Not even the most intense civics class would have prepared you for the theatrics coming our way in Congress.
I’ve read several articles about the Democrats’ strategy to get reform passed and signed into law and the GOP’s efforts to block reform. There’s at least a semester’s worth of study just in the Congressional manueverings, with a full year required to flow the Senate processes, parliamentary rules, and political manupulation thereof.
Politico has a pretty good synopsis, with the net being this.
1. The House has to pass the current Senate bill as is.
2. There are provisions in the Senate bill that are repugnant to many Dems; they will pass a ‘sidecar’ bill to address those provisions which will then go to the Senate.
3. The Senate Republicans will seek to delay the vote in the House and Senate thru debate, asking for votes on amendments to peel away Dem votes, and seeking rulings from the Senate parliamentarian on points of order. These last are a key part of the Republican strategy as the rules for what can and cannot be passed thru the reconciliation process are arcane and complicated.
4. If the Dems are successful, they will seek a vote that only requires 51 yeas, and the reform will pass.
It’s anyone’s guess if that will happen. If it does I’ll be looking closely at the final bills to ferret out the key provisions…
Posted via iPhone so typos are probable.

In what must be one of her more enlightened statements, Tea Party diva Sarah Palin told a crowd of Canadians that in her youth, “We used to hustle over the border for health care we received in Canada. And I think now, isn’t that ironic? “
You betcha.
That from the same person who has repeatedly referred to her good fortune in obtaining ‘good union jobs with great benefits’…
Big tip of the toque to Maggie Mahar for the info.

I’ve been avoiding posting on health reform of late, mostly because I’m so dismayed by what’s happened, and what’s happening.
The Republican Congress passed and then-President Bush signed into law Medicare Part D which added about $8 trillion to our national debt.
Now the Democrats want to one-up the GOP by passing what would be a massive entitlement expansion, with no meaningful cost containment. They want us to believe we can expand coverage now and fix the cost issue later.
No, we can’t, and no, we won’t. It is far more difficult to get people to give things up they already have than to convince them they can’t afford those things in the first place.
The health care reform debate has provided all the evidence we need to see how hard it is to get physicians, or insurance companies, or unions, or voters, or employers, or state regulators, or pharma, or device companies to agree to give back business/rights/revenue/coverage they have today.
Bob Laszewski said it well in his post today –

“adding 30 million more people to an unsustainable system expecting it will create an even bigger crisis and thereby force real reform is tantamount to reboarding the Titanic in the hopes it will sink faster. It is also hard to see how doing such a thing is the politically courageous thing to do.
Just where is the moral imperative in ramming a trillion dollar entitlement expansion through knowing full well it will make our long-term deficit nightmare even worse–for those now uninsured and for everyone else?
The Democratic health care bill makes little if any systemic changes to the health care system–certainly not at the level we need.”

Neither party is acting in the best interest of the nation, or of their own constituents for that matter. And anyone who believes we can pass it now and fix it later is living in a fantasy world.
One example proves the point. The bill presently under consideration doesn’t address the ongoing issue of Medicare physician compensation, a failure that precisely illustrates the problem of passing it now and fixing it later. Medicare physician compensation legislation was passed a decade ago, with hard and tough limits on physician reimbursement. Yet every year Congress votes to overturn the cuts, with the result that we now have a $300 billion deficit in the program.
What does this mean for you?
Not only is sausage making ugly to watch, it produces inedible results.

As presently conceived, health reform will fail. I’m talking not about the chances of a bill being signed into law but rather what happens when that happy day arrives.
I say this with deep regret, as I am an ardent advocate for health reform and a strong supporter of the President.
But we cannot force people of limited means to buy coverage they can’t afford, and we cannot force insurers to take all comers if people can opt out whenever they wish.
Without cost control, insurance costs won’t moderate, and without lower health insurance costs, many Americans can’t afford coverage. Despite the efforts of many, this seemingly-obvious conclusion hasn’t affected legislative efforts. Democrats are desperately trying to ram thru a huge entitlement expansion during a deep recession, while Republicans gleefully distort and demagogue, much more interested in helping the Dems commit political suicide than actually solve the health insurance crisis.
Over the last decade health insurance costs went up 131%; an annual rate of 8.7%.
If we are able to keep inflation to only 8.7% (doubtful in my mind), a family will pay $30,800 for insurance in 2019,
That inflation rate will moderate somewhat if everyone is covered (less need for cost shifting), but we’re still stuck with the prospect of forcing nursing aides making $12 an hour to buy coverage that they can’t afford.
To date private insurers have shown no ability to control costs; they’re too worried about on a reprise of the ‘managed care backlash’ of the nineteen-nineties when they should be thinking about the prospect of single-payer, a prospect that will look increasingly likely as health insurance costs approach $30,000 per family.
What does this mean for you?
There’s a lot of opportunities here for innovative, intelligent, creative approaches to coverage. Insurers and employers will have to leave their comfort zones and try solutions that will make them nervous, but the ones who do stand a much better chance of surviving than their conservative competitors.

Yesterday the Senate passed a bill extending unemployment and other benefits and subsidies for another month; one of the less well known provisions prevented imposition of a 21% cut in Meducare physician reimbursement.
‘Prevented’ isn’t exactly correct; the bill merely delayed implementation of the cuts till the end of March.
For years Congress has avoided implementing Medicare reimbursement decreases, bowing to intense lobbying by physian groups and other parties outraged at the very idea that their income will be reduced. I can’t really blame the docs; as I’ve reported here in the past physician income, especially generalist physician income, has not kept pace with inflation for several years.
What I’m less impressed with is the failure of physician advocacy groups to offer a reasonable alternative to the present fee-for-service system. Anyone with a clue acknowledges that FFS is one of the biggest problems in our health care system, rewarding providers for doing things to patients and not for keeping them healthy.
At some point we have to – must – adopt reimbursement methodologies that reward results not activity.
Don’t expect this to happen before the end of March. No, we’re much more likely to see the Senate boot this can once again, and with it the chance to fix a fundamental problem with our health care system.

The political grandstanding and point scoring on Capitol Hill will have significant repercussions for work comp, with some states directly – and quickly – affected and others feeling the impact later and more subtly.
I’m refering to the inability of the Senate to pass
legislation preventing the 21% cut in Medicare physician reimbursement that went into effect yesterday.
The Senate is trying to pass legislation to (temporarily) prevent the cut but Sen Bunning (R TN) is holding up passage. I’m a bit conflicted over Bunning’s move: he’s a bit of a wild card and rather erratic, but his stated rationale isn’t unreasonable; he wants to know where the money’s going to come from.
Regardless, several states base their WC fee schedules directly on Medicare: the cut will theoretically impact physician bills for services rendered beginning yesterday and cotinuing until the impasse is resolved.
I’m actually in DC now, if nothing’s changed before I get back to the office I’ll dig out my files and report on which states are directly affected.

I’ve never had a guest post on MCM but an email from a colleague inspired me to ask if I could publish it not as a comment but as a post.
The writer addresses the issues laid out in my post earlier this week about the inherent conflicts in many Americans’ desire to pay lower taxes while getting whatever care they want from whomever they want.
Here’s the guest post.
Your most recent posting and photos brings to mind a case I am now reviewing of a woman who is suing a nearby city for a sidewalk fall. She has more than a decade of treatment and I have gone thru over 4000 pages of files for everything from GI problems, multiple orthopedic interventions including several ineffective spine and knee surgeries, obesity, migraine, ‘fibromyalgia’, history of hysterectomy at young age for pelvic pain, multiple bouts of depression and anxiety, history of domestic abuse, opiate dependence, multiple work comp, auto and disability claims. Her pharmacy records alone are a 59 page printout from 2006 through 2009. Providers include primary care, GI specialists, Gynecology, MSW, Psychiatry, Psychology, ARNP, chiropractors, massage therapy, acupuncture, neurosurgeons, orthopedists, physiatrists, physical therapy, neurology and some I have may be forgetting. And the file even includes over 100 pages of emails to and from the patient and the various providers.
I could go on. My task focuses mainly on causality of the recent injury claim to her back and spine complaints. As a psychiatrist I have been engaged along with other physicians because of the big picture; emotional issues are likely significant or primary drivers for her multiple somatic complaints, surgery, narcotic consumption and life decisions in general. Her demands for this injury are about $600,000 according to the referring attorney, with the inference being that her current problems are the result of a minor slip and fall in 2006.
I found myself wondering how much her care has cost the rest of us and how little of the care had any real value in terms of doing anything meaningful for her health and her life. She currently has chronic multi-system pain complaints, history of multiple surgeries without obvious underlying pathology or positive outcome in most cases, and she is now opiate addicted. My impression is that there may be more than a million dollars in care that she has received over the past decade or more. It is far from clear whether health reform would in any way change this for better or worse but she represents the Pareto principal (ie 80/20 or 90/10 or 95/5 rule in her case) in practice and she is far from alone. I am likely one of the minority of people engaged in the health debate who actually see individuals that reflect the problems we face in society and in health care. This case is an example of how we as a society medicalize emotional and social problems and the extraordinary level of waste represented by many medical interventions, to the degree that the interventions side-step or avoid what is really going on – but spend extraordinary resources in the process. Most practitioners can likely share similar stories from their training or practice, but it seems to be a secret hiding in plain sight. Consider the difference between this scenario and the meager resources available in much of the world for life changing and saving care. The cost of her care could vaccinate large geographic regions in the 3rd world and actually save lives if we could somehow reallocate the resources.
I find it interesting that some folks like us are willing to pay more in taxes for a better society, while we likely use relatively little in terms of government services – while many who rely on government largesse, like those riding power chairs because they are too lazy to walk, who may be collecting their own Social Security and Medicare while perhaps pulling out far more than they ever put in – are holding tea parties. Many of these protesters are one pink slip away from no health care and no income, yet they protest for who and for what?