With the 2008 federal elections now concluded, Washington is set to undergo a major political and policy transformation. How will healthcare legislation be affected by the arrival of the incoming Obama administration and the new Congress? Childs spoke with Healthcare Informatics Senior Contributing Editor Mark Hagland to discuss prospects.
MH: How quickly might healthcare legislation of various types move in the new Congress?
BC: I’m pretty impressed by how President-Elect Obama and the new Congress are really stepping into gear pretty quickly; it’s almost unprecedented. When I think about the incoming Clinton administration back in 1993, it was really a very slow process, because everything became centralized in the White House, and that really hurt them. And that’s because they didn’t have the support on Capitol Hill. And the Daschle choice [President-elect Obama’s appointment of former Senator Tom Daschle to head HHS] was a brilliant one in terms of moving legislation forward. He’s a coalition-builder and a moderate.
MH: With regard to trying to move something as complex as comprehensive health insurance reform forward, will it matter whether the Democratic majority numbers 58, 59, or 60 seats out of 100?
BC: Yes, it will. Cloture is where it’s at. One of the big lessons from the last healthcare reform effort [in 1993, under then-First Lady Hillary Clinton], is that if you try to move a bill that is just a partisan plan, you’re going to fail. But [if the Democrats attain a 60-seat majority in the Senate], the ability of the Republicans to wage an effective opposition plan becomes undermined by the fact that there are 60 votes in place.
It sounds contradictory, but you can express bipartisanship by having the partisan strength, by having the hammer. And then of course, Sen. Kennedy just named Barbara Mikulski, Hillary Clinton, and I think, Debbie Stabenow, to these different work committees on healthcare, so he’s moving. So it’s moving forward on an access agenda, a quality agenda, and a cost-savings agenda. There seems to be a lot of focus on a broad agenda.
MH: What might the order of legislation be?
BC: The first thing to come up is SCHIP [the State Children’s Health Insurance Program], because that will be expiring. And the foundation of the renewal of SCHIP was passed in the House and Senate, but vetoed by President Bush. And they’ll have to deal with Medicare moratoriums in March or April The broader issue is that Congress will have to legislate a ‘physician fix.’ Previous legislation passed included a sustainable growth-rate formula that would require a future cut to physician salaries. They’ll have to do something about that, because a 21 percent cut is political suicide.
MH: Meanwhile, what are the prospects for pay-for-performance bills moving forward quickly in Congress?
BC: They’re very good. The Baucus-Grassley bill [a bipartisan discussion draft of legislation, introduced into the Senate Finance Committee by Chairman Max Baucus (D-Mont.) and Ranking Member Charles Grassley (R-Iowa)] would establish value-based purchasing across Medicare for inpatient care.
MH: Could the Baucus-Grassley bill pass Congress?
BC: Yes; concern over value is what’s driving things forward now. The big concern is how we address the twin problems in healthcare: costs are high and the quality is spotty. And one of the things we learned from our project [the CMS/Premier Hospital Quality Incentive Demonstration (HQID) project] is that pay for performance can work. In fact, we worked closely with Baucus and Grassley on the design of their bill. And we’ve worked to educate the Congressional staffs on what good policy is on this. So we’ve worked with the hospital community to develop some common principles on value-based purchasing.
MH: And as a result of the experiences with the HQID project, members of Congress will see it’s possible to move these levers, then, correct?
BC: Yes. The thing people are concerned about with pay for performance is unintended consequences. So our refrain to members of Congress has been, we know it works, but also, when we implement it, let’s not try to do a ‘big bang,’ let’s build it in phases. Because there are hospitals that have a harder time than others, and we don’t want something that may cause hospitals to not treat certain patients, or create any other unintended consequence.
MH: Meanwhile, e-prescribing has already moved forward.
BC: Yes, e-prescribing was written into the Medicare fee adjustment bill passed in Congress in early July, with bonuses for physicians to e-prescribe beginning next year, which turn into penalties for not e-prescribing by 2012.
MH: And EMR-related legislation?
BC: Something will definitely happen on EMR. The question will be the specifics of how the legislation is written. Will hospitals receive grants for implementing EMRs? Will they receive payment bonuses? I’m not sure what the best approach is.
MH: Will EMR legislation likely pass before comprehensive health insurance reform?
BC: Yes. The big stumbling block will be privacy issues, because there will be additional burdens placed on hospitals over and above their current requirements under HIPAA. But there is a Senate bill out there and a House bill out there, and they’re very different. Most likely, it’ll end up in the Medicare bill at the end of the year.
MH: Comprehensive health insurance reform still has very good chances, though?
BC: Yes. One interesting sign is that the health insurance industry just came out with a guaranteed mandate and community rating. So there’s a lot happening. And the interesting thing is how quickly this is happening.