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Editor’s note: the story goes on (if you go to the link) to talk about the impact health care costs are having in keeping people in the workforce longer.
According to findings from the 2009 EBRI/MGA Consumer Engagement in Health Care Survey, the labor-force participation rate is increasing for those age 55 and older. The percentage of civilian non-institutionalized Americans age 55 or older who were in the labor force declined from 34.6 percent 1975 to 29.4 percent in 1993. However, since 1993, the labor-force participation rate has steadily increased, reaching 39.4 percent in 2008—the highest level over the 1975–2008 period. For those ages 55–64 (the near elderly), this is being driven almost exclusively by the increase of women in the work force; the male participation rate is flat to declining. However, among those age 65 and older (the elderly), labor-force participation is increasing for both males and females. Education is a strong factor in an individual’s participation in the labor force at older ages: Individuals with higher levels of education are significantly more likely to be in the labor force than those with lower levels of education.
With Washington placing insurers in their cross-hairs and proclaiming that there isn’t enough competition among insurers, I wonder if the public has thought about what more competition among health insurers might mean.
First, a few facts. The portion of the premium that is devoted to care (otherwise known as MLR or Medical Loss Ratio) runs between 78 and 82% of premium. You can find these numbers in the quarterly financial reports of the public insurers. These claims payments are a result of contracted reimbursement rates between the insurer and providers (doctors, hospitals, labs, etc.)
Back to the original question. Will more competition drive premium costs downward. If market power in terms of volume allows you to negotiate a better rate then on at least 78% of the bill the costs may go up instead of down with new entrants into the market. The insurers will not be able to negotiate the same favorable terms with providers as they are now. Unless you think they are keeping reimbursements artificially high … I doubt you could find a physician or a hospital that would agree with that.
Therefore the government must be counting on the reduction of the remaining 18-22% to not only be reduced, but to overcome any loss of market power on the contracting with providers. Since the insurers will be smaller, they will have less market power with all of their other providers of products and services as well — from phones, to facilities, and on an on.
Perhaps in this context competition isn’t such a good idea if your goal is to reduce costs.
Then again, perhaps what they are talking about at the Federal level is all of the costly mandates that the states put on insurance providers. Requirements for coverage types, lengths of stay and so on. So maybe the issue isn’t with private enterprise, but rather with government regulation.
What do you think a couple of thousand page health care bill is going to do to the volume of regulation?
Editor’s note: The big fear of the House Democrats: if the Senate requires the original bill to be signed into law before it will vote on the side car, is it possible that the side car does not get passed — or it gets changed and sent to the House for another vote and it doesn’t agree, etc. and we end up with the original Senate Bill as the law of the land?
Here is an analysis by ERIC.
THE ERISA INDUSTRY COMMITTEE
Advocating the Employee Benefit and Compensation Interests of America’s Major Employers
March 16, 2010
Healthcare reform is now in the root canal stage of the process, where pain and procedures seem to be dwarfing more substantive considerations. At the moment, all eyes are focused on the House, where Speaker Nancy Pelosi (D-CA) must come up with 216 votes to approve the healthcare legislation passed by the Senate last December as well as a “sidecar” bill that would make enough changes to the Senate bill to assure an “aye” vote in the House for the legislative package as a whole.
House action: Yesterday the House Budget Committee got the ball rolling by approving a “placeholder” bill that has now been sent to the House Rules Committee. The Rules Committee will substitute the “real” reform language for the fake language and then have a vote on a “rule” for the bill – i.e., how it will be packaged, how many amendments can be offered, how long debate can last, etc.; a vote in the Rules Committee could take place Wednesday or Thursday.
If all goes as planned and the House Rules Committee reports out the legislation, a vote on the overall reform package in the House could occur Friday or, more likely, late Saturday afternoon. At this point it is not entirely clear what this package will entail, i.e., if the Rules committee will keep the Senate legislation and a House sidecar bill separate or whether the two will be combined. In the latter scenario, a vote to approve the sidecar would be “deemed” to also be a vote for the Senate bill.
One potential sticking point in all of this is that the Congressional Budget Office has still not released its final “score” on the legislative package; this score is important because a bill that bursts the $1 trillion optical ceiling for the cost of the legislation will have a harder time picking up stray votes in the House.
Note: the legislative language for the sidecar bill also has yet not been released.
Senate action: If the House summons 216 votes to approve this new healthcare reform package and avoids the numerous potholes that could cause its wheels to fall off, the last stage is consideration in the Senate. At this point, the Senate bill will have been approved by both the House and the Senate and will have been sent to the president for his signature; although no definitive statement has been issued by the Senate parliamentarian, it appears that the president must sign the Senate bill into law before a reconciliation bill can amend it in the Senate. What the Senate will consider and vote on is just the sidecar reconciliation bill.
As has been made much of lately, the Senate needs only a majority vote to approve the sidecar reconciliation bill and not the 60 votes to overcome a filibuster. The trade-off, though, is that the reconciliation bill may not include any policy provisions that do not have a budgetary effect on the bill’s bottom line. (That is why Speaker Pelosi has been hamstrung in her ability to add a provision to the sidecar bar to appease anti-abortion House Democrats.)
But here’s another rub: the Senate may not necessarily want to approve the sidecar bill exactly as it was sent over by the House; the problem is that any changes to the sidecar would mean that the bill would need to go back to the House for another vote. This would probably sound the death knell for healthcare reform legislation.
Lowering BP reduces health risks at all weight levels
Data from the Perindopril Protection Against Recurrent Stroke Study showed lowering blood pressure reduced the risk of vascular disease and stroke among patients of all body weights. Overweight and obese patients, however, have a greater baseline cardiovascular risk, so they saw the biggest benefit of all study participants, researchers said. Medscape (free registration)/Heartwire (3/12)
Hospitals are changing culture of handling medical errors
Assessing blame for medical errors is difficult, and hospitals are looking to see if their own systems may be partly responsible when providers make mistakes. The National Quality Forum has developed a Care of the Caregiver standard, and the Just Culture model stresses the middle ground between blaming a physician or nurse and holding a system failure accountable. The Wall Street Journal (3/16)
March 15, 2010
To: Interested Parties From: Ranking Republican David Dreier (R-San Dimas, CA)
Subject: The Slaughter Solution: Bending the Rules Beyond Belief
The Democratic Majority has a problem with their efforts to pass healthcare legislation, and it’s political: they simply do not have enough Members in the House willing to vote for the Senate-passed healthcare bill. That’s understandable because it’s an awful bill loaded with special interest provisions. To solve their political problem, they’re looking for a procedural solution. That’s where the Rules Committee comes in.
On Sunday, senior presidential advisor David Axelrod said on ABC News’ This Week, “We don’t want to see procedural gimmicks used to try to prevent an up-or-down vote on this issue.” But gimmicks seem to be exactly what House Democrats are planning to use.
According to a Friday report in Politico, “[Speaker] Pelosi reminded her members, as she frequently does, that she wants to make the whole process as quick and politically painless as possible, a person present said.” Given the widespread unpopularity of the healthcare process, and the Senate bill in particular, it may be quick, but it won’t be painless. How will they attempt it? The “Slaughter Solution.”
If House Democrats are going to be able to move the Senate-passed healthcare bill and a reconciliation “fix-it” package, they are going to have to seriously bend the rules to make it happen. Moving the Bill through the House Under the Democratic Majority’s strategy, they must get 2 bills to the President’s desk: (1) the Senate-passed healthcare bill and (2) the reconciliation “fix-it” legislation colloquially referred to as the “sidecar.”
The House Budget Committee is beginning the process by marking up the “fix-it” bill today. That bill will be just a shell. Its text will be replaced in the Rules Committee with the still unseen (as of Monday morning) text of the reconciliation bill.
Bearing in mind the main problem facing the Majority — a lack of votes for the Senate-passed bill — we expect them to use the rule providing for consideration of the Senate and sidecar bills to minimize the number of difficult votes they will have to force their Members to take.
There are at least five potential paths illustrated in the table below. Senate Bill (Senate Amendment to H.R. 3950)
Reconciliation “Sidecar” (yet to be reported by Budget Committee
Scenario 1: “Play it Straight” Rule provides for an up or down vote Rule provides for an up or down vote
Scenario 2: “Slaughter Solution 1″ Rule “deems” the Senate bill passed immediately and sends the bill to the President Rule provides for an up or down vote
Scenario 3: “Slaughter Solution 2″ Rule “deems” the Senate bill passed upon House adoption of reconciliation sidecar Rule provides for an up or down vote
Scenario 4: “Slaughter Solution 3″ Rule “deems” the Senate bill passed when the Senate passes the reconciliation sidecar Rule provides for an up or down vote
Scenario 5: “The Double Whammy” Rule #2 “deems the Senate bill passed immediately and sends the bill to the President
Rule #1 allows the Rules Committee to turn off the motion to recommit
Rule #2 “deems” the sidecar bill passed immediately and sends the bill to the Senate
If the Majority were to handle these items under regular order, we could expect up or down votes on both the Senate-passed healthcare bill and the sidecar bill. We know that won’t happen. Their political problem is a lack of will to take that all-important first vote on the Senate healthcare bill.
This brings us to the “Slaughter Solution” and its many variations. The Slaughter Solution When the Chairwoman of the Rules Committee floated the proposed “Slaughter Solution” last week, the outcry was immediate. What she proposed was using a rule providing for consideration of both the Senate and sidecar bills to “deem” the Senate bill as passed, avoiding the political problems that stem from taking a true up or down vote on the horribly unpopular legislation.
The Slaughter Solution comes in three flavors: in the first, the rule simply self-enacts the Senate bill and sends it along to the President for his signature; the second deems the Senate healthcare bill adopted only upon House passage of the reconciliation package; and the third, most egregious option, conditions adoption of the Senate healthcare package on the Senate passage of the reconciliation sidecar. Only then would the Senate-passed healthcare bill be approved by the House.
In all three of these scenarios, the Senate-passed healthcare bill wouldn’t be given an up or down vote on its own. While it appears that the Democratic majority has not definitively settled on a strategy, the third Slaughter Solution may not be viable. Recent reports indicated that the Senate parliamentarian has thrown cold water on that scenario by asserting that the House must approve and the President must sign the Senate-passed healthcare bill before the Senate can even begin the reconciliation process.
The reasoning was that the reconciliation instructions contained in the Budget Resolution require changes in law, and changes to a yet-to-be-enacted bill don’t count. Even Speaker Pelosi and Majority Leader Hoyer seem to have accepted this detail as a reality that must be confronted.
There is one final scenario that is so over the top that it’s unlikely that even this Majority would attempt it. But considering their track record, it’s worth mentioning – if they are running into serious problems rounding up those final votes, they may try anything.
Due to reforms put in place at the beginning of the Republican majority, the Rules Committee is prohibited from reporting a rule which eliminates the minority’s ability to offer a final amendment to a new bill before the House, called a motion to recommit. If the Democratic Majority were to first pass a rule “turning off” the motion to recommit, they would be able to perform a magic trick I’m calling the “double-whammy:” one rule could self-enact both the Senate health care package and the reconciliation sidecar, meaning with one vote we could pass both bills without anyone having ever actually voted up or down on them.
What Happens Next? After the Budget Committee finishes its markup, the Rules Committee will meet, and we expect to report a rule matching one of the 3 Slaughter solutions described above. Assuming that the Democrats muster enough votes to pass the rule, it’s likely that the Senate bill will be on its way to the President, and the Senate will have the reconciliation sidecar in its hands.
It is worth remembering that the reconciliation process is entirely about the Senate. While it enables the Majority to side-step many of the Senate’s 60-vote requirements, it is also tightly restricted by the Budget Act and Senate rules. So the House-passed sidecar bill must meet the Senate’s tests for reconciliation, and the individual provisions in the bill must avoid running afoul of the “Byrd Rule,” which prohibits inclusion of non-budget related items in a reconciliation bill.
This raises a number of questions that can only be answered once the reconciliation sidecar has left the House and begins moving through the Senate process:
Does the “sidecar” qualify as reconciliation legislation in the eyes of the Senate? If the House makes any mistakes in its handling of the bill, it may be enough to call into question the legislation’s status, and could easily derail the entire process with no chance of getting it restarted. Merely titling a bill “reconciliation” is not enough; the Senate looks at the process which passed the bill to define its status. The more shortcuts the Majority takes with the rule, the higher the probability of problems on this front.
Are any of the provisions subject to strike under the Byrd Rule? If a Senator’s point of order that a provision violates the Byrd Rule is sustained, and they can’t get 60 votes to retain it, then even if the Senate passes the reconciliation bill, it must come back to the House for another vote. Depending on what got stricken, it could make House passage difficult.
Will any amendments be adopted? While the use of the reconciliation process limits debate, it does not limit the ability of Senators to offer amendments. Any amendments adopted will force the bill back to the House for yet another vote. Again, depending on the substance of the any adopted amendments, it could make a House vote difficult. The one thing that history demonstrates is that the reconciliation process in the Senate is unpredictable. No matter how well you “scrub” the provisions in a bill for potential Byrd rule violations, something always gets through.
The Deficit Reduction Act of 2005 had 3 provisions which were stricken on Byrd rule points of order despite a thorough review. The notion that the reconciliation bill will be immediately cleared by the Senate for the President is difficult to fathom.
The Bottom Line
Reconciliation is no silver bullet. It requires a leap of faith that the Senate won’t change anything and — with all due respect to the Senate — that faith is misplaced. Institutionally, they simply can’t guarantee that outcome. Any House Democrat who votes for a rule that moves this process forward is really voting for one thing — to make the Senate-passed healthcare bill the law of the land. The actual language of the rule will be unequivocal on that point. Just because you use a bat to hit a ball instead of throwing it, your neighbor’s window is still just as broken.
A vote for the rule is a vote for the Senate bill. There is no getting around that fact. They can break any arm, bend any rule. But the Democratic Majority cannot deny that they are turning the process of our democracy on its head in an effort to achieve a highly unpopular, partisan objective.
Key results from a landmark federal study are in, and the results are disappointing for diabetics: Adding drugs to drive blood pressure and blood-fats lower than current targets did not prevent heart problems, and in some cases caused harmful side effects.
A decade ago, the federal government launched the three-part study to see whether intensely lowering blood sugar, blood pressure, or fats in the blood would reduce heart attacks and strokes in diabetics. The first piece of the study – about blood sugar – was stopped two years ago, when researchers saw more instead of less risk with that approach. Now, the other two parts of the study are in.
Psoriasis is a risk factor for heart attack, stroke
Psoriasis may raise the risk of heart attack, stroke and other cardiovascular problems, likely through a shared inflammatory response, Danish researchers told a cardiology conference. Study data showed severe psoriasis raised the risk of a heart attack by 24%, and having moderate or severe disease increased the odds of a stroke by 45%. HealthDay News
Editor’s note: It is critically important that we move the reimbursement system from fee for services to fee for care. A movement in that direction is bundled services, but it has to be more than that. Payment has to involve information about efficient process, quality, and outcomes. Otherwise in the words of Demming, “If you only focus on the ends, you may get it in ways you never intended.”
Expert: U.S. is on path toward health care payment reform
More than a dozen health care payment reform efforts are under way around the U.S., according to Karen Davis, president of the Commonwealth Fund. She told a conference that the country is on a path away from fee-for-service and heading toward bundled payments that go beyond pay-for-performance models. Healthcare Finance News (3/12)