(1) Early Expansion States – The House bill recognized that some states took the lead on expanding coverage to more citizens by “grandfathering” in their programs so they would not be harmed by the new federal proposal. This helps Massachusetts, since we are one of the leaders on this issue. The Senate bill does not take the general grandfathering approach but it includes language that specifically protects Massachusetts. Although the Senate language is not as generous as the House language, the Commonwealth does have some protection.
I am concerned that in reaction to other state-specific Senate language such as the now infamous “Cornhusker Kickback,” legitimate state-specific Senate provisions will be dropped, which would seriously damage Massachusetts. In fact, a March 10th article in Politico raises this very question and reports that the President wants the Massachusetts language out of the Senate bill. It is my understanding that without some type of grandfathering language; Massachusetts could lose in the range of $300 million per year. I am gathering more information about this aspect of the bill to determine if my concerns are valid.
(2) DSH cuts – Currently, Medicare and Medicaid provide extra payments to hospitals that serve higher-than-average shares of people without health insurance. These hospitals are called Disproportionate Share Hospitals, or DSH. In the 8th District for example, Boston Medical Center and Cambridge Health Alliance both depend on millions of dollars a year in DSH payments. The Senate bill would cut DSH payments by $42 Billion per year, as opposed to the $20 Billion cut proposed in the House. Such cuts, made before a new health care system is allowed to fully develop, would curtail the amount and quality of health care provided by DSH hospitals and their uninsured patients, thereby driving these sick and poor persons to other hospitals that will not be equipped or paid to handle the medical and social challenges they present. I am looking into this aspect of the Senate bill as well.
(3) Value Index – The Senate bill includes a proposal to adopt a so-called “value index”; the House bill does not include this proposal. It would adjust the way payments to physicians and other non-hospital providers are calculated. Supporters suggest it would encourage practices that are more frugal by rewarding “low cost areas”. Massachusetts is considered a “high cost area” due to various factors, including the regional cost of living, the relative poverty of the people served, and our financial commitment to educating America’s next generation of doctors. There are no limits on how much a physician’s payments could be reduced by this so-called “value index” and the method has never been tested at the physician level. Due to the probability of much lower payment rates to Massachusetts doctors, this proposal seems as though it would influence (1) where doctors practice (discouraging practice in Massachusetts), (2) how they treat patients in so-called “high cost areas”, and (3) how many doctors will be trained in America. Absent a thorough study of the impact of this so-called “value index”, it seems to me that it could seriously harm the quality of care in Massachusetts.
(4) Super IMAC – The Senate bill contains a proposal that would shift authority to set Medicare policies and reimbursement rates from the Congress to a board appointed by the President. This proposal has been referred to as the “Super Independent Medicare Advisory Council” by many. The House bill does not contain such a proposal, although it does require formal studies on many specific initiatives to improve the quality and cost effectiveness of the American health care system. Traditionally, reimbursement rates from Medicare are based on many factors including efficiency, complexity of the medical issues, whether the provider also bears costs associated with medical education for future doctors, whether the provider engages in research that advances medicine and the cost of living in different areas. Some argue that Medicare should focus ONLY on cost containment without regard for all the other factors that affect the cost of care and that have been traditionally considered. I am concerned that if this appointed board adopts the cost-containment only approach, Massachusetts could lose BILLIONS of dollars PER YEAR. Such a loss would hurt our world-renowned medical schools, teaching hospitals, and research programs. Those losses would undermine the quality of care we provide to our own citizens and slow progress in biomedical sciences globally. To make matters worse, I am concerned that it would quickly and inevitably result in Massachusetts losing tens of thousands of jobs and would seriously undermine one of our region’s economic engines. Other regions with heavy concentrations of health care would feel a similar impact, such as New York City, Philadelphia and Los Angeles. Finally, to add insult to injury, the elected representatives of the people impacted would no longer have a say in accepting, rejecting or amending any new approaches – the entire decision would be up to Presidential appointees. Moreover, I ask people who are happy to entrust these decisions to persons appointed by President Obama to remember that there will be other Presidents, with, perhaps, very different levels of commitment to medical care.
In addition to the specific concerns outlined above, I am also concerned that some of these issues simply CANNOT be “fixed” through reconciliation. For example, even if everyone agreed at this point that the so-called Super IMAC should not be implemented; the reconciliation process may not allow that change because technically the provision does not impact the budgetary aspects of the bill. I am still working on clarifying this segment of my concerns.
I am sure you have heard that there is a push to have the House vote on all of this next week. I do not know if that goal is attainable, but I must presume it is real. As with all legislation, I seek to be as well informed as possible – especially on complicated matters such as these that are so critically important to our region. As always, I welcome your thoughts on this matter – on health care reform in general or on any of the issues I have outlined above. I look forward to hearing from you and I will keep you informed regarding what I learn. Please feel free to contact my office at the phone numbers listed below, or you may email me through my website at http://www.house.gov/capuano/c…
Congressman Mike Capuano
8th District, Massachusetts
Committee on Transportation and Infrastructure
Committee on Financial Services
Committee on House Administration
Lack of a conference committe. Super IMAC. Reliance on fixes (you can trust me, I’m not like the others…). Obstructionst or Principled…
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p>Cong. Capuano raises good points, which have also been raised by GOP members.
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p>IMHO, the two existing passed bills should be referred to a traditional conference committee. It avoids the ‘scrap and begin again’ approach, and it also will allow members – not just leadership, but MEMBERS – to have input and to file amendments, which would then be voted up or down by the membership.
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p>What would the Congressman think of such an approach?
That is why everybody freaked when Brown got elected.
Which is all the constitution requires.
The Republicans would filibuster the conference report!
Just like the present discussion.
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p>The Democrats control the parliamentary process. They can pass whatever they want through reconciliation — everything affects the budget — just like the Republicans did before them.
VP Biden is the final arbiter of whether or not reconciliation rules are violated. He could simply decide they haven’t been.
Blow up the filibuster, with Biden making the ruling.
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p>About d-mn time.
is, indeed, nuclear option. If it comes down to it, I would support that. But g-d forbid that it is simple majority rule when the GOP is in charge.
because the filibuster did us so much good last time Democrats had more than 40 but fewer than 50 seats.
should be the absolute last option. There are many, many, many reasons why it should not happen outside of the normal process.
Thank goodness it saved us from Justices Alito and Roberts.
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p>Oh…what?
filibuster a supreme court nominee!
OR All Childs Left Behind, OR Medicare Part D when Republicans put in the provision about not letting government negotiate on the prices as a bulk buyer, OR on funding an illegal war, OR….
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p>Let the majority who rules fucking RULE. Dems or Repubs. I would be proud to wear our legislation – we’re on the side of the little people (when we’re not listening to Joe LIEberman or Nelson or B.Lincoln).
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p>Conversely LET the Repubs OWN their legislation when they are in the majority. I can bet on how quick their breakdown of all things fair and decent will get them long term minority status after that, similar to what we’d be experiencing now IF the Dems could f-ing pass anything – the fact we aren’t is the main difference between the enthusiasm gap between the parties and could lose us more seats than we should lose in Nov.
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p>Kill the filibuster. It’s outdated and abused (by them) and NOT used (by us).
None of them are about the bill, but the rules. And they carry a great deal of pre-supposition – ‘they’ will do this, and then ‘they’ will do that. An openly conferenced bill would allow both sides greater input and allow effective compromise to take place, which WOULD allow a 50-plus-1 bill to pass. It might EVEN garner 55 or 58…
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p>Who IS happy with this bill as it stands?
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p>By forcing this vote for a self-imposed timetable, you lose any work done to date.
than I am with the status quo.
almost every major concern of the Republican Party, serious or not, has been addressed. This is essentially a Republican bill, using a republican strategy (the personal mandate) to expand coverage. This was Mitt Romney’s bill, in essence.
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p>And what did the Democratic Party get for all that compromise? Not a single senate vote from the GOP in the Senate, and one vote from the GOP in the House (who probably won’t vote for it again).
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p>You are absolutely right that this bill has been illustrative of the current problem, but not in the way you put forward.
That said – the single biggest mistake happened at the VERY beginning. The refusal to conference the bill.
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p>If the GOP was outvoted, so be it. But using the process to prevent even knowing what’s IN the bill to get it done ‘quickly’ is what caused all the mistrust on the part of the general public (“You have to pass the bill to know what’s in it” = Speaker Pelosi).
The public doesn’t understand the legislative nuance that’s kept this bill dead for so long (a majority of the public doesn’t even know what the filibuster is) — when Democrats were trying to woo Republicans. Of course, the Republicans knew that — and were quite happy to get away with stonewalling the entire bill while the Democrats wasted time trying to get them to come to the bargaining table, taking all the blame for the stalled process they didn’t want or create. Lest ye not forget, when it comes to going for GOP votes, it was Max Baucus who decided to scrap all our hard-fought, gigantic Congressional majorities and POTUS victory, under the mistaken impression that the national GOP was actually interested in helping govern (and not just trying to kill everything to help their odds in 2010), going with a health care ‘gang’ consisting of an even number of Republicans and Democrats to hammer out a deal.
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p>Grassley himself ended up going against the very proposals he was formerly a champion of during that process. And when the Baucus mess became the inevitable disaster that it was, even after that point Harry Reid tried desperately to capture the two senators from Maine, amongst others.
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p>Health care reform never gained any traction until Democrats made it clear that they were willing to go it alone with reconciliation, because finally at that point it’s much harder for the GOP and a few rogue democrats to capture the entire process — which is to say, kill it. And, finally, with a democratic vote, the American people will see some action on this bill, which is what they wanted all along, when this gets the up-or-down vote that it deserves and that President Bush almost always got when he was President.
Name two Republicans that would vote for a bill the President would sign.
The House Dems are getting played.
TPM is just copying. DAVID M. HERSZENHORN and ROBERT PEAR:
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The fact is that Capuano is walking into the same trap the Ben Nelson did. Now you have Gutierrez pulling the same stunt.
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p>This is just another variation of divide and conquer.
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p>And in November, when the Republicans campaign on the fact that large Democratic majorities could not pass their own #1 priority, we can all sleep better knowing that for once they are telling the truth.
Is almost assuredly going to vote for this in the final countdown. Give it a rest, dude, fillet him when he DOESn’t, but can we please just take a deep breath? Preferably not breathing in the fumes? Thanks.
The bottom line, in my view, is that the Obama administration has not supported progressives like Congressman Capuano. What we are left with is a mediocre bill that is an improvement on the status quo for much of the country, and probably Massachusetts as well, subject to the resolution of some of the issues highlighted here, but a far cry from what the president was elected to accomplish.
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p>Congressman Capuano should be applauded for pushing to get the best possible deal for Massachusetts, but he should not help derail the entire Obama presidency by voting no.
I know you will do your damdest to get the strongest bill possible as soon as possible.
You’re very generous.
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p>On a serious note, you’re absolutely right for applauding Capuano. While a bunch of other people here have rabidly attacked him, he’s going to quietly get the bulk of our funding restored and protected before he gives it his vote and the bill passes.
his way of getting some attention on the problem.
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p>To the people who are in hysterics at Capuano – HEY GUYS: it’s called HORSE TRADING.
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p>Good lord, please let none of these hysterical dudes ever have to bargain in the marketplace, they’ll get FLEECED!
If GregR was a grog, he’d have:
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p>Per: -2
Bargain: 0
Guile: 0
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p>And he’d be kicked out of our covenant.
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p>(Yes, this is a total in joke for Ryan if he comes back to this thread, and Mr Lynne would get it as well, and probably no one else reading this would.) 😀
What part of this bill actually improves anything in this state? We already have an exchange, we already have restrictions on health insurance companies dropping people. We already have requirements on what insurance companies cover. Why should we give up funding in return for nothing?
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p>This bill seems to be unambiguously bad for Massachusetts and at best ambiguously good for most of the country. So why are people upset that a Mass rep is possibly going to vote against it?
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p>Health care reform died last summer because Obama doesn’t know how to lead (or isn’t willing to). The question now seems to be whether we want to give money to the insurance companies or not.
Massachusetts should suffer a bit. We are one of the richest states in the country and we have a rather nice head start on this issue. It would be only fair for Massachusetts to get the short end of the stick in health care reform.
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p>If every state is desperately fighting for its own interests, you don’t have good government, you just have chaos. I vote for the legislator who will benefit everyone, not just who will give me personally the most pork. To think otherwise is just the definition of evil.
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p>Also, although we do have a health insurance exchange already, there’s plenty of other reforms like closing the Medicare Part D doughnut hole which would be nice. And, of course, Massachusetts is deeply connected with the rest of the country. If the other 49 benefit, we benefit.
If he’s serious and persuades others to follow he will be largely responsible for preventing tens of millions of Americans from getting health insurance for a generation and in some cases forever.
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p>If it’s merely a stunt, he’s encouraging every other rep to make demands and blow up the whole bill.
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p>In either case how progressive!
he’s being a smart politician, making sure the policies that hurt his home state are removed.
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p>At the end of the day, he represents and is accountable to his district. If the deal is a bad deal for his district and this state, there’s no reason on earth he should vote for it. Don’t try to lay any sort of blame on him; the bill can be fixed and if it isn’t, lay the blame on Harry Reid and Barack Obama for the way they’ve (mis)handled this whole, entire process. After all, the House already passed a health care bill — and it was a helluva lot better than this POS.
Capuano voted for Medicare for All, HR 676. That was the right thing to do, but political money defeated it. The REAL solution is HR 676, but here we are considering the current Senate bill.
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p>Capuano is telling the truth. Taking money away from hospitals that treat the uninsured will make it much harder for people who are destitute to get emergency care, as hospitals will be forced out of this.
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p>The idea of having one set of rates for compensation to doctors would cause MD’s to leave Massachusetts. Why? Our cost of living is higher than, say, Arkansas, mostly due to real estate prices. It should be indexed to the cost of living, as the doctors have to live near where they work.
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p>Having the President, instead of Congress, set rates for doctors is asking for trouble, too. Representatives and Senators are more responsive to people at home (who need doctors to treat them) than the President, who could make the pay for doctors so low that they would quit medicine. It would be done to “balance the budget”, which is oh so important when a Democrat is in power but doesn’t matter when a Republican is.
I would hope that Biden would rule that adding important things like what Capuano has outlined is OK with reconciliation. However, with this White House, I would not expect them to fight hard for what the base wants. If they did that, they might get razzed by media gasbags, and that’s who the White House pays attention to, not ordinary people in great need.
Not only are Capuano’s misgivings right on the money, it is brave of him to tell us the truth about what’s really happening. That’s not the “safe” thing to do. But, he’s working to do what is right, considering the circumstances.