Medicare Reform – Health Stew

Below is an op-ed I wrote late last year for the Milbank Quarterly, published today.

Once upon a time, I believed that efforts to repeal the Affordable Care Act (ACA) would wither and die once the ACA’s major Medicaid and private insurance expansions became effective on January 1, 2014. After all, opponents had let Senator Ted Cruz (R-TX) trigger a 3-week federal government shutdown in October 2013 in a desperate final attempt to thwart the expansions. Over the course of 2 open enrollment periods, between 2013 and 2015, as many as 17 million previously uninsured Americans obtained coverage. Surely the worst was over. Now I am not so certain.

Since 2010, Americans have witnessed 3 near-death experiences relating to national health reform: first, the election of Scott Brown (R-MA) to the US Senate in January 2010, ending Democrats’ 60-vote filibuster-proof majority; second, the US Supreme Court’s decision in June 2012 upholding the constitutionality of the ACA writ large; and third, the November 6, 2012, federal elections in which a victory for presidential candidate Mitt Romney would have augured substantial repeal. By this standard, the October 2013 government shutdown and the 2015 Supreme Court case, King v Burwell, were faux near-death experiences, not the real thing. Continue reading “Is the Fate of the ACA Settle or Not?”

This week, you can be confident that the US Senate will approve bipartisan legislation approved on March 26 in the House of Representatives by an overwhelming (392-37) bipartisan majority to repeal a long-standing feature of Medicare physician payment policy called the Sustainable Growth Rate or SGR.

If you’ve never heard of SGR, you are among the 99%. Still, the SGR story has been fascinating and frustrating since it began as part of the 1997 Balanced Budget Act (BBA) agreed to by President Bill Clinton, House Speaker Newt Gingrich, and Senate Majority Leader Trent Lott. And as SGR begins its final exit, a host of good and not-so-good elements in the repeal legislation come into play.

What’s good and what’s not so good about this deal? Well, everything, depending on your point of view. Here are the leading candidates (and my grade):

Repealing SGR – very good
Refinancing the Children’s Health Insurance Program (CHIP) for two years – very good (excellent if it were for four years)
Authorizing $7.2 billion for community health centers and the National Health Service Corps – wonderful!
Replacing SGR with a more sensible set of physician payment quality incentives (that follow the logic of the ACA, believe it or not) – very good
Not paying for the $141 billion 10-year cost of SGR repeal to the federal Treasury – not so good though worthy of forgiveness this time

So, wow. Does this augur a new era of bipartisan Congressional cooperation on health policy? Nope. Let’s look at each of these in turn. Continue reading “Reality and Unreality in the New Congressional Medicare (SGR) Deal”