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Reform Insider

Too Bad They Can’t Vote

A substantial and growing cadre of prominent Republicans have come out in favor of health reform recently. A partial list: former majority leaders Bob Dole, Howard Baker and Bill Frist (who this week disputed critics who claimed that Obama was promoting socialized medicine), California Governor Schwarzenegger, former HHS Secretary Tommy Thompson, and former CMS chief Mark McClellan.  Not exactly a fringe element.

Yet there’s been no sign that these endorsements will move Republicans in Congress.  Maybe it’s something in the water in Washington, or maybe it’s just an indication of the extent of ideological or simply partisan polarization that so few sitting Republicans are willing to join party elder-statesmen in moving reform forward.  Right now, the calculus in the Republican caucus seems firmly set on continuing its near-unanimous opposition to reform – and carrying it into the 2010 elections and beyond (just in case you thought this issue was going away after passage.)

The Ladies from Maine Part I: Snowe Fall

Sen. Olympia Snowe’s aye vote on the Finance Committee reform bill ended intense speculation over which way the senior Senator from Maine would go.  To many, her vote suggests that she agrees with assessments that a yes vote in Finance gives her more leverage over the process going forward than continuing to dangle the carrot of her possible future support would.  Snowe is now positioned to limit the movement of the bill to the left as it’s combined with the more liberal HELP bill, to be a key decision-maker on floor amendments, and perhaps even to have a formal role in conference committee.

In the eyes of the beholder

What is it that Sen. Snowe wants as the process moves forward?  One priority is preventing the inclusion of a public option except as a fallback.  A second Snowe priority is affordability.  At the same time, she has opposed most of the options on the table advanced to make better subsidies available.

A contradiction?  Not necessarily.  Affordability in Sen. Snowe’s eyes seems to be more about slimming down the coverage people would receive rather than making subsidies better—an idea that is getting some support in Democratic quarters, as well, even though the Finance bill already offers much less generous coverage than other proposals, particularly for low-wage workers. Common Sense Affordability Protections, a paper released today by Community Catalyst and PICO, highlights the problems for low-income people in the Finance proposal and makes recommendations for how to fix them.

The Ladies from Maine Part 2: As Snowe goes so goes Collins?

Late last week, Sen. Susan Collins (R-ME) indicated her openness to supporting reform.  This is welcome news in some quarters because of the challenge of getting 60 votes even with support from Sen. Snowe.  On the other hand, Collins’ statement triggers some alarm bells.

The concern she voiced over potential cuts to Medicare benefits (and misrepresenting what is in the bill) should be read as coded opposition to eliminating current overpayments to Medicare Advantage plans and other efforts to reduce Medicare spending  — measures that form an important part of the financing of the Senate bill.

This wouldn’t be such a problem if the Senate weren’t already having such a difficult time agreeing on revenue options.

But attacks on the current financing mix continue, especially from medical device manufacturers concerned about new fees they would have to pay, and from unions and progressives unhappy with the proposed tax on insurers who offer high-cost plans.  This tax is almost certain to be passed on to enrollees and would fall disproportionately on states with high health care costs and firms with older workers.  Senate negotiators are working to modify both of these revenue sources but the struggle will be not to lose revenue in the process.

Say It Ain’t So, Joe

While Snowe signaled her support for reform and Collins indicated she is considering support, Sen. Lieberman (I-CT) chose this moment to reiterate that he is not on board with health reform.  Remember: President Obama arguably helped save Senator Lieberman’s political career, defending him against angry Democrats in the Senate after Lieberman endorsed John McCain for President last year.

This week, while many Democrats were carrying the fight to the insurance industry and looking to revoke the industry’s current anti-trust exemption, Lieberman distinguished himself by being the only Senator who caucuses with the Democrats to publicly embrace the conclusions of theflawed AHIP report – a move made all the more notable by the safe distance Republicans kept from the report.

The Big Smoosh

For the most part, the debate in the Senate Finance Committee resulted in improvements to the original bill proposed by Finance Chair Max Baucus.  Now, as Baucus, Chris Dodd and Majority Leader Reid work to wrap up efforts to combine the Finance and HELP bills (possibly as soon as Tuesday), there is hope for additional improvements.   But keeping Snowe on board, trying to bring along Collins and nailing down support from Lieberman and other conservative Democratic holdouts is creating a powerful counter-pressure that is likely to limit gains.

Once a bill goes to the floor, the central task will be to hold onto the financing and to hold the line against “wedge issue” amendments like further restrictions on coverage for immigrants, as Republicans try to force Democrats to take what they feel will be unpopular votes to create a record for the 2010 election.

Medicare physician fee fix: Where There’s a Will There’s a Way

The fate of the “Sustainable Growth Rate” – the provision in the Medicare law that requires Medicare physician payment rates to be cut every year if spending exceeds a certain target (as it always does) – has been a key issue in reform.  This week, a fix for that provision is likely to be separated from the larger health reform bill and brought to the Senate floor without a requirement to offset its $250 billion price tag with new revenue or budget cuts.

From where we sit, this is both good news and bad news.  The good news is that doing the physician payment fix without a “pay-for” leaves more revenue available for health reform and helps keep the cost of reform under the $900 billion set by President Obama.  The bad news is what the fix says about the relative importance to lawmakers of improving physician payments over providing health insurance for millions of un- and under-insured people which, unlike the doc fix, must be budget neutral.