# Medicare Reimbursement Rates

Zaun swings at Boswell, hits Latham and King

Republican Congressional candidate Brad Zaun has promised to give voters 14 reasons not to re-elect 14-year incumbent Leonard Boswell in Iowa’s third district. Last week Zaun unveiled reason number 1: Boswell “has been listed as a ‘follower’ according to the non-partisan website www.GovTrack.us. […] Boswell has sponsored only 66 bills since January 7, 1997, and 63 never made it out of committee. Only three of Boswell’s bills were successfully enacted…and of those three, two were for renaming federal buildings.”

Bleeding Heartland readers who are familiar with the workings of the Iowa Senate may be amused by backbencher Zaun calling someone else a “follower.” Technically, Zaun is one of four assistant Iowa Senate Republican leaders; that’s a four-way tie for the number 3 spot in an 18-member caucus. He isn’t exactly a commanding presence at the capitol. Boswell was much more influential as Iowa Senate president in the 1990s before his first election to Congress. But I digress.

Zaun misleads by implying members of Congress can only be judged by the bills they sponsor, and I’ll have more to say on that after the jump. First, let’s see how Iowa’s two Republicans in the House of Representatives look through GovTrack’s prism.  

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Medicare payment breakthrough and other health insurance reform news

It’s crunch time for health insurance reform, and Senator Tom Harkin and the three Iowa Democrats in the House “announced a major breakthrough today on the issue of Medicare payment reform in the final health care reform bill,” according to a joint press release. Excerpt:

[Representatives Dave] Loebsack, [Senator Tom] Harkin, [Leonard] Boswell and [Bruce] Braley have been outspoken advocates for changing the way Medicare pays health care providers for services, from its current fee-for-service system into a quality and value-based system.

Loebsack, Harkin, Boswell and Braley helped negotiate a compromise adding language to the health care reform bill that provides an immediate $800 million to address geographic disparities for both doctors and hospitals, as well as written guarantees from Health and Human Services Secretary Kathleen Sebelius for further action to reform Medicare reimbursement rates that do not qualify for reconciliation under the Byrd Rule. The Senate bill previously only provided a Medicare reimbursement fix for doctors.

The House reconciliation package maintained automatic implementation of a value index as part of the reimbursement structures for doctors, beginning in 2015.  This language was secured in the Senate bill with the help of Harkin and is based on Braley’s Medicare Payment Improvement Act, introduced in June 2009. Under the fixes secured in the Senate bill and the House reconciliation package, Iowa doctors will see five percent increases in current Medicare reimbursement rates in both 2010 and 2011.

I posted the whole press release, containing more details, after the jump. This deal appears to have secured the vote of Peter DeFazio (OR-04) as well. Yesterday he threatened to vote no because of language on the Medicare payments disparity.

President Barack Obama gave House Democrats a pep-talk today, and his speech (which wasn’t pre-written) got rave reviews from many Democrats. If only the Senate bill were as good as Obama made it sound. (UPDATE: I posted the White House transcript of Obama’s speech after the jump.)

House Democratic leaders have decided to ditch the “deem and pass” method for passing health insurance reform with a single vote, even though the legislative procedure isn’t as rare or controversial as Republicans would have you believe. Instead, the House will hold an hour of flood debate tomorrow on “the rule to allow reconcilation to get to the floor,” then House members will vote on the rule, then they will debate the Senate health insurance reform bill and vote on it. I assume this means that House Speaker Nancy Pelosi is confident she has the 216 votes she needs.

Bart Stupak is now claiming only about half a dozen Democrats are willing to vote against the bill unless it contains major new restrictions on private insurance coverage of abortion. Stupak was supposed to hold a press conference this morning, but he cancelled it, so maybe that means he didn’t get the deal he was hoping for from Pelosi. David Dayen speculates on who is still in the Stupak bloc. David Waldman warns about the prospect that Stupak will use a “motion to recommit” to try to get his anti-abortion language into the reconciliation fix package.

Outside the Capitol, tea party protesters shouted racist insults and held signs threatening gun violence if health care reform passes. Congressional Republicans should disavow this reprehensible behavior, but of course they won’t.

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Braley undecided on health insurance reform vote (updated)

On Sunday, the House of Representatives will vote on the Senate’s health insurance reform bill and some “fixes” to that bill. The procedural details have not been fully worked out (David Waldman takes you through the weeds here and here), but it’s clear that the vote will be very close. House Speaker Nancy Pelosi needs to find 216 votes to pass the bill.

Various whip counts are floating around the internet. Take your pick from David Dayen’s version at FireDogLake, the Chris Bowers tally at Open Left, or the latest from The Hill staff. Several Democrats who voted against the House health care reform bill in November have announced plans to vote for this version. However, others who voted for the House bill remain undecided or have said they will vote no.

Today Peter DeFazio (OR-04) threatened to vote no on the bill because of changes in language on correcting geographical disparities in Medicare spending. DeFazio explained, “We spent months working this out. If we don’t get it in this bill, we will never get it.” The Huffington Post reported that other House Democrats share DeFazio’s concerns.

Because all three Iowa Democrats in the House strongly supported the changes to Medicare reimbursement rates that were included in the House bill, I contacted their offices today to find out whether they, like DeFazio, consider this issue a deal-breaker. I have not yet heard back from staffers for Representative Leonard Boswell (IA-03) or Dave Loebsack (IA-02), but a spokeswoman for Bruce Braley (IA-01) sent me this response:

Congressman Braley has spent hours in meetings with Speaker Pelosi and House Leadership this week, discussing the need to correct geographic disparities in Medicare reimbursement and how those corrections can be accomplished in this final bill.  Congressman Braley is still very much undecided on how he will vote on the reconciliation package and this is one of many factors that will play a role in his final decision.

I’ve never seen Braley on any list of wavering Democrats on the health insurance reform bill. If he and DeFazio do end up voting no, it will be much harder for Pelosi to find 216 votes. On the other hand, a compromise could be reached before Sunday:

At her press briefing Friday morning, House Speaker Nancy Pelosi (D-Calif.) was asked about Rep. Peter Defazio’s objections to the removal of the Medicare disparity fix from the final bill. “We’re working on that language,” said Pelosi. “I feel comfortable about where we are heading.” She said she supports the language that was in the House bill and is working toward restoring it as much as possible.

“We have reached agreement before,” she said of the dicey political issue.

I will update this post if and when I hear back from Loebsack’s and Boswell’s offices.

UPDATE: Loebsack’s spokeswoman confirmed that he will vote for the bill. Boswell seems like a firm yes as well, judging from an e-mail blast he sent yesterday, which I have posted after the jump.

SATURDAY UPDATE: Braley confirmed that he will vote for the bill because of the deal on Medicare reimbursement payments I discussed in more detail here.

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Year in review: Iowa politics in 2009 (part 2)

Following up on my review of news from the first half of last year, I’ve posted links to Bleeding Heartland’s coverage of Iowa politics from July through December 2009 after the jump.

Hot topics on this blog during the second half of the year included the governor’s race, the special election in Iowa House district 90, candidates announcing plans to run for the state legislature next year, the growing number of Republicans ready to challenge Representative Leonard Boswell, state budget constraints, and a scandal involving the tax credit for film-making.

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New GOP robocall uses old GOP playbook

Oh no! Representative Leonard Boswell must be quaking in his boots now that the National Republican Campaign Committee is running this robocall against him in Iowa’s third district:

“Leonard Boswell spent 2009 helping liberal Speaker Nancy Pelosi push a massive government takeover of health care, a cap-and-trade energy bill that will increase costs for Iowa workers, and a massive $787 billion pork-laden spending bill that he called a stimulus but that has not helped the Iowa economy. Tell him your New Year’s resolution is to watch his votes in 2010 to make sure he is voting for Iowa families, not the liberal agenda of the Democrat party leaders in Washington.”

For years, Republicans have trotted out versions of this script against Boswell: blah blah blah Nancy Pelosi blah blah blah liberal agenda blah blah blah Democrat Party. It hasn’t resonated before, so why would it work now?

Specifically, I don’t think they will get far running against the stimulus package. Even in a weak economy, Boswell will be able to point to dozens of programs from the stimulus bill that benefited Iowa families. He has brought money to the district through several other bills passed this year as well. The Republican alternative, passing no stimulus and freezing federal spending, would have made the recession far worse.

The health care bill doesn’t even contain a weak public insurance option, let alone a “government takeover.” I don’t dispute that there will be plenty for the Republicans to attack in that bill, but Boswell will be able to point to items that benefit Iowans, such as new Medicare reimbursement rates to benefit low-volume hospitals (including Grinnell Regional Medical Center and Skiff Medical Center in Newton).

Boswell fought for concessions in the climate change bill that weakened the bill from my perspective but will be touted by his campaign as protecting sectors of the Iowa economy. Anyway, many people’s utility bills are lower this winter because the recession has brought down natural gas prices.

It’s fine with me if the NRCC wants to drain its coffers by funding robocalls like this around the country. I doubt they will scare Boswell into retirement or succeed in branding him as a Washington liberal.

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Boswell is a swing vote on health care reform

The House of Representatives will soon bring a health care reform bill up for a floor vote. All three relevant committees have approved bills containing a public health insurance option. In August, Jacob Hacker explained one of the key differences between those bills (pdf file):

The versions of the House bill approved by the House Ways and Means Committee and  House Education and Labor Committee contain a Medicare tie-in that has two crucial  characteristics:

    1.  Providers participating in Medicare would automatically be considered participating  providers in the new public plan, although they would have the right to opt out.

    2.  Initial payments to providers would be set at Medicare rates plus 5 percent. After  three years, the Secretary of Health and Human Services could adjust rates. But  during the crucial start-up period, the public plan would be able to piggyback on  Medicare’s payment methodology. 17    

     These are good provisions. They would be even better if they included an explicit  protection of providers’ rights to join the public plan. Private plans (at least those that  participate in the exchange) should be prohibited from setting as a condition of participation  in their networks that providers not join the public plan.

     By contrast, the House Energy and Commerce Committee approved the House bill  with amendments that preserve only the first of these two elements. 18 Providers participating  in Medicare would be presumed to participate in the new public plan (but, again, allowed to  opt out). 19 However, rather than setting the rates the public plan would pay providers on the  basis of Medicare rates, the Secretary of Health and Human Services would have to  “negotiate” rates directly with providers. 20 These rates in the aggregate would have to be  between Medicare rates and private rates, but no other details are given. 21 This is a not-so-good provision that could drive up individual premiums and federal costs, burdening  Americans as health care consumers and taxpayers alike. It threatens the viability of the  public plan because it may require the government to pay providers higher rates than they would otherwise accept if the rates were set.

Click here to download Hacker’s full report, which includes analysis of the Senate HELP Committee’s bill.

When the House Energy and Commerce Committee passed a watered-down bill to placate Blue Dog Democrats, most people assumed that this compromise would be the health care reform bill sent to the House floor. However, House Progressives have been rounding up votes for the stronger public option provisions, and yesterday Progressive Caucus co-chair Raul Grijalva claimed to have 210 votes supporting or leaning toward supporting the stronger bill. Speaker Nancy Pelosi won’t bring that bill to the floor unless she is sure she has the 218 votes needed to pass, however. As many as 19 House Democrats have not decided whether they would support the “Medicare plus 5 percent” public option.

Chris Bowers published a pdf file listing 36 House Democrats who are either undecided, “lean yes” or “lean no” on the stronger public option. Representative Leonard Boswell (IA-03) is on that list. It’s not clear whether he is undecided or leaning one way or the other. I have sought clarification from his office and will update this post when I hear back.

You know the drill. Boswell needs to hear from as many constituents as possible. The “Medicare plus 5 percent” version of the public option is better policy, and if the House approves it, our negotiating position in the Senate will be stronger. I would call Boswell’s office rather than e-mail, because phone calls are harder for staffers to ignore. Office contact information:

Washington DC Office

Phone: (202) 225-3806

Fax: (202) 225-5608

Iowa District Office

Phone: (515) 282-1909

Fax: (515) 282-1785

Toll Free Phone: (888) 432-1984

In related news, Boswell joined Representatives Bruce Braley (IA-01) and Dave Loebsack (IA-02) today in announcing final legislative language to change “the way Medicare pays healthcare providers for services, from its current fee-for-service system into a quality and value-based system.” After the jump I’ve posted a joint press release explaining how this deal will affect Medicare reimbursement rates.

UPDATE: Supposedly there are at least 218 votes in the House for the “robust” public option. The deal on Medicare reimbursement rates helped secure some extra votes for the public option. Also, the House bill will strip the insurance industry of its anti-trust exemption.

CORRECTION: Apparently we don’t have 218 votes for the stronger public option after all.

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Harkin serves up health care promise at Steak Fry

Senator Tom Harkin told a crowd of nearly 2,000 people today that health care reform including a public health insurance option will pass before this Christmas. Speaking at his 32nd Annual Steak Fry in Indianola, Harkin joked,

“This is my kind of town-hall meeting,” […] because he didn’t see any Republicans standing up to say, “Keep your government hands off my Medicare.”

Harkin and event headliner Al Franken predicted that health care reform would pass with some Republican votes, which seems unlikely if the final version of the bill contains a public option. Republican Senator Olympia Snowe of Maine has been the focus of White House courting on health care, but she opposes a public option, apparently because it has the potential to provide lower-cost health insurance.

The Senate Committee on Health, Education, Labor and Pensions passed a bill this summer containing a public option, but according to one critic, the HELP bill’s public option is anything but robust:

the actual provisions in the HELP Committee bill call for numerous “community health insurance options,” not the single “Medicare-like” plan promised by “public option” advocates. That means the individual “options” will probably be as small and weak as the co-ops now under discussion in the Senate Finance Committee. More importantly, these “community options” will almost certainly be run by insurance companies.

The public option in the bill that cleared the House Energy and Commerce Committee, HR 3200, is also weak in several respects.

President Barack Obama met with 17 relatively conservative Democratic senators on Thursday, reinforcing many people’s fears that he was ready to discard the public option. The same day, Harkin assured the Progressive Populist blog that 51 votes can be found in the Senate for a bill with a public option.

So what about all the hubub about the Blue Dogs and/or Progressives opting out if the bill doesn’t meet their liking? Harkin said don’t put too much stock in those statements.

“Look, around here people are always jockeying for power. That’s all this is,” Harkin said.

The only chance of making this bill stronger, in my opinion, is getting a large bloc of House Democrats to draw a line in the sand. If you live in Iowa’s first, second or third Congressional districts, please contact Bruce Braley, Dave Loebsack or Leonard Boswell to urge them not to accept any bill containing a “trigger” (which is guaranteed to fail) or some other fake public health insurance option. Organizing for America has a new petition out if you prefer that method of generating an e-mail to your member of Congress.

UPDATE: Don’t miss John Deeth’s entertaining liveblog from this event, with lots of photos. Braley and Loebsack praised Boswell for standing up for a public option (unlike many Blue Dogs).

From Chase Martyn’s write-up at Iowa Independent:

Boswell and fellow Democratic U.S. Reps. Bruce Braley and Dave Loebsack also expressed optimism that a final bill would include measures to reform medicare reimbursement rates. Medicare currently pays doctors in rural states like Iowa less than what doctors in densely populated states receive for the same procedures.

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House health care bill will change Medicare reimbursements

The offices of Congressmen Bruce Braley (IA-01), Dave Loebsack (IA-02) and Leonard Boswell (IA-03) announced big news on Friday afternoon:

Boswell, Loebsack, and Braley helped negotiate a compromise adding language to the healthcare reform bill changing Medicare to a quality-based payment system in two years.  Specifically, the compromise would (1) require Medicare to conduct a two-year study on a value-based system, and (2) at the end of the two year study period, Medicare would switch to a quality-based system unless Congress specifically cast a vote to disallow that change. […]

Medicare currently operates under a fee-for-service system, basing payments to doctors and hospitals on the amount of procedures completed and the number of patients seen.  This system creates a financial incentive to order more and more procedures.  Ironically, according to many studies, this increased number of procedures does not result in better outcomes for patients.

Boswell, Loebsack, and Braley have strongly advocated a switch to a Medicare payment system based on value and quality, which determines payments based on procedures’ effect on patient health.  In June, Rep. Braley introduced the Medicare Payment Improvement Act with Rep. Ron Kind (D-WI).  Reps. Boswell and Loebsack are co-sponsors of the legislation.  The bill would have required Medicare to switch to a quality-based payment system, outlining specific details on how to measure quality and value.

If Congress adopts a health care bill containing this provision, it will be very good news for Iowa health care providers, who are reimbursed by Medicare at much lower rates than in some other parts of the country. I’ve posted the whole press release from Braley’s, Loebsack’s and Boswell’s offices after the jump.

On a related note, Iowans who support a strong public health insurance option should contact Boswell’s office. There is some confusion surrounding his position on this issue. He expressed support for a public option in June. In early July he signed a good letter from a group of Blue Dogs and New Democrats advocating for a public option. However, when confronted on camera this week, Boswell said he wasn’t against a public option and wants to see the final version of the health care bill before making a decision.

A public option could provide coverage and competition in the majority of U.S. markets that are currently dominated by one or two private health insurance providers. It also could save hundreds of billions of dollars. Supporters of the public option can Stand With Dr. Dean here. Please also consider signing up with Health Care for America Now. Senators Richard Durbin, Patrick Leahy and Chuck Schumer set up this online petition supporting a public option as well.

In other health care reform news, Senator Tom Harkin is rightly frustrated that the Congressional Budget Office scoring of the Senate Health, Education, Labor and Pensions Committee bill didn’t include any cost savings from the prevention measures Harkin fought to have included. He’s concerned that the language on prevention might not survive Senate negotiations:

“We got a lot of savings out of it. But they just don’t score it that way. And I’ve got to fight like the dickens to make sure we keep it in there,” he added. “Otherwise, people will say, ‘We’ve got some costs here. But we don’t have any savings, and since we have costs, not savings, we’ll throw that overboard.’ “

Thanks for fighting the good fight, Senator Harkin. Private sector companies that have focused on prevention have reduced costs for treating some chronic conditions.

UPDATE: Boswell’s official website explains his position on health care. He seems focused on whether the public option will be “self-sustaining and deficit neutral,” as opposed to whether it will provide competition or coverage to his constituents who are badly served by the status quo.

Funny, I don’t ever remember Boswell insisting that other government spending (like agriculture subsidies) need to be self-sustaining or deficit neutral. If universal health care isn’t worth spending public money on, what is?

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