Medical Device Daily Washington Editor

WASHINGTON – The second day of this year's National Health Policy Conference, hosted by Academy Health (Washington) and the healthcare policy journal Health Affairs, included the usual discussions about how to reform healthcare, but the chairman of the Senate Finance Committee made it clear that a single-payer system is simply not in the cards.

In a speech at the onset of the second day, Sen. Max Baucus (D-Montana), chairman of the Senate Finance Committee, said "I believe this Congress has a duty to reform healthcare," and that "I'm here to tell you that our day has arrived," thanks to the fact that the White House and both houses of Congress are held by the Democratic Party.

Baucus gave no indication that he was aware of the impending announcement that former Sen. Tom Daschle would withdraw from consideration for the Secretary of Health and Human Services post a short while later (Medical Device Daily, Feb. 4, 2009), delivering his address with nary a sign of distress.

He also ruled out a single-payer system. "Most believe we should build on our current system ... and not undermine our employer-based system," Baucus remarked, adding that "as much as we all want a better system overnight ... change will not be possible overnight."

Baucus said, "I sense a genuine interest in working together on the part of key Republicans in the Senate," but other priorities abound "at a time of severe economic crisis." So while the lessons of the healthcare reform efforts of 1993 suggest a need to move quickly, "complex problems require time to understand."

Baucus attempted to sound the tone of a deficit hawk, but hedged the bet immediately. "I believe we will never address the federal deficit in this country" without healthcare reform, he said, but he warned that savings will not happen "in every budget window." He also argued that some items "must be addressed before we move to healthcare reform," including the Children's Health Insurance Program [CHIP], "which I expect to go to the President any day now. That's a big down payment" on healthcare reform, he said.

A member of the audience asked Baucus why he does not favor a single-payer system. "I think at this time, the single-payer is not going to get even to first base in Congress," Baucus remarked.

"It takes time to turn those big ships," Baucus commented, comparing the U.S. healthcare economy to an ocean liner as opposed to the nimble patrol torpedo boats of World War II fame. He also noted that the U.S. "is more of an entrepreneurial country" than most European nations, so "we have to come up with a uniquely American result."

Single-payer coverage "may come later, but it's not going to happen in America, in my view," he said.

Rep. Pete Stark (D-California), chairman of the House Ways and Means health subcommittee, was unable to make the session due to illness, and appearing in his stead was Rep. Xavier Becerra (D-California).

"When you think of healthcare reform, I hope you think in terms of a betting line," he said, noting that most discussions seem to zero in on the impressive technological capability in U.S. healthcare. However, Becerra suggested that the bar be set on different supports. He said he would prefer to aim for universal coverage and cost containment.

"Winning is relative. I'd rather have a better healthcare system than more of a healthcare system," he said, adding that resources are plentiful, but not well administered.

Becerra asserted that payment reform could save hundreds of billions of dollars in Medicare that could go to expanding coverage. "I want those $800 billion in Medicare savings," and "I want President Obama to get us out of Iraq. That's another $700 billion," he said. However, he expressed more optimism than Baucus about a single-payer option.

"I'm one of those who believe that single-payer has life" in Congress, Becerra said, but he suggested that the idea has more traction in the House of Representatives. "The Senate is often where things get stuck" where healthcare reform is concerned.

Despite his call for a single-payer system, Becerra echoed Baucus's comment that any approach to universal coverage in the U.S. would have to be uniquely fitted to the U.S. "I don't think you're going to find us replicating any existing model," he said. He also suggested that many who exhibit little interest in single-payer care would sing a different tune were it politically feasible to make such comments, given their constituencies.

The aggregate effect of all the constituent pressures cannot be ignored, either. "We have to take into account the idiosyncrasies of 535 people in Congress" Becerra said.

Interoperability not ready for spending

Healthcare information technology(HIT) is a necessary but insufficient ingredient in healthcare cost savings, but remarks by Congressional staffers at the meeting made clear that Congress has conceded that interoperability standards for HIT will not be in place in time for the billions in HIT spending embodied in the economic stimulus legislation, even though much of that money does not hit until 2011.

The issue came up in a meeting of a working group of the Senate Health, Education, Labor and Pensions (HELP) Committee last month, with Sen. Barbara Mikulski (D- Maryland) asserting that "we don't want another techno boondoggle" in reference to an earlier failure to ensure interoperability standards in previous federal HIT spending (Medical Device Daily, Jan. 16, 2009). All the same, Mikulski refused to answer questions after the hearing and her staffers declined to respond to the question directly.

Wendell Primus, legislative assistant to House Speaker Nancy Pelosi (D-California), addressed the overlap in HIT provisions in the economic stimulus bills in the House and Senate. "The provisions are quite similar," he said, but he added that "the real key to HIT is what the administration does in implementing those provisions."

Daniel Elling, a staffer for Republican members of the House Ways and Means Committee, said the stimulus bills' HIT money "doesn't start flowing until 2011, which calls into question the immediacy of its impact on the economy." He posed the question of whether the money will go to doctors and hospitals before standards are established.

Elling said that the Department of Health and Human Services indicated that it will not happen, and a GOP move to require this was turned back. Elling also stated that physicians could get as much as $65,000 each for HIT without having to show a need for the entire sum. "They could keep that extra $45,000 and go buy a car with it," he said.

Ryan Long, a staffer with the House Energy and Commerce Committee's GOP members, said, "what we're concerned about is that if we start throwing money out from Washington before standards" are published, it will be money down the drain.

Cybele Bjorklund, a staffer for the majority party in the House Ways and Means health subcommittee, said the House stimulus bill puts money into HIT for Medicare and Medicaid "to advance adoption" and as "a down payment toward health reform." So "while it's true that the bulk of the money doesn't start flowing until 2011," the move is necessary to make healthcare reform work.

Bjorklund continued to argue the stimulus bill as a healthcare reform bill. She said HIT is part of a series of reforms because of which "we're going to achieve savings of about $12 billion" in both public and private markets. "This is a worthwhile investment, but something that takes a few years to set up," she said.

CE institute debate flares up

Regarding the comparative effectiveness (CE) coordinating council provided for in the bill, Elling said, "a lot of people didn't like the way HMOs told doctors how they could treat patients. This government entity is a super-HMO," a situation he argued would upset voters because coverage would be restricted.

Bjorklund retorted that Democrats "are deeply committed to establishing a long-term, robust comparative effectiveness research program," but made the case that the bill "is really constrained to those stimulative requirements" that go to the Agency for Healthcare Research and Quality and the National Institutes of Health.

The coordinating council is "is a get-your-federal-house-in-order kind of council," she said, without explaining the meaning of the phrase. "There is absolutely nothing in here ... that deals with coverage," she said.

Elling's response was that the language in the House report regarding the board says "this research will be used to determine coverage." Bjorklund responded that the report language does not parallel the language in the bill and that the language in the report "is not as relevant as the legislative language."

"The firestorm [raised by] that one misbegotten sentence ... should be fair warning" about "a well-funded effort by the opposition to drag us into the gutter," Bjorklund said to applause from the audience.