Health care: Dems just don't have the votes

Now that the White House and Democrats are making a last push to pass their so-far-unpassable national health care bills, the only thing that matters is whether they can get 217 votes for victory in the House and 50 votes (plus the vice-president's tie-breaker) for reconciliation in the Senate. Good policy doesn't matter. Bad policy doesn't matter. All that matters is votes.

The White House and Democrats have lost sight of the essential insanity of the process -- desperately searching for corners to cut so they can pass an enormous re-ordering of the American economy that Americans don't want -- because all they can think about now is passing something. It could be anything, as long as it is "comprehensive."

So where are the votes? Start in the House. House Democrats have to do two things. First, they have to pass the health care bill that Senate Democrats passed on December 24 -- Cornhusker Kickback, Louisiana Purchase and all. They could stop there and send the bill to the president's desk, but that, of course, is not going to happen. So they then have to pass a set of agreed-upon "fixes" to the Senate bill that the Senate would then pass by using the reconciliation process. (The fixes will start in the House; reconciliation bills have to originate in the House because all revenue measures have to originate in the House.)

The original House health care bill passed last November by a 220 to 215 margin. But supporters have lost four votes since then. Democrat Rep. Robert Wexler has left the House, and Rep. Neil Abercrombie is expected to leave this week. Rep. John Murtha died, and Republican Rep. Joseph Cao, the only GOP lawmaker to vote for the bill, now says he will vote against the measure. That leaves Democrats with 216 votes, one short of the 217 it will take to pass. (That number is one less than the usual 218 because of the vacancies in the House.)

In addition, it's thought that some number of Democrats who voted for the original bill will likely vote against the Senate version because it lacks the House bill's language on the subject of abortion (the president's proposed compromise doesn't help on that subject, either). Republicans estimate there may be 11 such Democrats. If there are, that takes the number down to 205, which means Speaker Nancy Pelosi will need to find a dozen "yes" votes to make up the difference. It is widely thought that she had some possible yes votes in reserve last November, to be used if they were absolutely essential to passage. Are there 12? No one knows.

And that doesn't begin to consider the Democrats who voted in favor of the House bill last November but have now finally been persuaded, by continued public opposition in the polls, the Senate election in Massachusetts, and the generally worsening political climate for Democrats, that another vote in favor of the wildly unpopular health bill would be suicidal. Can Pelosi really be willing to bet that she can get everyone who originally voted yes on the bill to vote yes again? And for the Democrats who originally voted against the bill -- does anyone believe that any are going to change their minds to vote yes?

Remember, no matter what you hear, the House will have to vote yes on the original Senate bill, outrages and all. Democratic leaders will try to arrange things so that that vote will somehow be obscured, and the emphasis will be on the "fixes" reconciliation bill, but for health care to become law, the House will have to approve the Senate bill. Do you think the Democrats' Republican opponents might mention that in the coming campaign? Of course they will. Which means Democrats will be explaining and explaining and explaining that they fixed the outrageous problems in the bill at the same time they passed it. Would you want to make that case every day on the stump?

The bottom line: Pelosi is probably many votes short of being able to pass the Senate bill, along with the still-unwritten fixes. In public Democrats are trying to create a sense of inevitability about the bill -- they've tried to do that at various times during the year-long process -- but there is absolutely nothing inevitable about the passage of their national health care plan.

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Obama plan may pass in pieces

Antitrust measure could win bipartisan support in House

Top House Democrats on Tuesday left open the prospect of President Obama's comprehensive health care overhaul failing and passing pieces of it, a process already being used to try to repeal health insurance industry antitrust protections. The antitrust measure, which was not in the reform framework Mr. Obama released Monday, could pass the House Wednesday with bipartisan support, which would mark the first time Republicans and Democrats have been able to agree in the health debate. It would come a day ahead of Mr. Obama's health summit.

House Majority Leader Steny H. Hoyer said Democrats support Mr. Obama's outline, but if a complete overhaul bill can't get through Congress, there are good pieces that should become law. "We may not be able to do it all," he said. "I hope we can do it all in a comprehensive piece of legislation that would provide affordable, accessible, quality health care to all Americans. But having said that, if we can't, then you know me - if you can't do a whole, doing part is also good."

House Speaker Nancy Pelosi stressed the importance of repealing the antitrust protections and that Democrats can simultaneously pass a small bill alongside work on the comprehensive bill. "We will be taking up comprehensive health insurance reform shortly but we wanted to make sure that in paving the way for that legislation we paved the way for fairness, for competition, for better care, better quality, better affordability for the American people," she said.

The antitrust bill repeals the 1945 McCarran-Ferguson Act that exempted the insurance industry from federal antitrust rules. "For too may decades the health insurance companies have enjoyed monopoly protections that are enjoyed really by no other industry, with the exception of Major League Baseball," said Rep. Tom Perriello, the Virginia Democrat who introduced the bill. "The result of this has been a lack of competition and a lack of accountability that has helped send prices up for consumers and working families across the country."

It's unclear what impact the repeal would have. Democrats say it would increase competition and stop bid rigging and price fixing. Insurance companies oppose it because they say it would lead to regulatory confusion and that state law already prevents anticompetitive practices. The Congressional Budget Office, Congress' nonpartisan budgetkeeper, found that the repeal would have "no significant effects" on the federal budget or private insurance premiums.

Insurers say McCarran-Ferguson never allowed them to engage in price-fixing or bid-rigging. "Health insurance is one of the most regulated industries in America at both the federal and state levels," said Karen Ignagni, president and chief executive officer of America's Health Insurance Plans (AHIP), an industry trade group. "The Act is extremely limited in scope and has nothing to do with competition within the health insurance industry." AHIP says that insurers are subject to federal antitrust laws in addition to other state and federal regulations.

The repeal has support in the Senate as well. Nineteen Democrats signed on to a letter to Mr. Obama, Ms. Pelosi and Mr. Reid asking them to include the repeal in their final health bill.

White House spokesman Robert Gibbs said Tuesday that the antitrust bill would be done in addition to a comprehensive bill, not instead of. "This will ultimately complement health care reform in ensuring the changes that you make in the market - that the ability to look into potential anti-competitive practices, that that's not, quite frankly, illegal to do," he said. "This is not in lieu of something to make broader changes in the insurance market. This is a complementary step along the way."

Democrats on Capitol Hill say they are cautiously supportive of Mr. Obama's health reform outline, which closely follows what the Senate passed in December but includes a number of repairs designed to please the House.

The plan was written with reconciliation in mind, White House officials said. That's the complicated procedural tool Democrats could use to pass the bill with only 51 votes, circumventing a Republican filibuster. Senate Majority Leader Harry Reid said Democrats have not decided to pursue that route but chastised Republicans, who on Tuesday labeled the proposed use of reconciliation a rare procedural "trick."

"I've been told that my Republican friends are lamenting reconciliation, but I would recommend for them to go back and look at history," Mr. Reid said. "Since 1981, reconciliation has been used 21 times. The vast majority of those reconciliation efforts have been by Republicans ... realistically, they should stop crying about reconciliation as if it's never been done before."

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With reform dead, health care debate becomes pure politics

Question: When should you start suspecting President Obama isn't serious about a health care proposal? Answer: When he doesn't have the pharmaceutical industry on his side.

The biggest changes Obama has proposed to the Senate bill -- such as price controls on insurers and higher taxes on drug companies -- don't look like moves to get Republican votes or help the bill glide thought the filibuster-proof budget reconciliation process. It looks like Obama is simply trying to push his heretofore allies (drug makers) and uneasy partners (health insurers) fully onto the other side of the fence with the Republicans, thus painting a helpful political picture for 2010.

The White House spent 2009 publicly decrying the "special interests" supposedly undermining their "reform" of the health care market. But the White House also spent 2009 privately cutting deals with drug companies -- deals that fueled public skepticism about the bill and left the president's liberal base feeling jilted.

Even the insurers made out well in last year's negotiations, successfully killing the public option, inserting insurance mandates on both individuals and employers, and securing massive subsidies for the purchase of health insurance. Former Democratic National Committee Chairman Howard Dean was exaggerating, but not all that much, when he called the Senate bill "a bigger bailout for the insurance industry than AIG."

Still, Obama portrayed his "reform" effort as a struggle against "those who profit from the status quo." For the most part, the White House never named these dastardly profiteers, possibly because industry was mostly on the president's side.

So while he spent 2009 battling imaginary foes over a real bill, Obama now might be battling real foes over an imaginary bill. Without reading minds, we can't know for sure if Obama believes he can still pass a health care bill, or if he truly sees the rough outline he issued Monday as the path toward making a bill become a law.

But there's plenty of reason to believe his current proposal is simply a political wedge: An effort to actually drive the insurers and drug makers into fierce opposition, thus helping Democrats frame the 2010 elections as "reformers" vs. "fat-cat industries." In other words, it looks to me like the president has decided to engage the same game he has accused -- not always unfairly -- Republicans of playing: Drawing political battle lines rather than trying to reform anything.

Look at the Web page the White House debuted for this week's proposal and summit. As of Tuesday morning, the page dedicated more words to attacking insurers than to laying out policies, highlighting blog posts with these headlines: "Nobody is Immune from Insurance Company Abuses," "Premiums, Profits, and the Need for Health Reform," "Putting Health Care in the Hands of Consumers -- Not Insurance Companies," "The Insurers and the Ultimate Irony."

Insurers aren't the only bad guys Obama's proposal would drive into the nay camp (that is, the GOP camp). The bill would also slap a Medicare tax on "unearned income" such as investments and rent, thus drawing more blood from wealthy investors and landlords.

We saw the first glimpses of the Democrats' 2010 strategy at Obama's rally for Massachusetts Senate candidate Martha Coakley. "Whose side are you going to be on?" Obama asked, the side of the "special interests" or of working Americans.

The "whose side are you on" motif is a favorite of Democrats going back to Adlai Stevenson. But it's an awkward one to ask about Obama's first year, in which he sided with big energy companies in backing the House climate change bill, with the largest cigarette company in signing a tobacco bill, with the insurers in signing an expansion of subsidies for children's health insurance, with the Chamber of Commerce in signing the largest spending bill in history (and Big Coal in including the largest earmark in history), with Wall Street in ramping up the bailouts of the financial industry, and of course with drug companies in backing the Senate's subsidy-packed health care bill.

This renewed push for health care reform gives Obama an opportunity to set a different stage. Proposing federal price controls on insurance premiums is bad policy, but good politics. Bad policy proposals are fine and can get plenty of Democratic votes if the package is really just filibuster bait. If Obama can't pass a reform, at least he can force the Republicans to stand with insurers, drug makers, landlords, and wealthy investors in killing a bill described as "reform."

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Medicare is Cheating Seniors Out of Care, Says New Study

Chronically low Medicare reimbursement rates to physicians and hospitals are forcing doctors to limit the number of Medicare patients they see - or opt out of the program altogether - with devastating results to seniors' health care options, says a new study, "Medicare Doctor Shortage Endangers Seniors' Access to Care," by Matt Patterson of the National Center for Public Policy Research.

From the Southwest to Florida, from the Midwest to New York, primary care doctors and specialists at both hospitals and private practices are turning away Medicare patients because they cannot afford to treat them, the study concludes.

The report analyzes government data, health care provider statistics, and news reports from across the country to paint a frightening picture of a government program failing the most vulnerable members of our society: our seniors. Among the findings:

* Some Mayo Clinic facilities are no longer accepting Medicare patients for primary care, turning thousands of seniors away from their trusted physicians.

* 30 percent of Medicare patients seeking a new primary care doctor reported difficulty finding one, including 17 percent who claim they had "big" problems finding a new doctor.

* Only 73 percent of Medicare participating family doctors are accepting new Medicare patients.

* Only 38 percent of Texas primary care physicians say they will accept new Medicare patients in the face of low Medicare reimbursements.

* More than half of California hospitals reported operating at a loss, due in part to low Medicare reimbursements.

* Hospitals in Iowa report trouble recruiting new doctors thanks to low Medicare reimbursements, and warn that the trend may be a threat to the quality of future care.

Says Patterson, "At a time when President Barack Obama is proposing yet another $1 trillion health care plan, Medicare - the original government health insurance program - is going bankrupt, underfunding doctors, and cheating seniors out of care. Why don't we worry about meeting our existing health care obligations before we take on additional burdens?"

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Specialist British nurses ‘ too stretched to care for all who need it’

Nurses who provide specialist services for the long-term sick are overstretched and unable to deliver care to all who need it, health unions and charities say today. The Royal College of Nursing (RCN) and other bodies said that the NHS could save millions of pounds by investing in nurses to support people with conditions such as Parkinson’s disease, multiple sclerosis and epilepsy. But despite recent pledges by the Government to provide cancer patients with dedicated care, other specialist posts were vulnerable to cuts as the health service faces several years of financial restrain, the RCN said.

The union surveyed almost 300 specialist nurses working in 60 NHS organisations and charities and found that only 36 per cent believed that all those patients who needed specialist nursing received it. Of the 49 per cent who identified problems accessing specialist care, 69 per cent said it was because specialist nurse services were oversubscribed and could not take on new patients. More than a third said that they had seen cuts in services over the past 12 months, while 57 per cent are concerned that jobs will be threatened in the near future.

Specialist nurses work in areas including cancer care, diabetes and asthma, helping to keep people out of hospital by offering advice on medication and day-to-day living. The RCN estimates that £56 million a year could be saved on care for people with Parkinson’s through greater use of specialist nurses. A further £180 million could be saved by treating multiple sclerosis at home rather than in hospital, while £84 million could be shaved off the community health budgets if specialist nurses, rather than GPs, supported people with epilepsy.

Dr Peter Carter, general secretary of the RCN, told The Times that despite pledges from ministers to help to support more people in their homes and prevent unnecessary hospital visits, nursing posts were vulnerable when local health managers sought to cut costs. “Nurses realise that whoever wins the next election will be looking to make savings and to deliver more for less. The pressure on services with the economic downturn is going to go on for several years and things are likely to get worse before they get better,” he said. “Anecdotally, at the moment there is talk of local managers ‘reviewing skill mix’, which is just a euphemism for cutting staff.”

When the NHS was last in deficit in 2006, up to 23,000 nursing posts were lost, frozen or downgraded, in many cases depriving patients of specialist advice and care, Dr Carter said. “While the temptation may be to cut or downgrade specialist nursing roles, this would be a false economy which would only add to the growing cost of treating long-term conditions,” he added. About 17 million people in Britain are living with a chronic condition.

The RCN is calling for specialist posts to be supported by guaranteed funding, underwritten by the NHS, to ensure that short term cutbacks do not jeopardise posts in the long-term. Charities supporting the RCN’s policy recommendations include the Parkinson’s Disease Society, Macmillan Cancer Support, the Terrence Higgins Trust and the MS Society.

Norman Lamb, the Liberal Democrats’ health spokesman, commented yesterday: “Cuts are already taking place in marked contrast to the Prime Minister’s commitment for cancer patients to get personal support at home from specialist nurses. “Instead of chasing headlines, the Government needs to show how it intends to improve care.”

Meg Macarthur, senior policy officer at Breakthrough Breast Cancer, another of the charities supporting the call, said: “The threat to breast care and other specialist nurses is potentially devastating to patients. “We know that these nurses play a significant role in their care and recovery, offering an invaluable service throughout their treatment journey.”

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Australia: Private emergency room opens as an alternative to long waits at government hospitals

Patients who pay $195 can jump the queues at hospital emergency departments when the nation's largest health fund opens its first standalone clinic today. Medibank is guaranteeing patients with minor injuries and illnesses will be treated within one hour at its first Rapid Care Clinic in Brisbane. The fund is confident it will have a Sydney facility operating in June.

The clinics, staffed by specialist emergency doctors, will deal with urgent but non-life-threatening medical conditions such as broken bones, sprain, cuts and minor burns, viruses, headaches, earaches and sore eyes.

Twenty thousand patients a month wait more than the clinically-recommended one hour to be treated in the clogged emergency departments in public hospitals.

Single mother Kylie Endycott, who spent five hours at Sydney's Royal Prince Alfred Hospital yesterday after her one-year-old son Beau had difficulty breathing, said the clinics were a great idea but thought fees could be altered for different family situations.

Almost 170,000 people using a public hospital emergency department leave in frustration every year because of their wait for treatment. Medibank hopes to fill this gap. "Anybody who experienced attending a busy hospital emergency room with a minor injury or sick child, tried to get an appointment with their GP at short notice or out-of hours, will understand the Rapid Care Clinic," Medibank managing director George Savvides said.

The clinics will be open 365 days a year from 8am to 9pm to anyone, although Medibank members pay just $150 for a consultation and face no charge for X-rays, plaster or stitches. The clinics will refer conditions such as chest pain, severe breathing difficulty, acute stomach pain, severe burns, loss of consciousness, head and neck injuries or pregnancy-related conditions to the nearest hospital.

Emergency medicine specialist Dr Peter Herron - who runs the Brisbane clinic, which has been open for a week and a half - has treated seven people including several fractures, a bee sting, a laceration and an earache.

Australian Medical Association president Dr Andrew Pesce said the clinics would help those who could afford them but was disappointed that underfunding of the public hospital system had made them necessary. He is concerned they will lead to further fragmentation of patient care. Those who use these clinics can't claim for their treatment from their health fund or Medicare and must pay the full cost out of their own pocket. The Health Services arm of the fund has run similar clinics for corporate clients for years.

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