The Wonk Room

Republicans Work To Undermine Affordability Measures In Kennedy Health Bill

During today’s mark-up session of the HELP Committee’s health care proposal, Republicans introduced at least seven amendments designed to lower the subsidies available to Americans who purchase coverage through the Exchange. Sens. Mike Enzi (R-WY) and Judd Gregg (R-NH) both argued that Americans above 250 percent of the Federal Poverty Level (FPL) — or $45,775 for a family of 3 — could easily afford health care coverage:

- Enzi 200: To eliminate subsidies for those above 250 percent of poverty
- Enzi 201: To eliminate subsidies for those above 250 percent of poverty
- Enzi 202: To provide for reductions in subsidies
- Enzi 211: To limit subsidies to those below 250 percent of poverty.
- Enzi 251: To limit subsidies to those below 250 percent of poverty
- Gregg 223: To limit subsidies to those below 200 percent of poverty.
- Roberts 203: Limiting Premium and Cost-Sharing credits to people below 200% of FPL

Watch a compilation:

In reality, millions of Americans at about 250% FPL are struggling to afford skyrocketing health care costs. A recent study concluded that medical debt contributed to 62 percent of U.S. personal bankruptcies in 2007 — and 78 percent of bankruptcy filers had health insurance but “still were overwhelmed by their medical debt.“ One in five Americans had trouble paying their health care bills in 2007 and even moderate levels of out-of-pocket spending — spending that is as low as 5 or 10 percent of family income —created medical bill problems.

Health care reform must end medical debt and medical bankruptcy, but Republican affordability measures are simply insufficient. The question of affordability is two-fold: which income levels do we subsidize and how much subsidies should the eligible families receive. While the cost of living varies widely across the country, on average, a family of three would need at least $37,919 – or about 200% FPL – to afford their basic necessities not including health care costs. So families up to 200% need to be subsidized, but who else?

Well, researchers suggest that families that spend more than 5-9% of their gross income on health care begin confronting affordability problems. As Karen Pollitz points out, “depending on what premiums are charged for qualified health benefit plans” subsidies capped above a certain level “may prove to be insufficient to ensure affordable health care for all Americans.” Congress “might consider instead a rule that no individual or family will have to pay more than 10 percent of income on health insurance premiums….cutting subsidies off entirely at an arbitrary income level can leave families vulnerable,” she says. Families at approximately 500% FPL ($110,250 for a family of four), however, can typically afford the cost of coverage.

Of course, the entire goal of reform is to slow the growth of health care costs and lower premiums for families. In this sense, subsidizing coverage — that is, making sure that every family can afford to access needed services — is a way of saving money in the long haul. After all, the billions we’re spending on subsidies is a small fraction of the $40 trillion we’re projected to spend on health care in the next ten years if we fail to slow the growth of spending.

Why Comparative Effectiveness Research Will Not Ration Care

During yesterday’s mark-up of the HELP Committee’s ‘Affordable Health Choices Act,’ Sens. Tom Coburn (R-OK), Pat Roberts (R-KS), Mike Enzi (R-WY) and Orrin Hatch (R-UT) introduced multiple amendments preventing the government from using the results of comparative effectiveness research (CER). Responding to the Republican charges, Sen. Barbara Mikulski (D-MD) pointed out that existing language already prevented the new comparative effectiveness council from using the research to make coverage decisions:

We get into this cost. We get into this repetitive word, “rationing”, “rationing.” It goes over very well with focus groups, but it has no rational here. If you go to page 323 of the actual bill, where it says ‘Incorporation.’ We absolutely prohibit that this, anything related to the Center For Health Outcomes, otherwise known as comparative effectiveness, that there “shall not be construed as mandates for payment, coverage, or treatment.” It is in the bill. Page 323, lines 5 through 7.

Watch a compilation:

Republicans relied on a three-part attack. One, ignore the existing language and offer redundant amendments prohibiting the comparative effectiveness center from mandating that doctors prescribe ‘the best’ treatments. Two — this is a somewhat more coherent strategy — argue that the Center for Medicare and Medicaid Services (CMS) could use the information to make coverage decisions for Medicare. And three, if the government uses the comparative research results to establish best practice guidelines, then doctors who don’t follow the guidelines but rather consider the individual needs of their patients, could be liable for malpractice claims.

But even the last two arguments fall apart on close scrutiny. The government isn’t mandating that doctors adopt the results of CER and it is not rationing care. Each patient has his or her unique needs and the ultimate decision for how to proceed should be left to the doctor and the patient. Currently, approximately one-third of all treatments have never been proven to produce better outcomes; CER would provide doctors with unbiased information about the most effective treatments, help doctors and patients make better informed decisions, and improve the quality of care.

Moreover, far from establishing one-size-fits all medicine or dictating treatments, properly conducted CER will actually promote faster adoption of personalized care. As Alan Garber of Stanford and Sean Tunis of the Center for Medical Technology Policy point out, “far from impeding personalized medicine, CER offers a way to hasten the discovery of the best approaches to personalization, providing more and better information with which to craft a management strategy for each individual patient.” The new CER council and CMS seek to preserve a personalized approach — that is, allow doctors to make decisions based on a patient’s history and individual needs — while eliminating truly ineffective treatments.

CER results are rarely black and white and no one study should serve as a final word on a coverage decision. But given the amount of unnecessary, redundant and ultimately harmful treatments, the government has an interest in informing health care providers about best practices– and this is what the legislation does and our doctors want. More efficient medicine is better medicine, and anyone who wants to prevent the system from wasting money is in the pockets of the medical industrial complex that is getting rich while we get sick.

After all, the “art of medicine,” as Coburn calls it, already relies on certain standards and practice guidelines and physicians often incorporate their knowledge of the patient and clinical experience to offer a patient-centered approach, as such only about half of the recommended guidelines are followed. Ultimately, however, doctors are not superheroes; they should not be ignoring “standard protocols” or attempting to re-enact the heroics of Fox’s HOUSE. They are currently driven by a set of professional standards and procedures, and as patients, it is in our interest to encourage providers to incorporate certain guidelines (derived from CER) into routine practice. After all, “the last thing most Americans want from this wise use of taxpayer funds is more published research gathering dust on library shelves.”

Tom Coburn: ‘I Think Health Care In This Country Is Pretty Good,’ Only ‘Some Fall Through The Cracks’

During yesterday’s mark-up of the HELP committee’s ‘Affordable Health Care Act,’ Sen. Tom Coburn (R-OK) questioned the need for reform. “I think this health care is pretty damn good, I think it’s pretty dang good,” Coburn said:

I’ll tell you the other reason I think health care in this country is pretty good and good for my Medicaid patients and good for patients with no health insurance. Because when somebody gets cancer, most of the time we get them well. Most of the time we get them well. Some fall through the cracks, that’s true. But as a two-time cancer survivor, I think this health care is pretty damn good, I think it’s pretty dang good.

Watch it:

But just last month, the senator unveiled ‘The Patients’ Choice Act,’ a GOP alternative to the President’s plan, which recognized the health care crisis. “It is time to publicly admit that the health care system in America is broken…And 47 million Americans worry what will happen to them or their children if they get sick,” a summary of the bill read. Now, just a month later, Coburn, who is clearly satisfied with his own government-sponsored health care plan, has lost interest in helping Americans secure access to affordable.

In his four years in the Senate, Coburn has earned the reputation of “a fly in the soup,” abusing the senate’s hold privilege — a technique which allows senators to “object to bringing a bill or nomination to the floor for consideration” — to prevent “the Senate leadership” from bringing matters to a vote. Remarkably, Coburn’s obstructionism has even led “senate aides to now take legislation directly to Coburn’s office” to ensure “he has no objections.” Last summer, Sen. Harry Reid (D-NV) wrapped most of the non-controversial bills held by Coburn into one large measure — called the Tomnibus — in an effort to pass the mostly bipartisan legislation.

In an effort to delay the committee’s reform efforts, Coburn plans to offer numerous nuance amendments (read them all here):

- Doctor on doctor spying: To establish a demonstration project that uses practicing health care professionals to conduct undercover investigations of other health care providers in order to determine the quality of health care provided by such other providers. [Coburn, 11 & 87]

- Protecting unborn children: To provide for the establishment of an Office of Unborn Children’s Health (O.U.C.H.) [Coburn, 13]

- Toying with legislation: To clarify the intent of the prevention and public health investment fund [Coburn, 17]; Coburn To clarify the intent of the prevention and public health investment fund [Coburn, 18]; To restate the purpose of the Prevention and Public health Investment Fund [Coburn, 19]; To reduce funding and provide for a termination date for the Prevention and Public Health Investment Fund. [Coburn, 20]

Reform may be a joke to the well-insured Coburn, but for the Americans struggling with cancer, access to affordable health coverage is a very serious concern. As the American Cancer Society points out, people who are uninsured are more likely to be diagnosed with advanced cancer and too many insured Americans have a hard time affording their treatments. In Oklahoma, an average family pays $1,900 more in premiums because of the broken health care system and some 50 families “fall through the cracks” every day when they lose their health insurance.

Republican Senators Attempt To Obstruct Markup of Health Care Bill

Today, as the HELP Committee began marking up the ‘Affordable Health Care Act,’ Republicans tried to obstruct the effort by complaining that the Congressional Budget Office (CBO) had not yet scored the entire proposal.

But as Sam Stein reported yesterday, it was Republicans who pushed for the incomplete HELP bill to be studied by the CBO, and “when poor results came back,” they pretended that the agency scored the entire bill. Indeed, yesterday, Reps. John Boehner (R-OH), Eric Cantor (R-VA), Sens. Mike Enzi (R-WY) and John McCain (R-AZ) criticized the committee for producing a bill that cost $1 trillion but covered only 16 million Americans, purposely ignoring the CBO’s admission that “those figures are not likely to represent the impact that more comprehensive proposals…would have both on the federal budget and on the extent of insurance coverage.”

But today, Sens. McCain and Judd Gregg (R-NH) argued that the hearing be postponed until a full cost-analysis is available. Watch it:

The delaying tactics extended into the GOP’s amendments. Rather than offering constructive improvements that could lower costs and expand coverage, a good number of the GOP’s proposed amendments do nothing to solve the health care crisis:

- Coburn 51: To prohibit the use of funds to build football stadiums.

- Coburn 111: To prohibit the Department of Health and Human Services from providing funding for fashion shows.

- Enzi 59: To prohibit the Secretary from requiring the use of best practices.

- Enzi 87: To strike provisions relating to oral health.

- Coburn 43: To rename the community health program subtitle IV – would rename it the “Federal Takeover of Local Communities.”

- Coburn 102: To limit the amount the Department of Health and Human Services may spend on conferences each year

- Coburn 29: To ensure that abortion providers are not co‐locating at schools in order to be integrated into school‐based health clinics and gain access to potential clients.

Ezra Klein observes that “the Republicans on HELP feel, or say they feel, that they were frozen out of this process. They say the bill is inadequate and its path to creation has been unforgivably partisan.” But these Republican fail to advance reform or solve the health care crisis. Rather, they preserve the current system, which, as Sen. Barbara Mikulsky (D-MD) observed during the hearing, “is a combination of Adam Smith, Darth Vader, and Invasion of the Body Snatchers.”