Now that both the Senate and the House have passed health reform bills, what can we expect next? As you chat with friends and family over the holiday, do you know what is in these bills and what might emerge in the final version?
The Senators and Representatives won't be back to work for a week or two. Meanwhile, staff of both houses will be talking by phone this week and meeting in person with the Leadership of the House and the Senate next week to work out the differences between the two approaches in some form of "conference committee". How that conference committee gets constituted and which "house" sets the rules is unbelievably complicated. ( If you are truly into detail, check out this great Daily Kos blog that tells you more than you would ever need to know about how this process might work.)
Bottom line? Negotiations are proceeding now and will continue into January, with the hope that a final bill can be voted on by the end of January or early February 2010.
If you want to know more about what is in these bills, here are two sites with good information, and this post on Huffington comparing the two bills:
1. The Kaiser Family Foundation has a great site where you can create your own "side by side" comparison of the two main pieces of legislation - the House leadership bill and the Senate leadership bill.
2. Health Affairs has a blog that offers a variety of different viewpoints on the two bills. Two pieces by Timothy Jost, one on insurance reform provisions and one on delivery system and cost control, are great and readable summaries of what is in these bills. Jost makes a list of things that were added to the Senate bill via the "manager's amendment" (which was passed on Christmas Eve) that attempt to address changing the way we pay for and deliver health care.
Jost's list below includes just a few new initiatives in the Senate's manager's amendment (with some of my comments in italics and parentheses as to why they are important). This list does not even include what was already in the Senate or House bills. A list of some of those other provisions can be referenced here.
New initiatives in the manager's amendment
Some of the initiatives are pilot programs that can be scaled up program-wide without further congressional permission if they succeed. Others are programs that are funded on a short term basis or for a limited number of sites, again to see if a program actually has promise before extending it too broadly. Finally, yet other programs are indeed new nationwide initiatives that will become a permanent part of the landscape.
--"Balancing payment incentives" to incentivize new program initiatives to encourage the use of Medicaid-funded home and community-based care in states that rely disproportionately on institutional long-term care. (This means a lot to parents of children with disabilities. They have fought long and hard to get their kids out of institutions and into programs in their communities and homes, but Medicaid rules have sometimes made it difficult to do so.)
--Funding for state malpractice reform initiatives (States currently have jurisdiction over malpractice reform, so this provision could help evaluate which approaches seem to work best)
-- Extended federal funding for the CHIP program for 2014 and 2015. (The Children's Health Insurance Program needed this extra funding to be sure that the program stays viable while the Exchanges are being developed.)
-- The development of a value-based purchasing program for ambulatory surgical centers. (This may not seem like such a big deal, but it will encourage Medicare to purchase services more like large employers and large health plans do now, using "value" measures, instead of just paying for each service provided.)
-- New provisions for testing payment and delivery system innovation models by the Center for Medicare and Medicaid Innovation. (Among other things, this new Center will help to transform Medicare from a program that pays more when providers do more, to a program in which quality and outcomes can be measured and included in the payment formula.)
-- Development of a physician compare website with information on outcomes, patient safety, patient satisfaction, and continuity of care. (Right now it is very difficult for consumers to get this information)
-- Additional funding for training nurse practitioners, rural physicians, and preventive health and public health specialists. (If we are going to expand coverage, we need to be sure that people have access to doctors and nurses. This money will help jump start that training.)
-- Six billion dollars in new funding over 5 years for community health centers. (These centers have been the main source of care for the uninsured and the poor, and they will continue to be that until the exchanges are fully implemented over a five year period.)
-- Provision for $200 million in grants to small businesses for wellness programs. (Large employers fund these programs regularly, but small businesses have not been able to afford to do so.)
The main issues of disagreement between the House and the Senate approaches will be some of the following (with more issues described in this American Prospect article). It's good to keep in mind that the final version is going to look much more like the Senate plan than the House plan, given the need to keep the 60 Democratic votes together in the Senate:
1. How to fund reform - the House proposes a tax on the rich; the Senate proposes a tax on rich plans (those that cover everything with little copayments or coinsurance requirements for members). Both bills propose savings in the Medicare program -- not by cutting benefits as opponents have charged, but by paying providers differently so that there is more "pay for performance" and less "pay for doing more".
2. National vs. state "insurance exchanges" -- the House proposes a national exchange with state flexibility; the Senate proposes state exchanges.
3. The public option -- the House version has a weak public option; the Senate version has no public option but proposes that the Office of Personnel Management (OPM) that manages the benefits of federal employees (including Senate and House reps) - offer and manage at least one nonprofit plan in each state exchange.
4. The abortion provision -- the House "Stupak" amendment or the Senate "Ben Nelson" amendment? I wrote this blog for the Huffington Post on the House amendment. The Senate abortion provision is complicated and burdensome but may be what has to be passed at this point. Stupak is not likely to get his way.
5. The amount of subsidies -- the House provides more generous subsidies than the Senate, but the cost of the House bill is greater. So the debate will be how to make sure people can afford to buy insurance if they are mandated to do so, without breaking the bank.
How health reform may affect you? This article in USA Today gives a good breakdown of the impact of reform on various groups such as Medicare beneficiaries and employees of small or large companies. If you already have insurance, you may see very little change to what you already have. If you do not have insurance, you will begin to see some changes as early as next year, and hopefully the final bill will accelerate some of the insurance reforms so you cannot be denied coverage. Most importantly, the provisions in this legislation need to bring costs under control, and how soon that can happen is anyone's guess (except the CBO!).
A version of this was blog was posted at: http://peacecorpsworldwide.org/health-reform-health-care/