend that curve that's rising in multiples of inflation every year, we're going to be broke either way."
Several years ago, Vermont implemented its "Blueprint for Health" with an emphasis on better chronic disease management and preventive care. Even with one of the nation's largest Medicaid populations (rising from 26% this year to 28% next year), the state, which received federal waivers, has been able to save about a quarter of a billion dollars over the past five years, said Douglas.
"It's not something that happens overnight. It's about bending the curve and making progress over time," Douglas said.
Tennessee, though, ended up facing painful choices with its TennCare program, which first only covered Medicaid patients in 1994. With costs spiraling out of control—at one point the state was spending more under the Medicaid pharmacy benefit than for higher education—Gov. Phil Bredesen (D-TN) said the state had to make many cuts.
The lesson from this experience, Bredesen said, is to consider moving "one step at a time instead of just leaping of the end of the dock on these issues."
Gov. Deval Patrick (D-MA) noted that nearly 98% of his state's population is now insured. However, one issue that remains a continual nagging problem is healthcare cost containment. To better address this area, focus needs to placed on prevention, Patrick said.
"There is a responsibility that individuals and families must take around wellness so that we can move to a 'health' care system, as opposed to a 'sick' care system that we have today," he added. "We have some ideas around cost control, particularly around payment reform, that we are looking to implement right now. But it cannot be understated the importance of each of us doing what we can to look over our own health and our own healthy choices."
Governors pointed to their states as role models for federal health reform.
"We need to recognize that the states are a big part of the solution," said Gov. Haley Barbour (R-MS). He added that annual increases in Medicaid spending in his state have dropped from 20% to 2% because of initiatives, such as using preferred drug lists, increasing emphasis on generic drugs, and using face-to-face determination for eligibility.
"There are common sense ideas everywhere that can cut costs," said Gov. Ed Rendell (D-PA).
Federal efforts have fallen short, he said, on emphasizing cost cutting—while many examples are emerging on how that can be done. In Pennsylvania, one of those ideas taking shape is requiring all emergency room to create a non-urgent facility to care for patients 24/7.
"People go to an emergency room because we designed a delivery system that's open only 8 in the morning to 4:30 in the afternoon Monday through Friday. Anytime outside of that time you go to an emergency room," he said.
With this new facility, nurse practitioners or physician assistants can provide service more quickly and at a lower cost. "Non-urgent, 24/7 rooms can be an big answer to the overload costs of emergency care," he added.
In Washington State, meanwhile, a panel of experts is looking at common diagnoses and what are the most effective treatments—exclusive of costs, said Gov. Christine Gregoire (D-WA). One example is back pain where providers might call for surgery, when physical therapy might provide greater benefit to an individual patient.
"When we talk about what Congress is doing versus what we are seeing, the frustration we share is we want real healthcare reform—not about health insurance reform," she said. "Things like better quality care at reduced costs to patients is really where we think we ought to be headed."
A move by acting Centers for Medicare and Medicaid Services Administrator and Chief Operating Officer Charlene M. Frizzera on Wednesday reflects efforts by the agency to take some new directions—as it waits for an administrator and healthcare reform.
"The good news is that the reorganization appears to emphasize innovation and demonstration projects, which are desperately needed given the stalemate on health reform on the Hill,” says John Gorman, CEO of Gorman Health Group, in Washington, DC. "There's much that CMS can do through its demonstration authority that doesn't require 60 votes to move forward.
"The bad news is how beneficiary choices—particularly health plans—have been deemphasized by folding that authority into a general Medicare center," Gorman says on the news that one of the centers, the Center for Medicare, will combine Medicare fee for service, managed care, and Medicare Advantage. "Medicare Advantage represents about 25% of beneficiaries, but embedded within a function managing all of Medicare, runs the danger of 'ugly stepchild syndrome' or benign neglect for health plans."
Reorganizations at CMS happen during virtually every administration, Gorman says, and only a handful in the last 20 years have made any significant impact.
CMS has not had a Senate-confirmed administrator since June 2006 when Mark McClennen left and the Obama administration has not forwarded a name for confirmation yet.
"It may be a while before we know if this reorg will stick," he adds.
Paul Keckley, executive director of the Deloitte Center for Health Solutions in Washington, says CMS’ moves were expected.
"I think the Secretary [of the Department of Health and Human Services] is now organizing efforts around some pretty predictable themes. One is connecting health services with human services—the emphasis on community health centers, community mental health centers, federally qualified health centers," he says.
Another theme is looking at the alignment of physicians and hospitals in local communities.
"I think it's appropriate. I think it's a fresh look of what CMS can be doing other than just administering Medicare, he adds.
Recent events have put the simple medical checklist in the spotlight.
For instance, the Department of Health and Human Services last summer highlighted work among Michigan hospital ICUs to sharply reduce healthcare-associated infections (HAIs) with checklists. The World Health Organization said it is supporting the global use of surgical safety checklists. And bestselling author Atul Gawande has written about the topic in his new book, The Checklist Manifesto.
But in the midst of these activities come words of caution—brought to you by the team from Johns Hopkins University that helped put the checklist in the medical spotlight: Checklists can be useful and helpful, but they are not a panacea to all patient safety problems.
Use of checklists—or at least familiarity with them—appear common in many hospitals across the country. In the HealthLeaders Media Industry Survey 2010, for instance, 88.8% of quality leaders said their organizations used a checklist system to prevent errors in the hospital operating room, while 11.2% said they did not use such a system [Question 38].
Peter Pronovost, MD, PhD, a professor of anesthesiology and critical care medicine at JHU's School of Medicine, Baltimore, and his staff are credited with preventing thousands of central line infections at Hopkins. This was done partly because of a now well-known five step checklist:
Wash hands with soap
Clean patient's skin with chlorhexidine antiseptic
Put sterile drapes on the entire patient
Wear sterile gown and mask
Put sterile dressing over the insertion site
Pronovost and his colleagues later assisted a Michigan program that was associated with a 66% reduction in catheter related bloodstream infections in the state’s hospitals, saving more than 1,500 lives and $200 million in the first 18 months alone. Again, the checklist played an important role here.
Writing in the latest issue of the journal Critical Care, they note that checklists "have the tremendous potential to improve patient outcomes by democratizing knowledge and helping ensure that all patients receive evidence based best practices and safe high quality care."
However, in reality, these checklists need to be accompanied by a "change in the culture"—where nurses, for instance, are empowered to question doctors who don't follow the steps properly or where members of a healthcare team toss out long held beliefs that infections are an inevitable cost of being in the hospital. "Just having a checklist on a piece of paper isn't going to be enough," Pronovost said in a statement.
Sean Berenholtz, MD, an associate professor with the departments of anesthesiology, critical care medicine, and health policy and management at Hopkins, and a member of the team that has worked on the development of the checklist, says checklists do appear to be "popping up everywhere."
"Everyone wants to do a checklist. The message becomes that . . . checklists are the simple solution for solving an adaptive problem with a technical solution," he says. "It needs to be embedded in a broader effort to evaluate and address local context. It needs to add value. If providers don't believe in the value of the checklist, they'll just check a box."
Berenholtz says that when implementing checklists, it’s helpful to use the Comprehensive Unit-based Safety Program (CUSP) to help focus efforts to "improve culture and context." This initiative includes steps to:
Educate providers on the science of safety—to help them understand that "the vast majority of errors aren't the result of one provider...[but] rather it's a whole system that allows that error to occur."
Use a written survey with staff on how the next patient could be harmed and what can be done to reduce that harm.
Partner with senior executives to help bridge any gaps between senior leaders and frontline providers.
Help staff learn from defects or problems.
Implement teamwork tools (with daily goals) and talk about the whole program that goes along with the checklists.
The eventual goal, the researchers wrote, is that checklists should be created that are "succinct, unambiguous, focused, and ultimately effective, and efficient." And, when ultimately faced with a crisis, "we can react quickly and decisively, knowing that the items we act out from the checklist are well thought out, tested, and will provide us with the results we want."
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The first set of reports ever produced to provide comparative health data for all 3,000-plus counties in all 50 states was released Wednesday by the Robert Wood Johnson Foundation and University of Wisconsin's Population Health Institute.
The 50-state reports are designed to help public health and community leaders, policymakers, consumers, and others to understand the health of their counties—compared with others within their state—and find ways to improve the overall health of their population.
"We view the country health rankings as an important companion to America's health rankings," said Risa Lavizzo Mourey, MD, president and CEO of the Robert Wood Johnson Foundation at a briefing in Washington, DC. The rankings are important because "they tell us a story about the factors that influence how healthy we are and how long we live," she added.
"They tell us that health depends on more than healthcare, and they tell us health happens in our communities—where we live, learn, work, and play," she said. The rankings are "an important tool in helping to pinpoint health problems—which means more of a likelihood of solving problems."
The foundation worked with the University of Wisconsin to develop a "robust Web site." The Web site provides comparisons on health factors related to health behaviors, clinical care, social and economic factors, and physical environment. The rankings will be used to mark progress over time. "We believe this is a new chapter in our nation's health," she said.
For the first time, people have a tool "to help identify what is making people in every county unhealthy," said Patrick Remington, MD, associate dean for public health at the University of Wisconsin School of Medicine and Public Health. Wisconsin first looked at the variations in healthcare by county beginning in 2003.
"We hope this kind of check up will mobilize community leaders to take action and invest in programs and policy changes that make their counties healthier places to live," he said.
Close attention is paid to morbidity and mortality rates in the counties—how healthy they are and how long they lived. In particular, researchers used five measures to assess the level of overall health or health outcomes by county:
The rate of people dying before age 75
The percentage of people who reported being in fair or poor health
The number of days people reported being in poor physical health
The number of days in poor mental health
The rate of low birth weight infants
The counties also were ranked on key factors that affect health, such as: smoking, obesity, binge drinking, access to primary care providers, rates of high school graduation, rates of violent crime, air pollution levels, liquor store density, unemployment rates, and number of children living in poverty.
More than 80% of the less healthy areas were found in small or rural areas of the states. Only 2% of the least healthy communities were in suburbs, Remington said.
Among the reported findings among the counties are:
Premature death rates. The least healthy counties have significantly higher rates of premature death—some are 2.5 times higher than the healthiest counties.
Self reported health. People living in the least healthy counties reported being in significantly poorer health—2.1 times higher rates of people who report being in fair or poor health, compared with the healthiest counties.
Smoking rates. People living in the least healthy counties are much more likely to smoke—more than 26%, compared to only 16% in the healthiest counties.
Preventable hospitalizations. People living in the least healthy counties are 60% more likely to be admitted to the hospital for preventable conditions—a sign of poor outpatient and primary care.
Children living in poverty. The least healthy counties have higher rates of poverty, with 30% of children living in poverty—more tan three times higher than the rate in the healthiest counties (9%).
Access to healthy foods. The 50 least healthy counties have fewer places where people can find healthy food—only 33% of zip codes have at least one grocery store, compared to almost half (47%) of zip codes in the healthiest counties.
Sometimes, a county's rank could show a pattern of strengths and weaknesses, Remington said. For instance, Woods County, OK, ranked first in the state for overall health, but ranked 48th out of 77 on clinical care access and quality.
Meanwhile, Carbon County, MT, ranked second in the state for overall health, but ranked 39th out of 44 on factors related to the physical environment, such as air pollution, access to healthy foods, and liquor store density.
In just over a week, congressional leaders will meet on Feb. 25 with President Obama in a televised healthcare reform summit.
As a way of anticipating questions about the two reform bills passed last year by the House and the Senate, RAND researchers have been examining the impact of the bills, with a focus on access, quality, and cost.
Their analysis was done using "micro simulation" methods, which provide a "way of quantifying how well a policy option will achieve its goal," said Elizabeth McGlynn, associate director of RAND Health and co-leader of the RAND Compare initiative. These methods are similar to the methods "used by the Congressional Budget Office to provide Congress with estimates of the effects of proposed legislation on federal spending."
Both bills would reduce the number of individuals without health insurance by more than 50%, McGlynn said Tuesday at a telebriefing. "We project that by 2019—if no new laws are passed—about 53 million people will be uninsured. The House bill (HR 3962) would reduce that number to 24 million, whereas the Senate bill (HR 3590) would reduce that number to 25 million."
National spending on healthcare would rise slightly more than it would if the bills were not passed—related to increased Medicaid spending and federal subsidies for those participating in a health exchange, McGlynn said. "We estimate that under the House bill, national spending would increase about 3.3%, whereas the increase would be 2% under the Senate bill."
Under the House bill, government spending would rise by $1 trillion between 2013 and 2019, McGlynn said. Under the Senate bill, "We project an increase of $899 billion between 2014 and 2019."
Among other findings in the RAND analysis:
Under the House bill, by 2019, about 12 million more people would be enrolled in employer sponsored insurance. At the same time, 10 million more would be enrolled in Medicaid, and 8 million more would be enrolled in non-group insurance, including the national Health Insurance Exchange proposed by the bill.
Under the Senate bill, employer sponsored insurance members would increase by 12 million, and the number of insured in the non-group market—including the state level Health Benefit Exchanges proposed in the bill—would increase by 10 million.
By 2019, in the Senate bill, about 28 million people would purchase insurance through the Health Benefit Exchanges mandated by the legislation. The exchanges would be state run organizations through which private companies would sell health insurance to individuals. An estimated 15 million who use the exchanges would qualify for government subsidies to help pay for their insurance.
Of the 25 million Americans who would remain uninsured in 2019, about one third (9 million) would be eligible for Medicaid but not enroll. There may be opportunities to further increase coverage by conducting outreach efforts to improve Medicaid enrollment among those newly eligible, according to researchers.
The individual mandate plays the "largest role" in increasing insurance coverage, according to McGlynn. It could reduce the number of uninsured by 21.5 million (41%). The employer penalties and Medicaid expansions by themselves would reduce the number of uninsured Americans by 1.5 million and 8 million, respectively.
If eligibility for Medicaid were set at 150% of the federal poverty level (such as in the House bill)—rather than 133% as it is in the Senate bill—the number of Medicaid beneficiaries would increase by about 2 million. However, the number of uninsured would decrease by only about 600,000.
Reducing Medicaid eligibility to 100% of the federal poverty level would result in 4 million fewer people enrolled in Medicaid and 1 million more people uninsured than under HR 3590.
Subsidies and penalties associated with the individual mandate are "essential to the success of the policy option," said McGlynn. In the absence of penalties for individuals who do not purchase insurance, 10 million more people would be uninsured. In the absence of subsidies to offset the costs of insurance, 13 million more people would be uninsured.
Eliminating penalties for employers who do not offer insurance and who have at least one employee who obtains a federal subsidy would increase the number of uninsured by 700,000 and would increase cumulative federal spending between 2014 and 2019 by $98 billion.
Of the 26 million Americans age 18 or older who were infected by the H1N1 flu in 2009, more than a quarter of them may have contracted it from their coworkers, according to a new briefing paper from the Washington, DC-based Institute for Women's Policy Research.
Looking at the period between September through November 2009, the researchers—using data from the Centers for Disease Control and Prevention (CDC) and the Bureau of Labor Statistics—estimated that more than 7 million workers may have infected their fellow employees. This pattern was particularly prevalent among those in industries or companies with traditionally lower paying sick-day coverage.
"Work attendance by infected employees is a public health issue due to contagion," said study co-author Robert Drago, PhD, a professor of labor studies and women's studies at Penn State University.
Drago added that the US is one of only a few developed nations without universal paid sick days. While the vast majority (90%) of public sector employees do receive paid sick days, only about 60% of private sector employees have access to paid sick days. This leaves the nation ill prepared for outbreaks of contagious illness, he added.
"Workers without paid sick days must choose whether to go to work sick or lose pay—a choice that many can't afford to make," said the other co-author, Kevin Miller, PhD, a senior research associate with the Institute.
Absences related to illnesses during the H1N1 pandemic reached a peak in October. The drop in absence rates between October and November was twice as steep in the public sector as it was in the private sector, suggesting that the concept of "presenteeism"— appearing at work while ill—was common among private sector employees without paid sick days.
Although data on both private and public sector employees show absence rates declining in November, the decline is less steep for employees in the private sector. The absence rate in the private sector in November decreased by only 8.9% from the October rate, while in the public sector the decline in absence between October and November was more than twice as steep, at 21.8%. The absence rate was higher among workers in the public sector—consistent with greater access to paid sick days.
For the entire 2009-2010 flu season through Jan. 16, the CDC is estimating that between 41 million and 84 million cases of the deadly H1N1 flu virus occurred in the U.S.
While the H1N1 flu virus is appearing to level off, it is still causing hospitalizations and even death. Between 183,000 and 378,000 H1N1 related hospitalizations have occurred between April 2009 and Jan. 16, the CDC reported. Approximately 8,330 to 17,160,2009 people have died from the virus, with much of the hospitalizations and deaths occurring among those individuals ages 18 to 64.
