CALL TO ACTION

HEALTH REFORM 2009
SENATE FINANCE COMMITTEE CHAIRMAN MAX BAUCUS DMONT.
November 12, 2008
U.S. Senator Max Baucus (D-Mont.)
Chairman, Senate Finance Committee
CALL TO ACTION HEALTH REFORM 2009
w w w . f i n a n c c . s c n a t c . g o v - T c l : 2 0 2 - 2 2 4 - 4 5 1 5

REFORMING AMERICA’S HEALTH CARE SYSTEM:
A CALL TO ACTION


It is the duty of the next Congress to reform America’s health care system. In 2009,
Congress must take up and act on meaningful health reform legislation that achieves
coverage for every American while also addressing the underlying problems in our health
system. The urgency of this task has become undeniable.

In preparing to act, I led the U.S. Senate Finance Committee in holding nine hearings on
health care reform this year and hosted a day-long health summit in June 2008 to explore
in greater depth the problems plaguing our health system. I have spent a good deal of time
talking to colleagues on both sides of the aisle and to stakeholders in the health care
industry to get their perspectives on the issues that matter. And perhaps most importantly,
in listening sessions across the state of Montana, I have heard from many Americans about
the challenges so many patients and families face in getting access to affordable health
coverage and paying medical bills.

This paper — this Call to Action — represents the next step. It is not intended to be a
legislative proposal. Nor is it an exhaustive exploration of every health care issue that
should or needs to be addressed, or that will be considered. Rather, it details my vision for
health care reform. The plan outlined here addresses health care coverage, quality, and
cost. Many components would require an initial investment but, over time, would vastly
improve the quality of the health care that Americans receive and reduce the cost of that
health care, ultimately putting our system on a more sustainable path. The policies in this
paper are designed so that after ten years the U.S. would spend no more on health care than
is currently projected, but we would spend those resources more efficiently and would
provide better-quality coverage to all Americans.

The health system is so complex that any solution will demand time and attention to make
sure that we get it right. This plan is most certainly a work in progress. But this Call to
Action is intended to encourage constructive input by policymakers, stakeholders, and
health policy thought leaders to move us forward. I look forward to discussing this plan
with President-Elect Obama, with my colleagues in Congress, and with stakeholders in the
health care system, working collaboratively with all to enact effective health reform.

Americans who care deeply about the future of our health system and our economy must
take up the fight together for comprehensive health care reform. My door is open and I
seek partners with “can do” spirits and open minds. I believe — very strongly — that
every American has a right to high-quality health care through affordable, portable,
meaningful health coverage. And I believe that Americans cannot wait any longer.




Max Baucus
Chairman
U.S. Senate Committee on Finance


2
TABLE OF CONTENTS

EXECUTIVE SUMMARY......................................................................... iii


CHAPTER I THE CASE FOR REFORM.......................................... 1

ACCESS!MILLIONS OF AMERICANS LACK COVERAGE............................................... 1

COST! GROWTH IN HEALTH CARE SPENDING IS UNSUSTAINABLE FOR
FAMILIES, BUSINESSES, AND THE FEDERAL GOVERNMENT......................................... 3

QUALITY! POOR RETURN ON OUR HUGE INVESTMENT.............................................. 6

WHAT AMERICANS WANT FROM THEIR HEALTH CARE SYSTEM................................ 7

BAUCUS PRINCIPLES: THE VISION FOR OUR HEALTH CARE SYSTEM......................... 8


CHAPTER II BAUCUS PLAN: INCREASING ACCESS TO
AFFORDABLE HEALTH COVERAGE ................. 13

A. INDIVIDUAL RESPONSIBILITY.............................................................................. 15

B. STRENGTHENING THE EMPLOYER-BASED SYSTEM.............................................. 16

C. GUARANTEED ACCESS TO AFFORDABLE COVERAGE FOR INDIVIDUALS
AND SMALL BUSINESSES..................................................................................... 17

D. STRENGTHENING PUBLIC PROGRAMS.................................................................. 21

E. FOCUSING ON PREVENTION AND WELLNESS ....................................................... 28

F. ADDRESSING HEALTH DISPARITIES..................................................................... 30


CHAPTER III BAUCUS PLAN: IMPROVING VALUE BY
REFORMING THE HEALTH CARE
DELIVERY SYSTEM................................................. 36

A. STRENGTHENING THE ROLE OF PRIMARY CARE AND CHRONIC
CARE MANAGEMENT .......................................................................................... 37

B. REFOCUSING PAYMENT INCENTIVES TOWARD QUALITY .................................... 41

i
C. PROMOTING COLLABORATION AND ACCOUNTABILITY....................................... 48

D. HEALTH CARE INFRASTRUCTURE........................................................................ 55


CHAPTER IV BAUCUS PLAN: FINANCING A MORE
EFFICIENT HEALTH CARE SYSTEM.................. 65

A. FRAUD, WASTE, AND ABUSE............................................................................... 66

B. INCREASED TRANSPARENCY ............................................................................... 69

C. MEDICAL MALPRACTICE REFORM...................................................................... 74

D. PRIVATE INSURANCE PLANS IN MEDICARE ......................................................... 76

E. LONG-TERM CARE SERVICES AND SUPPORTS ..................................................... 78

F. TAX INCENTIVES FOR HEALTH COVERAGE ......................................................... 80


CONCLUSION ........................................................................................... 87
ii
EXECUTIVE SUMMARY

The link between health care costs and the economy is undeniable. Reforming the health
care system is essential to restoring America’s overall economy and the financial security
of our working families.

The case for reform is strong. The U.S. is the only developed country that does not
guarantee health coverage for all its citizens, with 46 million uninsured and another 25
million underinsured. As a result, families are struggling to keep up with out-of-pocket
costs for medical care. American businesses are straining to absorb rising health care costs
while staying competitive at home and around the world. Despite high levels of spending
on health care, research documents poor quality of care received by patients in the U.S.
Studies show, for example, that adults receive recommended care for many illnesses only
55 percent of the time. Children fare even worse.

Americans are acutely aware of problems in the country’s health care system, and they are
ready for change. They are not alone. The nation’s health care stakeholders — consumers,
businesses, labor, providers, plans, manufacturers, and state and local governments — are
signaling that they are ready and willing to engage in serious and comprehensive reform of
a health system in crisis. They recognize that the status quo of high costs, unacceptable
numbers of the uninsured and underinsured Americans, and far less than optimal quality
and value is unsustainable and intolerable. And, notably, the nation’s economists concur
that system reform is not only necessary to rationalize our health care system, but to
sustain our economy, our ability to compete internationally and, over the long haul, to deal
with our long-term fiscal challenges.

A high-performing health care system would guarantee all Americans affordable, quality
coverage no matter their age, health status, or medical history. Today, the costs of care for
the uninsured are largely borne by those with insurance; providers charge higher prices to
patients with private coverage to make up for uncompensated care, and these costs are
passed on to consumers in the form of increased premiums. Requiring all Americans to
have health insurance will help end the shifting of costs from the uninsured to the insured.

Covering all Americans would also ensure that the insurance market functions effectively.
Insurance works because policyholders pay into their plans when healthy, and have their
medical bills paid when they are sick. If a significant portion of Americans does not
purchase coverage until sick, then premiums for all enrollees will increase to cover insurer
outlays, and the problem of unaffordable coverage will persist. Finally, covering all
Americans is essential to effective prevention and wellness efforts and managing chronic
illnesses. Efforts to guard against and better manage illness are an effective tool to
improve health and contain costs but, without every American in the system, those efforts
will fall short of their full potential.

In a high-performing health care system, employers, individuals, health providers and
plans, as well as government would all bear responsibility and contribute to fulfilling the
goal of covering all Americans. Wellness and prevention would be prioritized. And
iii
increased quality would result in lower costs so that employers could afford to continue to
offer health coverage and still compete in a global marketplace. Our public health
programs would be on a more fiscally sustainable path. Ensuring that every American has
coverage would make health care truly portable, so that Americans are no longer locked
into a job based on a need to retain their health coverage. This Call to Action outlines a
vision for creating that high-performing health care system.

Like a sturdy stool, the Call to Action has three equally important legs: (1) a policy that
ensures meaningful coverage and care to all Americans; (2) an insistence that any such
expansion be coupled with an emphasis on higher quality, greater value, and — over time
— less costly care; and (3) an absolute commitment to weed out waste, eliminate
overpayments, and design a sustainable financing system that works for taxpayers as well
as for the nation’s recipients and providers of health care.

Ensuring Health Coverage for All Americans. The Baucus plan would ensure that
every individual can access affordable coverage by creating a nationwide insurance pool
called the Health Insurance Exchange. Those who already have health coverage could
keep what they have. But for those who need affordable, guaranteed coverage, the
Exchange would be a marketplace where Americans could easily compare and purchase
the plans of their choice. Private insurers offering coverage through the Exchange would
be precluded from discrimination based on pre-existing conditions. Premium subsidies
would be available to qualifying families and small businesses. By making health care
more affordable and universally available to all Americans, the Baucus plan would take a
major step toward eliminating racial and ethnic health disparities.

While the Exchange is being created, the Baucus plan would make health care coverage
immediately available to Americans aged 55 to 64 through a Medicare buy-in, and it would
begin to phase-out the current two-year waiting period for Medicare coverage for
individuals with disabilities. The plan would provide every American living below the
poverty level with access to Medicaid. This policy is consistent with the original intent of
Medicaid, and it is the quickest and most cost-effective way to cover every American
living in poverty. The Baucus plan would also ensure that all states use the State
Children’s Health Insurance Program (CHIP) to cover children at or below 250 percent of
the Federal poverty level, putting help within reach for more needy children. Finally,
recognizing that America cannot keep its promise to provide care to Native Americans and
Alaska Natives with the current level of Indian Health Service (IHS) funding, the Baucus
plan calls for additional funding for IHS.

Once affordable, high-quality, and meaningful health insurance options are available to all
Americans through their employers or through the Exchange, individuals would have a
responsibility to have health coverage. This step is necessary for insurance market reforms
to function properly and to end the cost shifting that occurs within the system. It is
expected that the vast majority of American employers would continue to provide coverage
as a competitive benefit to attract employees. Except for small firms, employers that
choose otherwise must contribute to a fund that would help cover those who remain
uninsured.
iv

The Baucus plan would immediately refocus our health care system toward prevention and
wellness, rather than on illness and treatment. Those who are uninsured ! and therefore
less likely to receive preventive care and treatment for major conditions ! would be given
a “RightChoices” card that guarantees access to recommended preventive care, including
services like a health risk assessment, physical exam, immunizations, and age and gender-
appropriate cancer screenings recommended by the U.S. Preventive Services Task Force.
Individuals without private coverage and not eligible or enrolled in a public health
coverage program, but whose RightChoices screening detected and diagnosed one or more
of the most common, costly chronic conditions, would qualify to receive treatment on a
temporary basis until viable coverage options are available under the Health Insurance
Exchange. Current Medicare, Medicaid, and CHIP beneficiaries would receive
recommended preventive services with little or no co-payment. Preventive services would
be covered by all insurance options offered through the Health Insurance Exchange.

Improving Health Care Quality and Value. Recognizing that any attempt to cover the
uninsured and reduce health care spending must address the perverse incentives fostered by
current payment systems, the Baucus plan includes delivery system reforms that would
improve quality and, over time, lower costs. The plan strengthens the role of primary care
and chronic care management. Primary care is the keystone of a high-performing health
care system. Increasing the supply and availability of primary care practitioners by
improving the value placed on their work is a necessary step toward meaningful reform.

The plan would refocus payment incentives toward quality and value. Today’s payment
systems reward providers for delivering more care rather than better care. A redefined
health system would realign payment incentives toward improving the quality of care
delivered to patients. Fixing the unstable and unsustainable Medicare physician payment
formula is a necessary step in this process. The plan would promote accountability and
coordination among providers by encouraging providers in different settings — physician
offices, inpatient hospitals, post-acute care settings, and others — to collaborate and
provide patient-centered care in a way that would improve quality and save money.

To facilitate the proposed delivery system reforms, the Baucus plan would improve the
health care infrastructure by investing in new comparative effectiveness research and
health information technology (IT). Health IT is needed for quality reporting and
improvement and to give providers ready access to better evidence and other clinical
decision-support tools. Reinvesting in the training of a twenty-first century health care
workforce is necessary for many delivery system reform goals to be realized.

Achieving Greater Efficiency and Sustainable Financing. The U.S. spends $2.3 trillion
per year on health care, and economists warn that rising health care costs represent a
serious threat to our long-term fiscal security. According to the Congressional Budget
Office, up to one-third of that spending — more than $700 billion — does not improve
Americans’ health outcomes. Excess spending must be eliminated and dollars put to better
use, not only to correct the imbalances of the current health care system, but to offset the
high costs of much-needed comprehensive reform.
v

Beyond measures to refocus the system on primary care, reward quality care, and invest in
critical research and technology, the Baucus plan would endorse direct steps in five
additional areas to curb excess health care spending. The plan would invest more to detect
and eliminate fraud, waste, and abuse in public programs. The plan would address
overpayments to private insurers in the Medicare Advantage program. The plan would
increase transparency of cost and quality information and would require disclosure of
payments and incentives to providers by drug or device makers that may lead to biased
decision-making. The plan also considers careful reforms of medical malpractice laws that
could lower administrative costs and health spending throughout the system, while
ensuring that injured patients are compensated fairly for their losses.

Long-term care services and supports are both a significant share of national health
expenditures and a driver of cost. Considering policies to shift the focus from institutional
care to services provided in the home and community could improve the quality of care
delivered and reduce costs. Finally, the plan would explore targeted reforms of the tax
code to make incentives more efficient, distribute benefits more fairly, and promote
smarter spending of health care dollars by consumers themselves.

Conclusion. I believe it is the duty of the next Congress to reform America’s health care
system. In 2009, Congress must take up and act on meaningful health reform legislation
that achieves coverage for all Americans while also addressing the underlying problems in
our health system. The urgency of this task has become undeniable.

In the short term, health care reform would cost taxpayers more than the government can
achieve in savings from all reforms and financing changes. Congressional leaders and the
public must be realistic about the timeframe in which the fiscal success of reform is
measured. If we fail to act, however, we will double our current national expenditure on
health care from $2 trillion to $4 trillion, continue to witness the plight of tens of millions
of our citizens without health insurance cost shifting to those who do, continue to tolerate
poor quality that leads to nearly 100,000 deaths a year, and watch our businesses become
less competitive and our nation go further into debt. In short, we all must realize that the
costs of inaction, both in human and financial terms, will eventually be far greater than any
initial outlays. We must choose to invest now in a health care system that will richly repay
the nation with greater health and economic stability in the long term.

vi
CHAPTER I THE CASE FOR REFORM

At a day-long health reform summit hosted by the Senate Finance Committee this year,
Federal Reserve Chairman Ben Bernanke said, “Improving the performance of our health-
care system is without a doubt one of the most important challenges that our nation
faces.”
1
With a world financial crisis demanding a significant investment of government
resources, some have asked whether the time is right for a large — and likely expensive —
effort at comprehensive health care reform in the United States. But the link between
health care costs and the economy is incontrovertible. Health care reform is not a
distraction from addressing our economic challenges; health care reform is an essential part
of restoring America’s overall economy and the finances of our working families.

Health care concerns are closely tied to economic anxiety. Sixty-two percent of voters in the
2008 elections agree that it is more important than ever to take on health care reform in light
of the economic downturn.
2
This moment in history is not unlike that faced by President
Franklin D. Roosevelt and the New Deal generation as they sought a path out of the Great
Depression. Now, as then, solving America’s economic challenges will require a
multifaceted response. Reforming the nation’s health care system will be an essential part of
shoring up the nation’s long-term economic strength.

The key challenges facing our health care system are lack of access to care, the cost of
care, and the need for better-quality care. Each of these challenges has a direct effect on
family budgets, on U.S. businesses, on government spending, and on the country’s ability
to compete globally. A better understanding of each of these key issues demonstrates the
need for immediate action by the next Congress.

ACCESS!MILLIONS OF AMERICANS LACK COVERAGE

3
The U.S. is the only developed country without health coverage for all of its citizens. An
estimated 45.7 million Americans, or 15.3 percent of the population, lacked health insurance
in 2007 — up from 38.4 million in 2000.
4
Those without health coverage generally
experience poorer health and worse health outcomes than those who are insured. Twenty-
three percent forgo necessary care every year due to cost. And a number of studies show that
the uninsured are less likely to receive preventive care or even care for traumatic injuries,
heart attacks, and chronic diseases.
5, , , 6 7 8
The Urban Institute reports that 22,000 uninsured
adults die prematurely each year as a direct result of lacking access to care.
9

A majority of the uninsured has low or moderate incomes (see Figure 1.1). About two-
thirds have family incomes less than twice the Federal poverty level (FPL).
10,11
Only one
in ten have incomes higher than four times the Federal poverty level.

12
Eight in ten of the uninsured come from working families. But these workers are either
not offered coverage by their employer and cannot access it through a family member, or
they do not qualify for employer-offered coverage. For example, they might not be eligible
because they work part-time.

1
Figure 1.1. Uninsured by Federal Poverty Level
100-199% FPL
29%
200-299% FPL
17%
300-399% FPL
8%
400%+FPL
10%
<100% FPL
37%

Source: KCMU/Urban Institute analysis of March 2008 CPS.



In addition to the uninsured,
another 25 million Americans are
“underinsured,” without enough
coverage to keep their medical
bills manageable. According to a
recent study by The
Commonwealth Fund,
REAL PEOPLE, REAL REASONS FOR REFORM:
13
In 2006, Lisa Kelly was diagnosed with acute leukemia.
She had insurance!an AARP Medical Advantage plan,
underwritten by UnitedHealth Group Inc. with a monthly
premium of $185. Unfortunately, the policy had a $37,000
annual limit. And due to the flimsy coverage provided by
her policy, the hospital, M.D. Anderson Cancer Center,
79 million Americans are unable
to pay their medical bills
requested an up-front cash payment of $105,000 before it
would start providing chemotherapy treatment. 14
— and
of those, more than 47 million
were insured when the expenses
were incurred.
Ms. Kelly enrolled in a high-risk insurance plan
administered by Blue Cross Blue Shield of Texas in
February 2007, with a monthly premium of $633. Since her 15
Despite their
insurance coverage, medical debt
keeps these Americans from
feeding their families, paying their
rent, or heating their homes.
Medical debt contributes to half of
all filed bankruptcies, and affects
approximately two million people
a year.
cancer was a pre-existing condition, she had to wait one
year for the new plan to cover her treatment. Although
Blue Cross started paying her new hospital bills earlier this
year, Ms. Kelly is still personally responsible for more than
$145,000 in bills incurred before February 2008, and she
is paying $2,000 each month for those bills. In June, she
learned that after being in remission for more than a year,
her leukemia has returned.
16


2
COST! GROWTH IN HEALTH CARE SPENDING IS UNSUSTAINABLE FOR FAMILIES,
BUSINESSES, AND THE FEDERAL GOVERNMENT

American families are struggling to keep up with out-of-pocket costs for health care.
American businesses are straining to absorb rising health care costs while staying
competitive at home and around the world. Federal and state budgets — as well as
taxpayers — are bearing an ever-increasing burden as entitlement programs such as
Medicare and Medicaid consume a larger share of public expenditures.

Failure to address problems in the health care system could undermine current efforts to
restore the economy. Ultimately, Congress cannot help American families’ finances or
address America’s economic woes in a lasting, meaningful way without health care reform.

Even before the current economic crisis, working families and individuals found their
health care in jeopardy as the cost of employer-sponsored coverage rose beyond the means
of businesses — particularly small businesses — and workers alike. As Figure 1.2 shows,
health insurance premiums have increased faster than wages and inflation for most years
between 1988 and 2007. Premiums have increased 117 percent for families and
individuals and 119 percent for employers between 1999 and 2008.

Figure 1.2. Illustrations of Health Insurance Premium Increases
$1,543
$3,354
$4,247
$9,325
1999 2008
Employer Contribution
Worker Contribution
12%
18%
14%
9%
1%
5%
8%
11%
6%
8%
9%
11%
14%
13%
1
9
8
8
1
9
8
9
1
9
9
0
1
9
9
3
1
9
9
6
1
9
9
9
2
0
0
0
2
0
0
1
2
0
0
2
2
0
0
3
2
0
0
4
2
0
0
5
2
0
0
6
2
0
0
7
Health Insurance Premiums
Overall Inflation
Workers' Earnings
Increases in Health Insurance Premiums
Compared to Other Indicators, 1988-2007
Average Health Insurance Premiums and
Worker Contributions for Family Coverage,
1999–2008
$5,791
$12,680
119%
increase
117%
increase

Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2008; KPMG Survey of Employer-
Sponsored Health Benefits, 1993, 1996; The Health Insurance Association of America (HIAA), 1988, 1989, 1990;
Bureau of Labor Statistics, Consumer Price Index, U.S. City Average of Annual Inflation, 1988-2007; Bureau of Labor
Statistics, Seasonally Adjusted Data from the Current Employment Statistics Survey, 1988-2007.

Why are premiums rising so fast? A recent synthesis of studies found that greater use of
medical technology is a driving force — contributing between 38 and 65 percent to health
care cost increases.
17
Other factors, including obesity, demographics, and productivity,
also contribute to growth in the cost of health care.
3

Additionally, hospitals and clinics provide an estimated $56 billion in uncompensated care
every year to people without health insurance,
18
and those who have health coverage pay
the bill through higher health care costs and increased premiums. A study of this “hidden
tax” estimated that ten percent of California health care premiums are attributable to cost
shifting due to the uninsured.
19

Even if workers can afford their portion of a premium, employers may not be able to afford
the rest. Because employers are the principal source of health insurance in the U.S.,
providing health benefits for more than 158 million people,
20
erosion in employer-
sponsored coverage is a serious problem.

Small business owners have
increasingly been forced to decide
among several painful options to offset
increasing health care costs — raising
health insurance premiums, limiting
raises or reducing bonus pay,
eliminating family health benefits, or
providing less-than-comprehensive
health coverage.
REAL PEOPLE, REAL REASONS FOR REFORM:
Phoenix Products, Inc., an Ohio firm, has operated for
31 years, growing from a youthful start-up company
into an established business with 47 employees. As
recently as 2003, Phoenix Products could afford to
provide a comprehensive health plan at a reasonable
cost. But as its employees grew older and health costs
increased, the company had to dramatically alter the
health plan benefit structure to keep providing any
coverage at all. The company moved away from
comprehensive benefits to a limited catastrophic

coverage plan. Even then, premiums increased ten
The story of Phoenix Products (left),
relayed to the Senate Finance Committee
at a June 2008 hearing,
percent each year from 2003 to 2007.
Renewing coverage in 2008 cost the company 35 21
is far too
common in the U.S. In 2000, 68 percent
of small to mid-size businesses (3-199
workers) offered health benefits, but
today that figure is 62 percent.
percent more than in 2007; the maximum increase
allowed under Ohio law. Quotes from other plans were
2½ times higher than the current rate. The company is
on the verge of losing its ability to offer insurance.
22

As rising health care costs threaten the stability and competitiveness of American
businesses, they threaten to destabilize the fiscal health of the country itself. Peter Orszag,
Director of the Congressional Budget Office, has appropriately noted that rising health care
costs represent the “single most important factor influencing the Federal Government’s
long-term fiscal balance.”
23
The U.S. spends more than 16 percent of our gross domestic
product (GDP) on health care — a much greater share than other industrialized nations
with high-quality systems and coverage for everyone. By 2017, health care expenditures
are expected to consume nearly 20 percent of the GDP (see Figure 1.3), or $4.3 trillion
annually.
24
Spending for Medicare and Medicaid, due to many of the same factors found
in the private sector, is projected to increase by 114 percent in ten years.
25
Over the same
period, the GDP will grow by just 64 percent.

4
Figure 1.3. Health Care Spending Poses Long Term
Challenges for U.S. Economy and Federal Budget
16.3%
20.5%
37.0%
43.0%
2007 2007 2050 2050
Health Care Spending
as % of GDP
Medicare & Medicaid
as % of Total Federal Budget

Sources: Keehan, “Health Spending Projections Through 2017”; CBO,
The Long Term Budget Outlook (Dec. 2007)

States face fiscal challenges ALSO. On average, states already spend 22 percent of their
budgets on Medicaid.
26
One effect of rising unemployment rates will be increased
eligibility for and enrollment in Medicaid. Many state governments are struggling to meet
balanced budget requirements.
27
In response, at least 29 states have already taken action to
reduce their budget deficits for fiscal year 2009.
28
States face limited choices in trying to
meet budget shortfalls; they can raise taxes or cut spending on Medicaid and other vital
services.

Finally, in the 21
st
century, when the economies of the world are ever more interconnected,
the strength of our health care system is increasingly important. Our international
competitiveness depends on the health of our workforce. Although polls show that many
Americans believe the U.S. health care system is better than other industrialized nations,
29

the numbers do not demonstrate this to be true.

As mentioned, the U.S. spends a greater percent of GDP and almost twice as much per
person on health care compared to other major industrialized countries (see Figure 1.4).
30

In a study of global health care systems, journalist and author T.R. Reid found startling
cost differences with the U.S. In Japan’s largely private system, the cost for magnetic
resonance imaging (MRI) is less than $100, compared to $1,200 in the U.S. In
Switzerland, home to profitable insurance companies and influential pharmaceutical
companies, administrative costs represent 5.5 percent of total costs, compared to about 22
percent for coverage purchased in the private insurance market in the U.S.
31
While there
must be a uniquely American answer to the question of containing health care costs, other
countries demonstrate the possibility of success.
5
Figure 1.4. Total Health Expenditures Per Capita,
U.S. and Selected Countries, 2006
$2,824
$6,714
$2,760
$4,311
$3,202
$4,250
$3,391
$4,303
$2,474
$2,614
$3,082
$3,371
$3,449
$2,668
$3,349
$3,678
$3,488
$3,606
$2,999
OECD Average
United States
U.K.
Switzerland
Sweden
Norway
Netherlands
Luxembourg
Japan
Italy
Ireland
Germany
France
Finland
Denmark
Canada
Belgium
Austria
Australia
Amounts in U.S.D. Source: Organisation for Economic Co-operation and Development, OECD Health
Data 2008, updated August 26, 2008. http://www.oecd.org/health/healthdata.


QUALITY! POOR RETURN ON OUR HUGE INVESTMENT

Despite high levels of spending on health care, the U.S. ranks last out of 19 industrialized
countries in unnecessary deaths.
32
America ranks 29
th
out of 37 countries for infant
mortality — tied with Slovakia and Poland, and below Cuba and Hungary.
33
The United
States has almost double the infant mortality rate of France or Germany.
34
A recent study
by the Institute of Medicine concluded that the current health care system is not making
progress toward improving quality or containing costs for patients or providers.
35


Research documenting poor quality of care received by patients in the U.S. is shocking. A
2003 RAND Corporation study found that adults received recommended care for many
illnesses only 55 percent of the time. Needed care for diabetes was delivered only 45
percent of the time and for pneumonia only 39 percent of the time. Patients with breast
cancer fared better, but still did not receive recommended care one-quarter of the time.

6
The same researchers at RAND found that children received recommended care only 47
percent of the time.
36
Recommended preventive services were provided just 41 percent of
the time, and children with chronic illnesses received about 53 percent of needed services.

Even more disturbing is the finding that all patients are at risk for poor quality care —
gender, age, race, income, and insurance status do not provide any advantage. Although
many patients do receive excellent care, many more receive uncoordinated, fragmented
care, are unable to access care when needed, or obtain care through hospital emergency
departments after their condition has worsened due to lack of timely intervention. Beyond
the known medical risks that low-quality care poses for individual Americans, the lack of
quality across our health care system contributes to the problem of rising costs.

In short, Americans are not getting their money’s worth when patients receive services of
little or no value
37,38
— such as hospitalizations that could have been prevented with
appropriate outpatient treatment, duplicate tests, or ineffective tests and treatments. Yet
the current system does little to steer providers toward the right choices. Even though
more care does not necessarily mean better care, Medicare and most other insurers
continue to pay for more visits, tests, imaging services, and procedures, regardless of
whether the treatment is effective or necessary, and pay even more when treatment results
in subsequent injury or illness.
39
Providers are not consistently encouraged to coordinate
patients’ care or to supply preventive and primary care services, even though such actions
can improve quality of care and reduce costs. Rewarding providers that furnish better
quality care, coordinate care, and use resources more judiciously could reduce costs and,
most importantly, better meet the health care needs of millions more American patients.
40

WHAT AMERICANS WANT FROM THEIR HEALTH CARE SYSTEM

Americans are acutely aware of problems in the country’s health care system, and ready
for change. Polling repeatedly demonstrates that Americans want and deserve better
access to care, better quality care, and better value from their health care system. More
than 70 percent of Americans rate our health care system as “fair” or “poor.”
41
When
asked whether our health system needs a complete overhaul, major repairs, or minor
tinkering, 90 percent of Americans respond that the system should be “completely rebuilt”
or that “fundamental changes” are needed.
42

At the same time, those who currently have health coverage do not want to lose those
benefits. Many people are satisfied with their personal providers or their current coverage
and do not want to jeopardize those connections to the system.

The majority of Americans also believes that coverage should be provided for the
uninsured, calling the issue of the uninsured a very serious problem.
43
Americans also
want relief from rapidly rising premiums and medical debt. Sixty-five percent of those
polled admit that it is “somewhat” or “very difficult” for them to afford health care and
health insurance.
44
Three out of four say that, over the past five years, the amount of
money that they have paid out of pocket for their own health care has increased.
45


7
Despite widespread agreement on the need for reform, the task remains difficult because
Americans do not necessarily agree on how to achieve it (see Figure 1.5). Although a
majority of respondents would support a mandate on employers to provide coverage, a
“Medicare-for-all” single-payer option, or a mandate that all individuals purchase
coverage, opposition to each of these options is also somewhat substantial. Moreover,
some of this support erodes when respondents are asked whether they would be willing to
have more government responsibility or higher taxes — though half of all surveyed in
2007 said they would support reform even under these circumstances.
46

Figure 1.5. Lack of Consensus on Reform Options
44%
51%
53%
62%
45%
39%
36%
31%
Tax Breaks to
Make Insurance
More Affordable
Individual
Mandate
Medicare-for-All
Employer
Mandate
Support Oppose

Source: Los Angeles Times/Bloomberg poll, Oct 19-22, 2007

Policymakers need to sift through the options and combine the best of American’s desires
for a new health care system to ensure health coverage for every American, increase the
quality of care for all, and reduce costs to make our system sustainable for the future.

BAUCUS PRINCIPLES: THE VISION FOR OUR HEALTH CARE SYSTEM

While there may be differences of opinion on the solutions, most Americans agree on the
principles that health reform should embrace. These principles form the foundation of this
Call to Action.

There is widespread agreement that every American should have health coverage. This
does not mean that a government program should provide the coverage. Such a system
may not be viable in a country that values individuality, choice, and a preference for
market-based solutions. A mix of public and private solutions must be found to keep our
system from leaving millions of Americans behind.

There is also agreement that our health care system must do a better job of containing
costs. Any serious health reform proposal must include policies that will slow the rate of
growth in health spending over time. The sustainability of the nation’s public programs,
America’s businesses — and the economy — depend on it. Along with efforts to rein in
8
health spending, the quality of care must improve, and payment systems should better align
incentives to foster a focus on providing better care rather than more care. Our system
must also encourage wellness and the prevention of disease through early detection,
modification of risk factors, and encouragement of healthy lifestyle choices. When illness
cannot be prevented, the focus should be on care coordination.

Another critical principle in health reform is the recognition that health care is a shared
responsibility. Employers, individuals, and government all have a role to play — and a
contribution to make — to the system. Employers should contribute toward health
insurance choices and financing. Individuals have the responsibility to get coverage, to
take better care of their own health, and to play a larger role in health care treatment
decisions. Providers should improve their performance to ensure consistent, high-quality
health care. Society, through state and Federal governments, should help those who lack
the means to buy insurance on their own and ensure that the insurance market is fair and
transparent.

With these principles in mind, it is possible to envision a high-performing health care
system in the future. Such a system would guarantee Americans the choice of a health
plan that they can afford. Employers, individuals, and government would all bear
responsibility and contribute toward fulfilling that goal. Wellness and prevention would be
encouraged. The costs of health care would be more manageable so that employers could
afford to offer coverage to their employees and still compete in a global marketplace. Our
public health programs would be on a more fiscally sustainable path than they are today.
Providing coverage to all Americans would make health care truly portable and allow
Americans to change jobs when they wanted, rather than remaining locked in by their need
for health coverage. This Call to Action represents a vision for creating that high-
performing health care system.

The system envisioned here guarantees access to affordable coverage for every American.
To ensure that affordable options are available to all, assistance must be provided to small
businesses, families, and individuals who currently struggle to find and afford health
coverage. This approach will allow every American to be enrolled in some form of health
care plan, either private or public. Those who like their current coverage arrangements
could keep what they have. Others, including the uninsured, would have options, and all
Americans would gain the ability to leave a job or start a new business without worrying
about prospects for future coverage. Providing coverage to all Americans would lower
costs by including the healthiest individuals in the risk pool to offset the costs of the
sickest individuals — and maintaining wellness rather than treating illness.

The system envisioned here would ensure that every individual could access affordable
coverage by creating a nationwide insurance pool, precluding discrimination by insurers
based on health status, and providing subsidies to low-income families. It also aims to
lower costs by improving the quality of the care that all Americans receive, promoting
better value for our dollar, and reforming the delivery system.

9
The passage and implementation of comprehensive health care reform will not happen
overnight. The health system is so complex that any solution will demand time and
attention to make sure that we get it right. But Americans without health insurance — as
well as those in need of better coverage or in danger of losing their coverage — need the
process to start now.


1
Ben S. Bernanke, “Challenges for Health-Care Reform” (Testimony before the Senate Committee on
Finance Health Care Summit, U.S. Senate, June 16, 2008).
http://finance.senate.gov/healthsummit2008/Statements/Chairman%20Bernanke’s%20Remarks.pdf.
2
Henry J. Kaiser Family Foundation, “Kaiser Health Care Tracking Poll: Election 2008,” The Kaiser Family
Foundation, http://www.kff.org/kaiserpolls/upload/7832.pdf.
3
“Coverage for all”, in this context, means that every citizen in the country has health care coverage. It does
not necessarily mean that this coverage is financed by government spending. While many developed
countries finance health care primarily through government funds, others finance coverage through a mix of
public and private spending.
4
U.S. Census Bureau, “Income, Poverty, and Health Insurance Coverage in the United States: 2007,” U.S.
Census Bureau, http://www.census.gov/prod/2008pubs/p60-235.pdf.
5
John Z. Ayanian et al., “Unmet Health Needs of Uninsured Adults in the United States,” Journal of the
American Medical Association, 284, no.16 (2000): 2061-9.
6
Richard G. Roetzheim et al, “Effects of Health Insurance and Race on Colorectal Cancer Treatments and
Outcomes,” American Journal of Public Health 90, no.11 (2000): 1746-54.
7
Jack Hadley, “Insurance Coverage, Medical Care Use, and Short-term Health Changes Following an
Unintentional Injury or the Onset of a Chronic Condition,” Journal of the American Medical Association,
297, no.10 (2007): 1073-84.
8
John G. Canto et al., “Payer Status and the Utilization of Hospital Resources in Acute Myocardial
Infarction,” Archives of Internal Medicine, 160, no.6 (2000): 817-23.
9
Stan Dorn, “Uninsured and Dying Because Of It: Updating the Institute of Medicine Analysis on the Impact
of Uninsurance on Mortality,” The Urban Institute, (2008), http://www.urban.org/publications/411588.html.
10
Henry J. Kaiser Family Foundation, “Five Basic Facts on the Uninsured,” The Kaiser Family Foundation,
(2008), http://www.kaiserfamilyfoundation.org/uninsured/upload/7806.pdf.
11
In 2008, 100 percent of the Federal poverty level for a family of three is $17,600 and for a family of four it
is $21,000. Two hundred percent of the Federal poverty level for a family of three is $35,200 and $42,400
for a family of four.
12
Henry J. Kaiser Family Foundation, “Five Basic Facts on the Uninsured,” The Kaiser Family Foundation,
(2008), http://www.kaiserfamilyfoundation.org/uninsured/upload/7806.pdf.
13
Lisa Kelly, “47 Million & Counting: Why the Health Care Marketplace is Broken,” (Testimony before the
Senate Committee on Finance, U.S. Senate, June 10, 2008).
14
Karen Davis, “Health of the Private Health Insurance Market,” (Testimony before the House Committee
on Ways and Means, Subcommittee on Health, U.S. House of Representatives, September 23, 2008).
15
Karen Davis, “Shifting Health Care Financial Risk to Families Is Not a Sound Strategy: The Changes
Needed to Ensure Americans’ Health Security,” The Commonwealth Fund, (2008).
16
David Himmelstein et al., “Illness and Injury as Contributors to Bankruptcy,” Health Affairs no. 24 (2005):
5-70.
10

17
Sarah Goodell and Paul B. Ginsburg, “High and Rising Health Care Costs: Demystifying U.S. Health Care
Spending,” The Robert Wood Johnson Foundation, (2008),
http://www.rwjf.org/files/research/101508.policysynthesis.costdrivers.brief.pdf.
18
Jack Hadley, John Holahan, Teresa A. Coughlin, and Dawn Miller, “Covering the Uninsured In 2008:
Current Costs, Sources Of Payment, and Incremental Costs,” Health Affairs, 27, no. 5, (2008): 399-415.
19
Peter Harbage and Len Nichols, “A Premium Price: The Hidden Cost All Californians Pay in Our
Fragmented Health Care System,” The New America Foundation, (2006),
http://www.newamerica.net/files/HealthIBNo3.pdf.
20
Kaiser Family Foundation and Health Research and Educational Trust, “Employer Health Benefits Survey,
2008,” The Kaiser Family Foundation, http://ehbs.kff.org/pdf/7790.pdf.
21
Raymond Arth, “47 Million & Counting: Why the Health Care Marketplace is Broken” (Testimony before
the Senate Committee on Finance, U.S. Senate, June 10, 2008).
22
Kaiser Family Foundation and Health Research and Educational Trust, “Employer Health Benefits Survey,
2008,” The Kaiser Family Foundation, http://ehbs.kff.org/pdf/7790.pdf.
23
Peter Orszag, “The Overuse, Underuse, and Misuse of Health Care,” (Testimony before the Senate
Committee on Finance, U.S. Senate, July 17, 2008).
24
Sean Keehan, et.al., “Health Spending Projections Through 2017: The Baby-Boom Generation Is Coming
to Medicare,” Health Affairs 27, no.2 (2008): 145-155.
25
Peter Orszag, “The Budget and Economic Outlook: Fiscal Years 2008 to 2018,” (Testimony before the
Senate Budget Committee, U.S. Senate, January 24, 2008).
26
National Association of State Budget Officers, “The Fiscal Survey of States” National Association of State
Budget Officers, (2008),
http://www.nasbo.org/Publications/PDFs/Fiscal%20Survey%20of%20the%20States%20June%202008.pdf.
27
National Conference of State Legislators, “State Balanced Budget Requirements,” NCSL, (2003).
http://www.ncsl.org/programs/fiscal/balreqs.htm. All States, except Vermont, are constitutionally bound to
balance their budgets.
28
Iris J. Lav, Jason Levitis, and Edwin Park, “House Plan Effectively Targets Fiscal Relief to States,” The
Center on Budget and Policy Priorities, (2008), http://www.cbpp.org/9-26-08sfp.pdf: 2.
29
Harvard University School of Public Health/Harris Interactive. “Americans’ Views on the U.S. Health
Care System Compared to Other Countries,” Harvard University/Harris Interactive, (2008).
30
The Commonwealth Fund, “Why Not the Best? Results from the National Scorecard on the U.S. Health
System Performance” The Commonwealth Fund, (2008),
http://www.commonwealthfund.org/usr_doc/StateScorecard.pdf?section=4039.
31
PBS, Frontline, “Sick Around the World,” www.pbs.org/wbgh/pages/frontline/sickaroundtheworld.
32
Ellen Nolte and C. Martin McKee, “Measuring the Health of Nations: Updating an Earlier Analysis,”
Health Affairs, 27, no. 1, (2008): 58-71.
33
Marian F. MacDorman and T.J. Mathews, “Recent Trends in Infant Mortality in the United States,”
Centers for Disease Control and Prevention, (2008).
34
Organization for Economic Co-Operation and Economic Development. “OECD Health Data 2008,”
OECD, (2008).
35
Committee on Quality of Health Care in America, “Crossing the Quality Chasm: A new Health System for
the 21
st
Century,” Institute of Medicine, (2001).
36
Rita Mangione-Smith, et al., “The Quality of Ambulatory Care Delivered to Children in the United States,”
New England Journal of Medicine, no. 357 (October 11, 2007): 1515-23.
11

37
Elliot S. Fisher et al., “The Implications of Regional Variations in Medicare Spending, Part 1: The Content,
Quality, and Accessibility of Care,” Annals of Internal Medicine 138, no. 4 (2003): 283.
38
Ibid., 293.
39
Committee on Quality of Health Care in America, “Crossing the Quality Chasm: A new Health System for
the 21
st
Century,” Institute of Medicine, (2001): 1-335.
40
Donald Berwick et al., “The Triple Aim: Care, Health and Cost,” Health Affairs 27, no. 3 (2008): 768.
41
Robert J. Blendon, “Lessons for the Next Debate: Understanding the Public on the Health Care
Costs/Uninsured Issue,” Harvard School of Public Health, and Kennedy School of Government.
42
CBS/NYT Poll (Conducted February 23-27, 2007),
http://www.cbsnews.com/stories/2007/03/01/opinion/polls/main2528357.shtml.
43
NPR/Kaiser Family Foundation/Harvard School of Public Health, “The Public on Requiring Individuals to
Have Health Insurance,” NPR/Kaiser Family Foundation/Harvard School of Public Health, (2008),
http://www.npr.org/programs/morning/features/2008/feb/insurance/summary.pdf
44
Kaiser Family Foundation, The Washington Post/Harvard University, “Low-Wage Workers Survey” The
Kaiser Family Foundation, (2008), http://www.kff.org/kaiserpolls/upload/7804.pdf.
45
Ibid.
46
CBS/NYT Poll (Conducted February 23-27, 2007),
http://www.cbsnews.com/stories/2007/03/01/opinion/polls/main2528357.shtml.
12
CHAPTER II BAUCUS PLAN: INCREASING ACCESS TO
AFFORDABLE HEALTH COVERAGE

Achieving health coverage for every American has proven an elusive goal for decades,
dating back to the first attempt at national health reform in the early 1900s by the
Progressive Party.
1
That effort failed, as did the Wagner-Murray-Dingell bill and attempts
by President Truman in the 1940s, the plan proposed by President Nixon in the 1970s, and
the Health Security Act proposed by President Clinton in 1993. Each was unsuccessful for
its own unique reasons.

Over the years, the U.S. health system has become very complex, with deeply entrenched
interests. Significant changes will take time to approve and implement. But the series of
changes and reforms envisioned in this Call to Action can eventually remake the current
system to ensure every American has access to high-quality health care through affordable,
portable, and meaningful health insurance.

The Baucus plan incorporates six important elements as it moves towards covering all
Americans:

" Individual Responsibility. Covering all Americans means the enrollment of every
individual in some form of health care plan, private or public. But the principle of
individual responsibility can be applied only when affordable options are available
to all.

" Strengthening the Employer-Based System. We must ensure the continued
viability of the employer-based system — the principal source of health coverage
for most Americans — to allow workers to keep the insurance that they currently
have and value. Eliminating employer-based coverage, as some have proposed,
would upend health care for more than half the American people — 158 million in
all.
2
This plan envisions a role for employers to contribute to employees’ access to
health care.

" Guaranteed Access to Affordable Coverage for Individuals and Small
Business. Additional assistance must be available to families, individuals, and
small businesses who currently struggle to find and afford health insurance. A
mechanism must be established to allow health care consumers to find and obtain
health coverage that best meet their needs.

This mechanism — the Health Insurance Exchange — will connect individuals and
employers to insurance offered at local, state, regional, or national levels. Insurers
offering coverage through the Exchange would need to meet certain requirements
established by a new Independent Health Coverage Council.

Reforms enacted through the Exchange could improve access to health coverage
for all. In order to make insurance affordable, the existing insurance market must
be reformed. The lack of appropriate standards and regulation in certain markets
13
fails far too many Americans who need health care. Requirements of the Exchange
would be extended to improve fair price and quality competition in the insurance
market as a whole so that coverage would be more affordable and available to more
Americans.

Creation of the Exchange would take time, but more immediate steps could provide
relief to Americans most in need of health coverage and begin to improve the
health of the country overall.

" Strengthening Public Programs. Existing public programs represent an effective
and efficient way to increase access to coverage and decrease the number of
uninsured. Offering individuals approaching age 65 the chance to buy into
Medicare early and eliminating the requirement that disabled individuals wait two
years to enroll in Medicare would ensure coverage to populations that the private
market is under-serving. Improving Medicaid and the State Children’s Health
Insurance Program (CHIP) could provide coverage quickly to additional low-
income Americans while serving current beneficiaries better. Increased attention
and funding for the Indian Health Service (IHS) could improve care for Native
American and Alaska Native populations. We can strengthen public health care
programs promptly, though the impact on state and Federal budgets must also be
considered.

" Focusing on Prevention and Wellness. Increased access to preventive care and
wellness is another step that could be accomplished in the short term. Increasing
the availability and effectiveness of primary care coverage could create a national
focus on maintaining wellness, rather than treating illness — which would improve
quality and reduce costs across the health care system.

" Addressing Health Disparities. In our current health care system, racial and
ethnic minorities disproportionately lack ready access to high-quality medical care.
This gives rise to differences in both health status and health care among various
groups in our diverse population. Our system also prohibits certain legal
immigrants from getting health care for five years. Though medical advances
benefit much of the population, health disparities continue to worsen for others.
These disparities must be addressed and ultimately eliminated. Americans want and
deserve a system that provides equal access to health coverage and health care for
all — regardless of age, race, ethnicity, or income — and that is what this Call to
Action would give them.

These six elements combine to give every American a role and a responsibility in
reforming our health care system to ensure coverage for every individual. The remainder
of this chapter provides additional detail on these elements.

14
A. INDIVIDUAL RESPONSIBILITY

Once affordable, high-quality, and meaningful health insurance options are available to all
Americans, it will be each individual’s responsibility to have coverage. This step is
necessary to make the entire health care system function properly.

Today, the costs of care for 46 million Americans without health insurance are largely
borne by those with insurance; providers charge higher prices to patients with private
coverage to make up for uncompensated care, and these costs are passed along to
consumers in the form of increased premiums.
3
The cost of that uncompensated care is
also unnecessarily inflated because patients without insurance often wait to receive care
until they have to go to the emergency room. Requiring all Americans to have health
coverage will help end the shifting of costs of the uninsured to the insured.

Requiring all Americans to have health coverage would also ensure that the insurance
market functions effectively. Insurance works because policyholders pay into their plans
when healthy, and have their medical bills paid when they are sick. If a significant portion
of Americans does not purchase coverage until sick, then premiums for all enrollees will
increase to cover insurer outlays, and the problem of unaffordable coverage will persist.
Finally, covering all Americans is essential to effective prevention and wellness efforts and
managing chronic illnesses. Efforts to guard against and better manage illness are an
effective tool to contain costs, but without every American in the system, those efforts will
fall short of their full potential.

Implementation of a responsibility for all individuals to have coverage would be fair as
long as every consumer has a reasonable avenue to find and purchase affordable health
care coverage. The Exchange envisioned in this plan, described more fully below, would
be the primary path for those shut out of or underserved by today’s health care system.
The Exchange would provide standardized information and a single, standard, simple form
for enrollment in a plan of the consumer’s choice. Available to all, the Exchange would
also allow individuals to enroll in health care plans in various convenient locations,
including physicians’ offices, local hospitals or schools, Departments of Motor Vehicles,
and local Social Security Offices.

The responsibility for all Americans to obtain coverage would be enforced possibly
through the U.S. tax system or some other point of contact between individuals and the
government. Every individual would receive a certificate of coverage from their insurer to
demonstrate that they are meeting their responsibility.

Enforcement of a responsibility to have health care through the tax system has advantages.
The biggest advantage is that most Americans already have contact with the IRS through
the annual filing of a tax return. Monitoring health insurance coverage through the tax
code would take advantage of this existing relationship. One issue to be addressed,
however, is how to deal with individuals who do not file a tax return due to their low tax
liability. If a premium subsidy for health care was administered through the tax code, the
15
non-filer issue would be significantly decreased because a number of current non-filers
would voluntarily file in order to get the assistance.

The Commonwealth of Massachusetts has had success with this approach. In the first year
of Massachusetts’ individual insurance requirement, 98.6 percent of taxpayers required to
file insurance information with their tax returns complied.
4
In fact, the health care reform
effort in Massachusetts generally has been extremely popular even with the requirement
for individual coverage. At the end of 2007, the majority of working-age adults in
Massachusetts — 71 percent —supported the state’s health reform efforts.
5

B. STRENGTHENING THE EMPLOYER-BASED SYSTEM

American employers, large and small, are instrumental in providing meaningful insurance
coverage to million of workers and their families. Employer involvement in the purchase
of health insurance provides many distinct advantages. The average employer contributes
84 percent of premiums for individual coverage and 73 percent of premiums for family
coverage.
6
Health insurance also costs less when purchased through an employer rather
than in the individual market, because employers provide a natural mechanism for pooling
risk by covering healthy and less healthy workers.
7
And because employers pool coverage
for an entire group, economies of scale can reduce administrative costs. Employers may
also have greater negotiating power with insurance companies and more sophistication in
evaluating benefits.

Besides lower premiums, participants in employer-based coverage enjoy other advantages.
Current law prevents them from being disqualified for pre-existing conditions or charged
higher premiums based on their medical histories. Standards already in Federal law
govern certain aspects of their insurance, as well as provide opportunities to remain
covered after losing group coverage. Additionally, the ability to pay premiums through
payroll deduction provides an easy and convenient way to purchase coverage.

The Baucus plan proposes to extend and build on the tradition and success of employer-
sponsored insurance. In a recent Gallup poll, 67 percent of Americans said that they were
either completely or somewhat satisfied with the health insurance benefits that their
employer offered.
8


To strengthen the connection of insurance to the workplace, all except the smallest
employers would offer a Section 125 plan under the Baucus plan. Section 125 plans allow
employees to pay their health insurance premiums through their employer’s payroll
deduction and with pre-tax dollars. Premiums paid with pre-tax dollars are not subject to
Federal and state taxes. By offering Section 125 plans, employers would make it easier
and cheaper for their workers to purchase insurance.

Large employers — especially firms paying high wages — have the greatest capability to
provide coverage to their employees. The vast majority of American employers in this
category would probably continue to provide coverage as a competitive benefit to recruit
employees. If these employers choose not to provide coverage, under the Baucus plan they
16
would have to contribute to a fund that would help to cover those who remained uninsured.
The contribution would likely be based on a percentage of payroll that took into account
the size and annual revenues of each firm. Mid-sized and small employers would also
have the option of providing adequate coverage or paying into the general coverage fund,
but the required contribution would be less for them than that for larger firms.

Businesses with the fewest workers and the lowest wages would be offered a new tax
credit to purchase health insurance for their employees (described below), and would be
exempt from contributions to the general coverage fund if they were still unable to offer
insurance to employees.

Workers prefer the support of employers and the convenience that employer-sponsored
health coverage provides. Health care reform must enable employers large and small to
continue providing coverage to workers, and to share the responsibility of maintaining a
healthy, productive, globally competitive workforce.

C. GUARANTEED ACCESS TO AFFORDABLE COVERAGE FOR INDIVIDUALS AND
SMALL BUSINESSES

Individuals and small businesses seeking health insurance on their own frequently
encounter serious challenges in obtaining coverage. For small businesses, the primary
obstacle is the cost of offering coverage to employees. For individuals, cost is also the
most significant factor, but individuals with pre-existing conditions may be denied
coverage at any price.

The Baucus plan envisions that the Health Insurance Exchange would offer a new
opportunity for individuals and small businesses to easily compare private coverage
options and a public plan and to purchase the policy that would work best for them.
Eligible individuals and small businesses would receive subsidies to make sure that
coverage would be affordable. Insurance companies would be prohibited from denying
coverage due to pre-existing conditions and from discriminating against individuals solely
due to their health status.

Health Insurance Exchange. The Baucus plan would establish the Health Insurance
Exchange through which individuals and small businesses in the market for insurance
could obtain affordable health care coverage. The Exchange would be an independent
entity, the primary purpose of which would be to organize affordable health insurance
options, create understandable, comparable information about those options, and develop a
standard application for enrollment in a chosen plan.

Participating employers must enroll all employees through the Exchange — not only the
sickest and most costly to insure.

Insurance plans participating in the Exchange could operate nationally, regionally, state-
wide, or locally. So that plans could be easily compared, qualifying insurers would have to
offer products that could be classified as high-, medium- or low-benefit options. Benefit
17
packages could differ within reason, but all structures would have to be actuarially
equivalent within benefit categories in order to prevent insurers from using benefit design
to discourage enrollment by people with health conditions. Differences in premiums
between packages would be due to the difference in benefits and not the differences in
expected risk. Participating insurers would have to charge the same price for the same
products inside and outside the Exchange.

Plans participating in the Exchange would be subject to oversight by states with regard to
consumer protections (e.g., grievance procedures, external review, oversight of agent
practices and training, market conduct). In addition, participating private plans would be
subject to state regulation related to solvency, reserve requirements, and premium taxes.

The Exchange would have authority to implement mechanisms to ensure that plans
enrolling sicker-than-expected people would not suffer a financial disadvantage compared
to those enrolling healthier people. Offsetting some of the potential risk to insurance plans
is intended to limit plans’ incentives to enroll only the healthiest individuals.

All plans participating in the Exchange would be subject to the same rating rules included
in the insurance market reforms described later in this chapter.

The Exchange would also include a new public plan option, similar to Medicare. This
option would abide by the same rules as private insurance plans participating in the
Exchange (e.g., offer the same levels of benefits and set the premiums the same way).
Rates paid to health care providers by this option would be determined by balancing the
goals of increasing competition and ensuring access for patients to high-quality health care.
A number of options could be considered to determine who runs the plan, who is eligible
for it, and how to ensure that the public-private insurance competition lowers costs and
improves quality. The Independent Health Coverage Council, described below, would
inform these decisions.

Federal funds would be needed to start up the Exchange, but it would be self-sustaining
within a few years. One option for making it so is a small assessment on premiums to fund
activities of the Exchange, as done today by the authorizing board of the Commonwealth
Connector in Massachusetts. Insurers would include the assessment as part of their
premiums and could remit it on a monthly or quarterly basis. Keeping insurance premiums
in the Exchange affordable must be the guiding principle in setting any assessment.

Independent Health Coverage Council. Reforming the health care system to cover all
Americans through a mix of private and public means involves complex decisions that
must be responsive to rapid changes in the health system. Such a system would require
oversight, but Congress cannot make all necessary decisions to guide it. For that reason,
the Baucus plan authorizes a board of directors — called the Independent Health Coverage
Council — to inform decisions that would help to guarantee that affordable health
insurance options were available. The President would appoint members of the Council
with the advice and consent of the Senate for set, staggered terms. The President would
choose Council members who were geographically diverse and have expertise in
18
insurance, health benefit design, actuarial science, economics, medicine, business, and
consumer protections.

The new Independent Health Coverage Council would define key terms in a reformed
health system. For example, it would define what “coverage” and “affordability” mean. In
doing so, it would, among other activities, consult with the Institute of Medicine and
review existing state laws. The Council would ensure that coverage would be affordable,
clinically appropriate, provide access to necessary health services, and protect enrollees
against high health care expenses. Specifically, the Council would ensure appropriate,
income-related annual limits on out-of-pocket costs so that families were not at risk of
bankruptcy by their medical expenses. The Council would also play a major role in
ensuring that the public plan option meets its goals of delivering high-quality and cost-
effective care.

The Independent Health Coverage Council would also set standards for chronic care
management and quality reporting. Insurers in the Exchange would collect and report on
the performance of providers in their networks. The Council would make care
management and quality reporting requirements consistent with those used by Medicare to
the extent practicable. Consistent measures of quality would make performance rating
more robust and better able to help Americans make decisions about their own care.

Input by the Independent Health Coverage Council would keep the activities of the
Exchange on track and insulated from the political process. The Council and the Exchange
would both be subject to regular reviews and oversight by the Comptroller General,
however, so that Congress—and the public—can closely monitor their activities.

Insurance Market Reforms. Currently, insurance companies can discriminate against
older and sicker patients by charging significantly higher premiums or denying coverage
altogether. Individuals with pre-existing conditions such as cancer, heart disease, and
asthma are at particular risk of being denied coverage by insurance companies or being
offered a policy that is unaffordable. In fact, a recent Commonwealth Fund study found
that insurance companies turned down one out of every five people who applied for
individual coverage due to pre-existing conditions.
9


While states have the authority to restrict this type of discrimination, very few have used
that authority. Under the Baucus plan, insurance companies could not deny coverage to
any individual nor discriminate against individuals with pre-existing conditions. Rules for
rating insurance policies — which have to do with how an insurer can determine a
policyholder’s premium based on various criteria such as age, tobacco use, previous
illness, or factors that encourage healthy lifestyles — will be specified in statute after
consultation with the National Association of Insurance Commissioners, consumer
advocates, plans and others. The ability of insurance companies to rate on age would also
be limited. In order to avoid severe adverse selection — a scenario under which the sickest
patients gravitate toward one part of the insurance market — the rating rules for the
Exchange would apply in the Exchange as well as in private non-group and small group
markets.
19

Small Business Tax Credit. As health care coverage becomes more expensive, many
small businesses simply cannot bear the additional cost of providing health coverage for
their employees. And for this reason, the number of small businesses offering their
employees health care coverage is declining. To help small businesses, the Baucus plan
would provide a targeted tax credit that small firms could use towards the cost of
purchasing health care coverage.

There are a number of ways that such a tax credit could be structured. One option is to
make the tax credit available to any small business, for both individual and family
coverage. Initially, the credit would be available to qualifying small businesses that
operate in states with patient-friendly insurance rating rules. After the initial
implementation, the tax credit would be available to small businesses that purchase
coverage for all of their employees in the Health Insurance Exchange and make a
meaningful contribution towards the cost of the premium for their employees’ health
care.
10


In order to target the tax credit most efficiently, the credit would be based on a firm’s size
and earnings per employee. The smallest firms with the lowest average earnings will be
eligible to receive a credit equal to half of the average total premium cost for employer-
sponsored insurance in the firm’s state. This credit will be phased down as firm size and
average earnings increase. The employee and earnings phase-outs work together, until the
credit is fully phased-out.

Premium Subsidies. In order to make health coverage affordable for all Americans,
refundable tax credits would be available to individuals and families with incomes at or
below four times the Federal poverty level. These tax subsidies would be available to
individuals and families who purchased coverage through the Health Insurance Exchange.

The Independent Health Coverage Council would define what an “affordable” premium is,
taking into account the reasonable percent of income to be spent on health care coverage.
The premium subsidy would make up the difference between the amount suggested by the
Council and the premium amount charged by the plan. The amount of the subsidy could
be based on a benchmark that would be equal to a locally adjusted, average premium in the
Exchange. This construct would encourage individuals to be prudent purchasers of health
care policies.

D. STRENGTHENING PUBLIC PROGRAMS

Medicaid and the State Children’s Health Insurance Program (CHIP) represent
cornerstones of America’s health care system. These programs provide access to health
care for approximately 67 million low-income Americans. Both programs have an
important role to play in health care reform, so the Baucus plan envisions specific
improvements to Medicaid and CHIP that ensure these programs function effectively and
efficiently in a reformed health care system. The Baucus plan also would improve
Medicare by providing an option to buy into the program for individuals who are near but
20
not yet 65, and who lack other insurance. The plan also would allow disabled individuals
access to Medicare without a waiting period. Finally, the plan would increase funding for
the Indian Health Service.

Medicare Buy In. The Baucus plan would make health care coverage immediately
available to Americans aged 55 to 64 through a Medicare buy-in. People in this age group
face greater risk of illness than their younger counterparts. And while they may require
increased access to medical care, they continue to have fewer and fewer affordable
insurance options as retiree health care coverage erodes and pre-existing conditions make
private insurance prohibitively expensive or impossible to obtain altogether.
11

In 2007, over four million people aged 55 to 64 were uninsured, or about 12 percent of the
total population in that age group.
12
This figure represents an increase of one million since
2000. While this age group tends to be one of the least likely to be uninsured, those who
do not have employer-sponsored benefits or retiree coverage through a former employer,
have fewer options for coverage than other age groups.

The individual insurance market can provide a source of coverage for this population, but
health insurance offerings in that market are often unaffordable — or even unavailable to
those with pre-existing health conditions. The average annual premium for those aged 60
to 64 was more than $5,000 for single coverage and $9,200 for family coverage in the
individual market in 2006-2007.
13
By contrast, coverage for a person aged 18 to 24 was
$1,360 for single coverage in the individual market and $2,850 for family coverage.

Declining health status and lack of affordable health insurance affect not only the health
and wellbeing of Americans aged 55 to 64, but also their pocketbooks. Nearly 12 percent
of those aged 55 to 64 report annual medical expenditures of more than $10,000.
5

Uninsured individuals in this age group find it increasingly difficult to cover their medical
bills as declining health can affect their ability to work and earn income. Uninsured
Americans aged 55 to 64 are twice as likely as their insured counterparts to report having
to delay seeking medical care, including needed surgeries.
14


To fill this gap in coverage, the Baucus plan would allow individuals aged 55 to 64 to buy
Medicare coverage. The option would be available to any individual in this age group who
otherwise did not have access to health coverage through a public plan or a group health
plan. The benefits would be the same as those available to current Medicare beneficiaries.

This new Medicare buy-in option is temporary. It would be available until the Health
Insurance Exchange was established. Once that new infrastructure is in place, Americans
55 to 64 years old who had not obtained coverage through the Medicare buy-in would be
able to buy insurance in the new marketplace. Those already enrolled in the Medicare buy-
in would have the option to remain in Medicare.

Medicare would charge enrollees electing the buy-in option an annual premium. The
premium amount would be calculated so that the total costs for the buy-in population
21
would be budget neutral. Thus, this option would not create new costs for the Medicare
program or for taxpayers.

Providing immediate assistance to the Americans aged 55 to 64 would benefit not only
individuals in this age group, but the Medicare program overall. An option for those 55 to
64 to buy into Medicare could enable individuals to remain healthy and continue working,
prevent disabling conditions, and provide protection from catastrophic medical costs.
15
It
would also help to ensure that individuals would not experience a break in coverage during
this age period, which could lead to improved health status upon Medicare eligibility at age
65. The Medicare program might also benefit through reduced costs for this population
relative to what might have been spent if these individuals were uninsured in the decade
prior to becoming Medicare eligible.
16

Phase Out of Disability Waiting Period. In 1972, the Congress expanded Medicare
eligibility to include people with disabilities.
17
At that time, Congress created a “Medicare
waiting period,” which requires people with disabilities to receive Social Security
Disability Insurance (SSDI) for 24 months prior to becoming eligible for Medicare
coverage. As a result of the 24-month Medicare waiting period, an estimated 400,000
Americans with disabilities are uninsured and many more are underinsured.
18
Forcing
Americans with disabilities to wait two years for Medicare coverage results in these people
having inadequate health care, falling into poverty or, ultimately, in death.

The Baucus plan would begin to phase-out the current two-year waiting period for
Medicare coverage for people with disabilities. It is anticipated that people with
disabilities would also eventually be able to purchase coverage in a reformed health
insurance market.

Medicaid. Established in 1965, Medicaid is a program intended to serve low-income
Americans and those with serious health conditions or disabilities. The Federal
government and the states share responsibility for funding and administration of Medicaid.
Medicaid currently covers approximately 61 million Americans
19
and is the source of
health insurance for 14 percent of non-elderly Americans (age 64 and below).
20
A
modernized Medicaid program is an essential component of health reform.

Federal law establishes certain categories of beneficiaries to which states must offer
Medicaid benefits as a condition for Federal financial participation. The mandatory
beneficiary populations are:

! Children under age six who are in families below 133 percent of the poverty level;
! Children over age six in families below 100 percent of the poverty level;
! Pregnant women with incomes below 133 percent of the poverty level;
! Elderly and poor individuals who receive cash assistance from the Supplemental
Security Income (SSI) program;
! Families who meet financial requirements of the former Aid to Families with
Dependent Children (AFDC) cash assistance program.
21


22
States have discretion to cover populations beyond those that Federal law mandates. In
fact, all states provide Medicaid benefits to optional populations.
22
Medicaid enrollment in
2007 is displayed in Table 2.1 below.

Table 2.1. Medicaid Enrollment in 2007
Number enrolled Percent of
Population (in millions) total Medicaid
enrollment
Children 29.2 48.0
Adults 16.2 26.6
Blind/Disabled 9.5 15.6
Elderly 6.0 9.9
Total 60.9 100
23
Source: Center for Medicare and Medicaid Services (CMS).

Federal law does not require states to cover adults under Medicaid, unless they are
disabled, elderly, or pregnant — regardless of income. Many states cover adults as an
optional population, though coverage is very limited. Twenty-seven states have eligibility
levels for non-working adults with incomes below the poverty level and 26 states have
eligibility levels less than the poverty level for working adults. All states except Alaska
and Connecticut have eligibility levels for disabled optional populations of less than the
poverty level.
24
Thus in most states, Medicaid coverage is limited to very low-income
Americans.

Medicaid is a vital source of coverage for low-income Americans, but existing state
Medicaid programs have not reached everyone living below the poverty level. The Baucus
plan aims to solve that problem by extending Medicaid eligibility to every American living
in poverty. Reducing the number of uninsured by increasing Medicaid enrollment has
been embraced by a diverse coalition, including the Commonwealth Fund
25
and the
insurance industry.
26
Making this change would provide at least 7.1 million low-income
people with access to health coverage.
27


Providing Medicaid to everyone below the poverty level is both consistent with the
original intent of Medicaid, and the easiest and quickest way to provide insurance to those
living in poverty. Building on the existing Medicaid program is also efficient. Moreover,
those at the bottom of the income scale are least likely to be able to purchase coverage on
their own, least likely to have employer-sponsored coverage, and if such coverage is
offered, least likely to be able to afford it.

Establishing a national eligibility minimum of 100 percent of the Federal poverty level
would help to streamline Medicaid. States currently have dozens of eligibility categories,
many with different poverty levels.
28
Determining eligibility under the Baucus plan would
be much easier than in the categorical eligibility system currently in place. This would
result in more equitable treatment for all Americans living in poverty.

23
Additional efforts to streamline Medicaid eligibility and enrollment are also part of the
plan. Uniform and simplified verification and renewal rules should be established to help
minimize the “churning” that typically occurs within Medicaid. States should get help
from the Federal government to engage in outreach to potentially eligible individuals and
to modernize their eligibility and enrollment data systems because the current systems are
so antiquated that they are unable to meet today’s data demands. Simplifying eligibility
would expedite and lower the costs associated with states’ eligibility determination
processes.

Existing mandatory eligibility populations would be unaffected by this plan. The same is
true for optional populations that states have elected to cover — because states would be
required to maintain current eligibility levels (even those above 100 percent of the poverty
level). Current Federal matching rates and other policies consistent with this policy would
remain intact for any population with income eligibility that exceeds 100 percent of the
poverty level. No one currently eligible would lose access to Medicaid.

The financial responsibility shared by the Federal and state governments is carried out
through a matching system, called the Federal Medical Assistance Percentage, or FMAP,
in which the Federal government and the state government each pay a certain percentage of
total Medicaid expenses. Each state’s FMAP rate is based on the state’s per capita income
level, thereby giving states with lower-than-average income levels a higher FMAP rate and
thus a higher Federal percentage match. According to Federal law, FMAP rates range from
50 percent to 83 percent and there is no cap on the total Federal financial participation.
Currently, 13 states receive the minimum 50 percent match, but the highest FMAP rate is
73 percent.
29


The goal of covering all Americans is an opportunity for the Federal government to partner
with states to reduce the number of low-income uninsured Americans. The Baucus plan
would invest new Federal resources to help states, and is committed to finding ways for the
Federal government and the states to share responsibility for the costs associated with
increased Medicaid enrollment.

The Baucus plan includes an additional improvement to the Medicaid program. Medicaid
must be strong and stable so that eligible individuals can rely on it, especially in times of
economic distress. In order to strengthen and stabilize Medicaid, states require help
managing the costs associated with unanticipated increases in Medicaid enrollment. When
the national economy experiences a downturn, state revenues decrease and Medicaid rolls
increase, as people lose jobs and health insurance. Every one-percent increase in the
national unemployment rate, for example, results in an additional one million people
enrolling in Medicaid.
30
One million new Medicaid beneficiaries increase state Medicaid
spending by $1.4 billion.
31

32
As all states (except Vermont) are constitutionally bound to balance their budgets, the
strain caused by decreased revenues and greater Medicaid participation forces states to
reduce spending — often cutting back safety net programs like Medicaid at a time when
they are needed most.
33

24

To ensure that Medicaid is a reliable component of a reformed American health care
system, this plan would increase FMAP rates when a predetermined combination of
circumstances measuring the timing, duration, and depth of an economic downturn occurs.
Creating this mechanism to maintain Medicaid’s stability during nationwide economic
slumps or significant downturns for individual states builds on recent success in addressing
tough economic situations. In 2003, as part of the Jobs and Growth Tax Relief
Reconciliation Act, Congress temporarily increased FMAP rates by 2.95 percent, so long
as states agreed not to cut benefit options during the FMAP increase.
34
A study by
Families USA found that for “every million dollars a state invests in Medicaid [it] will
generate, on average, $3.35 million in new state business activity . . . $1.23 million in new
wages, . . . and an average of 33.76 new jobs per state.”
35

The details of an economic indicator-based trigger and the level of assistance must be
responsible without being too rigid or too lax. In a 2006 report, the Government
Accountability Office (GAO) recommended consideration of two factors — the number of
states experiencing an increase in unemployment and the magnitude of that increase — in
setting a trigger.
36
Determining the specific trigger requires careful construction in order
to ensure that state economic distress is measured reliably and accurately. Similarly, the
amount and duration of the FMAP increase must be calibrated to provide states with
enough support for the right amount of time.

State Children’s Health Insurance Program (CHIP). When the Children’s Health
Insurance Program (CHIP) was created as part of the Balanced Budget Act of 1997, it was
the largest expansion of health insurance coverage for American children in more than 30
years.
37
CHIP was intended to provide health insurance to children whose families cannot
afford to purchase health insurance in the private market, but earn too much to qualify for
Medicaid.

Like Medicaid, CHIP is financed jointly by the state and Federal governments. The
Federal government pays a higher percentage of the total program costs for CHIP than for
Medicaid, averaging about 70 percent nationally.
38
Because CHIP is financed through a
block grant to states, the total Federal financial participation in CHIP is capped regardless
of rising costs or increased numbers of eligible children.

In its first ten years, CHIP helped to reduce the number of uninsured children by about
one-third overall, from 23 percent to 14 percent.
39
CHIP has reduced by one-quarter the
number of uninsured children with effective family incomes between 100-200 percent of
the poverty level.
40 41
In 2006, more than 6.5 million children were covered through CHIP.
Despite this progress, more than one in ten children remains uninsured.
42
25

Figure 2.1. Impact of CHIP on Uninsured Children

Source: Improving Children’s Health, Center on Budget and Policy
Priorities, 2007

CHIP gives states flexibility in establishing eligibility criteria, benefit structure, and cost-
sharing. States have used this flexibility to craft programs responsive to their unique
needs.
43


The original intent behind CHIP was to provide access to health insurance for all low-
income families who make too much to qualify for Medicaid, but not all CHIP programs
have met that goal. The Baucus plan would require states to use CHIP to cover all children
at or below 250 percent of the poverty level and who are not Medicaid eligible, putting
help within reach for more needy Americans. States that currently cover children above
250 percent of the poverty level would continue to do so. Existing matching and other
policies not inconsistent with a responsibility to have health coverage would remain in
place for states with income eligibility that exceeds 250 percent of the poverty level.

With an expansion of CHIP, the Federal government and states would join together to
reduce the number of uninsured children in America. Currently, capped Federal allotments
to states combined with expanded eligibility lead some states to exhaust available Federal
funding before the end of the fiscal year. In 2007, 14 states faced Federal funding
shortfalls, and as many as 37 states were expected to face similar financial challenges for
fiscal year 2008.
44
Under these financial constraints, some states are forced to cut back
their CHIP programs by freezing enrollment, enforcing longer waiting periods, or lowering
the income eligibility thresholds.
45


The Baucus plan would help states with the costs associated with increased CHIP
enrollment. The Federal government has several options to consider in helping the
states.
46


In addition, as our health care delivery system is modernized to improve quality and access
to care, similar efforts should be encouraged in Medicaid and CHIP to assure that our
26
nation’s most vulnerable populations receive the same high-quality care that is available to
those with Medicare or private insurance.

Health Care for Native Americans and Alaska Natives. The Indian Health Service (IHS)
currently provides health care services to an estimated 1.5 million Native Americans and
Alaska Natives who belong to more than 562 federally recognized tribes in 35 states.
47

IHS provides free health care to eligible Native Americans and Alaska Natives, with the
exception of certain urban programs or in circumstances where a tribe chooses to charge its
members for health care.
48

In a series of treaties and agreements forged with the tribes as sovereign nations, the U.S.
government promised to provide health care to Native Americans. Currently, the IHS is
responsible for making sure that promise is kept. IHS, however, is not the sole source of
health care for Native Americans. Tribal members are eligible for, among other programs,
Medicare, Medicaid, and CHIP. Native Americans also may have private insurance.

Native American and Alaska Native populations have unique health care concerns. Native
Americans are three times more likely to die from diabetes. And Native Americans suffer
from tuberculosis at a rate that is six times higher than the non-Indian population.
49
Many
members of these populations also live in physically remote areas, making the delivery of
care difficult and hindering the ability to recruit and retain health care professionals.
Additionally, cultural concerns must be respected in providing health care for Native
Americans and Alaska Natives.

The IHS health care delivery system is organized around 12 regional offices and 163 local
service units, and provides various medical services, including inpatient and outpatient
services, ambulatory, emergency, dental, and preventive health care.
50
In 2007, IHS
provided approximately 58,000 inpatient admissions and over ten million outpatient
visits.
51
IHS also contracts for medical services from local providers through what is
known as contract health services.

Funding for IHS consistently falls short of the amount needed to provide care for the
populations it serves. In fiscal year 2008, total funding for IHS was $4.3 billion, about 48
percent of estimated need. Current spending levels pale in comparison to those of other
Federal health care programs such as the Bureau of Prisons, Department of Veterans
Affairs and the Federal Employees Health Benefit Program (FEHBP).
52


The IHS itself has stated that its funding does not allow it to provide all the needed care for
eligible Indians. As a result, some services are “rationed,” with the most critical care given
first. IHS regulations require that, when resources or funds are insufficient, the agency
must set priorities for both direct and contract health care based on “relative medical
need.”
53
The reality of this underfunding is that money for contract health services does
not last the entire year, forcing IHS to limit services to circumstances involving a “loss of
life or limb” circumstance. This predicament is so common in Indian Country that many
tribal members fear that if they need care after June, they will be forced to go without.

27
IHS desperately needs additional funding. It is impossible to keep America’s promise to
provide care to Native Americans and Alaska Natives with the current level of IHS
funding. The Baucus plan would increase funding for IHS, as well as encourage
enrollment in other programs like Medicare, Medicaid, and CHIP for those who are
eligible to defray the costs borne by IHS directly.

E. FOCUSING ON PREVENTION AND WELLNESS

Chronic diseases — such as heart disease, stroke, cancer, and diabetes — are the most
prevalent and preventable of all health problems and also the most costly. Nearly half (45
percent) of Americans suffer from one or more chronic conditions,
54
and chronic disease
accounts for 70 percent of all deaths (more than 1.7 million people).
55
In addition,
increased rates of obesity and chronic disease are the primary cause of disability and
diminished quality of life.

The economic impact of chronic disease in the U.S. is staggering. A Milken Institute study
found that treatment of the seven most common chronic diseases, coupled with
productivity losses, costs the U.S. economy more than $1 trillion annually.
56
About 78
percent of the nation’s total health care spending is due to chronic illness.
57
Further, the
number of Americans who have become obese has doubled since 1987, accounting for
nearly 30 percent of the rise in health care spending between 1987 and 2005.
58
Despite the
human and economic cost of chronic disease, the U.S. health system does little to address
the underlying health problems that lead to these conditions.

For the sake of Americans’ health, and to truly change the economics of our health care
system, the U.S. must dramatically shift its health care focus toward preventing chronic
disease. An estimated 80 percent of heart disease, stroke, and type-2 diabetes, and 40
percent of cancers, could be prevented if Americans stopped smoking, adopted healthy
diets, and became more physically active.
59
Despite evidence that preventive services such
as smoking cessation work,
60
our health system continues to emphasize expensive
treatments. This approach is further complicated by a fractured delivery system in which
individuals with chronic conditions often see more than one provider and take multiple
medications.

Prevention must become a cornerstone of the health care system rather than an
afterthought. This shift requires a fundamental change in the way individuals perceive and
access the system as well as the way care is delivered. The system must support clinical
preventive services and community-based wellness approaches at the Federal, state, and
local levels. With a national culture of wellness, chronic disease and obesity will be better
managed and, more importantly, reduced.

Guaranteed Access to Clinical Preventive Services and Referral to Community
Resources. Those who are uninsured — and therefore less likely to receive preventive
care and even treatment for major conditions — must be given a means to begin
safeguarding and improving their health. This plan proposes “RightChoices,” a temporary
program to provide the uninsured with immediate access to a set of proven preventive
28
services such as a health risk assessment, physical exam, immunizations, and age and
gender appropriate cancer screenings recommended by the U.S. Preventive Services Task
Force. Based on a patient’s risk, a care plan would be developed to maintain good health,
and reduce the medical risks and costs of poor health. The RightChoices card would also
provide referral to community resources such as smoking cessation and nutrition programs
that have demonstrated success in changing and supporting healthy lifestyle choices.

Any individual eligible for RightChoices who is not eligible for or enrolled in a private
plan or public program such as Medicaid or Medicare, but whose RightChoices screening
detects and diagnoses one or more of the most common, costly chronic conditions would
qualify to receive treatment for those conditions. Treatment would be provided on a
temporary basis until viable coverage options are available under the Health Insurance
Exchange. Individuals with incomes below 200 percent of the Federal poverty level could
receive treatment at no cost.

To cover the cost of this care, states would receive a three-year capped allotment based on
factors such as the percentage of uninsured and the prevalence of these chronic illnesses.
These grants could also support the development of models to better manage, monitor, and
treat these chronically ill individuals such as certified community care teams.
61
It could
also be used for outreach to eligible, uninsured Americans.

Coverage for Prevention in Federal Health Programs and Private Plan Options.
Evidence suggests that 96 cents of every Medicare dollar and 83 cents of every Medicaid
dollar are used to treat chronic diseases.
62
Federal health programs must prioritize
prevention to ensure that taxpayer dollars are used more efficiently and effectively. The
Baucus plan would make prevention and wellness a priority in Medicare, Medicaid, and
CHIP.

The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) took a step
in this direction. MIPPA gave the Secretary of Health and Human Services the authority
to identify new preventive services recommended by the U.S. Preventive Services Task
Force for coverage under Medicare. The Baucus plan would do more, by reducing or
eliminating co-payments for recommended preventive services under Medicare. New
payment methodologies, combined with expanded use of health information technology,
would increase appropriate use of these recommended preventive services and better
manage the care of chronically ill beneficiaries.

Medicaid and CHIP beneficiaries would receive recommended preventive services without
co-payments. Medicaid enrollees subject to cost sharing of even a one dollar co-pay per
service used fewer physician services and received fewer preventive services including
immunizations (a 45 percent decrease) and pap smears (a 21.5 percent decrease) compared
to those not subject to a co-payment.
63

In addition, Congress should explore evidence-based approaches for obesity prevention
and treatment through demonstration projects in Medicare, Medicaid, and CHIP.
29
Demonstrations should test approaches that have shown clinical value in functioning
settings.

The Health Insurance Exchange created under the Baucus plan would require participating
plans to include certain preventive services in its benefit package. Such coverage would be
based on recommendations by appropriate entities such as the U.S Preventive Services
Task Force, the Advisory Committee on Immunization Practices, National Institutes of
Health, Centers for Disease Control and Prevention, and Institute of Medicine.

A National Focus on Wellness. The plan would provide grants to states or communities
to implement innovative, evidence-based prevention and wellness programs at the local
level. The programs would employ best practices identified by the Department of Health
and Human Services, the Institute of Medicine (IOM), and the Task Force on Community
Preventive Services.

Grants would encourage local governments, employers, schools, health care systems, other
community organizations, and individuals to work together and support healthy
lifestyles.
64
Communities would be empowered and encouraged to identify and overcome
barriers to healthy choices for all residents, regardless of health status, race or
socioeconomic status. Interventions that could improve and maintain the health of pre-
Medicare eligible individuals aged 55 to 64 would be explored. This investment makes
sense. Healthier older Americans require less expensive care; and evidence suggests that
this investment could result in less spending on future Medicare beneficiaries.
65


The plan would also support efforts by small businesses to create healthier work
environments with tax credits or other subsidies for proven wellness programs.
66
The
support provided by targeted tax credits or other subsidies and community challenge grants
would help lead individuals to make positive choices for their own health.

Finally, Congressional proposals have called for a more coordinated national strategy to
prevent chronic disease and reduce obesity.
67
The health of Americans is affected by
access to insurance, nutritious food and safe places to exercise among other factors.
Congress should authorize a study to identify the various federal programs that can help
prevent the development of chronic disease and suggest options to more effectively
coordinate efforts going forward.

F. ADDRESSING HEALTH DISPARITIES

Racial and ethnic health disparities are characterized by persistent gaps in both health
status and health care for minority populations. Disparities in the health status involve
increased rates of mortality, level of chronic disease burden, and perception of one’s
health. For example, a larger share of African Americans has diabetes, high blood pressure,
and heart disease than whites.
68
One of the most glaring differences in health status is
reflected in infant mortality. African American infants die at a rate of 13.6 per 1000 live
births — a rate that is higher than any other racial or ethnic group and twice that of
30
69
whites. The African-American infant mortality rate is even higher than that of Slovenia,
Poland, Kuwait, and Russia.
70


Disparity in health care is characterized by differences in the quality of medical care that is
provided and its availability to diverse populations. The landmark 2003 Institute of
Medicine (IOM) study, Unequal Treatment, demonstrated significant quality gaps in the
health care provided to African Americans and Latinos.
71
African Americans are 13
percent less likely to receive coronary angioplasty as whites.
72
African Americans are
more likely to undergo leg amputation related to diabetes and to have complications
following surgery.
73
In addition, Asians are less likely to receive timely antibiotic therapy
while hospitalized.
74


Lack of access is also a major factor affecting health care provided to racial and ethnic
minority groups. Barriers to health care can result from lack of health insurance coverage,
geographic location, language and cultural differences, and high cost. While only one-third
of the U.S. population is made up of racial and ethnic minorities, they represent over half
of the uninsured — over 30 percent of these two racial and ethnic groups are without
health care coverage.
75
Medicare and Medicaid cover most of those insured among
communities of color.

Language compatibility is also essential to ensuring quality health care for ethnically and
racially diverse groups. The ability for patients to communicate their needs to a provider is
critical. A lack of communication can mean an increased likelihood of medical errors and
patients not adhering to a treatment plan. Latinos and Asians report having poor
communication with their provider at a higher rate than other groups.
76

The Baucus plan would make health care affordable and universally available to all
Americans, a major step toward eliminating racial and ethnic health disparities. Subsidies
for low-income individuals and families, in particular, would be critical to make health
care obtainable by everyone. Currently, legal immigrant children and pregnant women are
subject to a five-year waiting period before they can become eligible for Medicaid or
CHIP. Not only does this exacerbate health disparities, but it increases the number of
uninsured. The waiting period should be eliminated and eligible legal immigrants should
have access to Medicaid and CHIP.
77

Addressing access to health insurance coverage is not the only step in addressing
disparities. Social determinants of health must also be addressed in the effort to eliminate
health disparities. Lack of adequate housing, living wages, appropriate education, and
clean environments adversely affect health status and well-being. All federal agencies that
have jurisdiction over these types of social programs should collaborate together to
improve the health and well-being of our communities.

The effort to document the extent of health disparities in the U.S. will require standard
methods of collecting data. Data collection must also be more reflective of the target
community from which data is gathered. Information must be reflected at the
subpopulation level. The Baucus plan would require participating plans in the Exchange to
31
collect and report data based on race, ethnicity, and gender. The plan also proposes to
include appropriate levels of funding to Federal agencies responsible for this type of data
collection, such as the National Health Interview Survey (NHIS) and the National Health
Care Survey (NHCS).


1
Anne-Emanuelle Birn, et al., “Struggles for National Health Reform in the United States,” American
Journal of Public Health, 93, no.1 (2003): 86-91.
2
Kaiser Family Foundation and Health Research and Educational Trust, “Employer Health Benefits Survey,
2008,” The Kaiser Family Foundation, http://ehbs.kff.org/pdf/7790.pdf.
3
Jack Hadley, John Holahan, Teresa A. Coughlin and Dawn Miller, “Covering the Uninsured In 2008:
Current Costs, Sources Of Payment, And Incremental Costs,” Health Affairs, 27, no. 5, (2008). Some
literature suggests that public payments also cover much of the costs associated with uncompensated care.
4
Department of Revenue News Release, “Most Taxpayers in Massachusetts Have Health Insurance,” The
Commonwealth of Massachusetts, (2008.)
5
Sharon K. Long, “On the Road to Universal Coverage: Impacts of Reform in Massachusetts at One Year,”
Health Affairs, 27, no. 4, (2008).
6
Kaiser Family Foundation and Health Research and Educational Trust, “Employer Health Benefits Survey,
2008,” The Kaiser Family Foundation, http://ehbs.kff.org/pdf/7790.pdf: 71.
7
Paul B. Ginsburg, “Employment-Based Health Benefits Under Universal Coverage,” Health Affairs, 27, no.
3 (2008): 675-685.
8
Survey was conducted by Gallup Organization, August 13-16, 2007 and based on telephone interviews with
a national adult sample of 1,019.
9
The Commonwealth Fund, “Nearly Nine of Ten Who Seek Individual Market Health Insurance Never Buy
a Plan”, The Commonwealth Fund, (2006).
10
For example, S. 2795, the Small Business Health Options Program, introduced by Senators Durbin and
Snowe, requires that employers cover at least 60 percent of their employees’ premium in order to qualify for
the tax credit.
11
Employee Benefit Research Institute, “Health Insurance Coverage of the Near Elderly, 1994"2005,” EBRI
Notes, 28. no.1 (2007), http://www.ebri.org/pdf/notespdf/EBRI_Notes_01-20071.pdf.
12
U.S. Census Bureau, “Income, Poverty, and Health Insurance Coverage in the United States,” U.S. Census
Bureau, (2007), www.census.gov/hhes/www/hlthins/historic/hihistt2.xls.
13
America’s Health Insurance Plans, “Individual Health Insurance 2006-2007: A Comprehensive Survey of
Premiums, Availability, and Benefits,” AHIP, (2007),
www.ahipresearch.org/pdfs/Individual_Market_Survey_December_2007.pdf.
14
John Holahan, (2004). “Health Insurance Coverage for the Near Elderly,” The Kaiser Family Foundation,
(2004), http://www.kff.org/uninsured/upload/Health-Insurance-Coverage-of-the-Near-Elderly-Report.pdf.
15
Ibid.
16
Jack Hadley and Timothy Waidmann, “Health Insurance and Health at Age 65: Implications for Medical
Care Spending on New Medicare Beneficiaries [Abstract],” Health Services Research: The Global Journal
for Improving Health Care Delivery and Policy, 41, no.2 (2006): 429-451.
17
The Social Security Amendments of 1972, P.L. 92-603
18
Stacy Berg Dale and James M. Verdier, “Elimination of Medicare’s Waiting Period for Seriously Disabled
Adults: Impact on Coverage and Costs,” The Commonwealth Fund, (2003),
http://www.commonwealthfund.org/usr_doc/660_Dale_elimination.pdf?section=4039
32

19
Center for Medicare and Medicaid Services, “Data Compendium,” CMS, (2008),
http://www.cms.hhs.gov/DataCompendium.
20
Henry J. Kaiser Family Foundation, “Medicaid’s Optional Population: Coverage and Benefits,” The Kaiser
Family Foundation, (2005): 2.
21
Henry J. Kaiser Family Foundation. “Medicaid: An Overview of Spending on ‘Mandatory’ vs. ‘Optional’
Populations and Services,” The Kaiser Family Foundation, (2005): 1.
22
Henry J. Kaiser Family Foundation. “Medicaid’s Optional Population: Coverage and Benefits,” The Kaiser
Family Foundation, (2005): 2.
23
Centers for Medicare and Medicaid Services (CMS). “Data Compendium,” CMS, (2008),
http://www.cms.hhs.gov/DataCompendium.
24
Henry J. Kaiser Family Foundation, “Medicaid’s Optional Population: Coverage and Benefits,” The Kaiser
Family Foundation, (2005),
http://www.kff.org/medicaid/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=51052: 2.
25
Joel S. Weissman, Alan M. Zaslavsky, Robert E. Wolf, John Z. Ayanian, “State Medicaid Coverage and
Access to Care,” Journal of Health Care for the Poor and Underserved, 19, no. 1, (2008): 307-19.
26
Robert Pear, “Health Insurance Industry Urges Expansion of Coverage,” The New York Times, November
4, 2006.
27
John Holahan and Alan Weil, “Toward Real Medicaid Reform,” Health Affairs 26, no. 2 (2007): 260-261
28
Henry J. Kaiser Family Foundation, “The Medicaid Resource List,” The Kaiser Family Foundation,
(2003): 5-6.
29
Henry J. Kaiser Family Foundation, “State Health Facts Online,” The Kaiser Family Foundation, (2008)
www.statehealthfacts.org.
30
Henry J. Kaiser Family Foundation, “Impact of Unemployment Growth on Medicaid and SCHIP and the
Number Uninsured,” The Kaiser Family Foundation, (2008) http://facts.kff.org/chart.aspx?ch=360.
31
Ibid.
32
National Conference of State Legislators, “State Balanced Budget Requirements,” NCSL, (2003)
http://www.ncsl.org/programs/fiscal/balreqs.htm.
33
Government Accountability Office, “Medicaid: Strategies to Help States Address Increased Expenditures
During Economic Downturns,” GAO, (2006), www.gao.gov/cgi-bin/getrept?GAO-07-97.
34
Public Law 108-27.
35
Families USA, “Medicaid: Good Medicine for State Economies,” Families USA, (2004): 3-4.
36
Government Accountability Office, “Medicaid: Strategies to Help States Address Increased Expenditures
During Economic Downturns,” GAO, (2006), www.gao.gov/cgi-bin/getrept?GAO-07-97.
37
Centers for Medicare and Medicaid Services, “State Children’s Health Insurance Program Summary,”
CMS, http://www.cms.hhs.gov/MedicaidGenInfo/05_SCHIP%20Information.asp.
38
Henry J. Kaiser Family Foundation, “State Children’s Health Insurance Program (SCHIP): Reauthorization
History,” The Kaiser Commission on Medicaid and the Uninsured, (2008)
http://www.kff.org/medicaid/7743.cfm.
39
Center on Budget Policy and Priorities, “Issue in Focus: Expanding Children’s Health Coverage,” CBPP,
(2008) http://www.cbpp.org/pubs/health.htm.
40
Peter Orszag, “Covering Uninsured Children: The Impact of the August 17 CHIP Directive,” (Testimony
before the Senate Committee on Finance, U.S. Senate, April 9, 2008).
33

41
Centers for Medicare and Medicaid Services, “SCHIP Enrolled In Year,” CMS, (2007),
http://www.cms.hhs.gov/NationalSCHIPPolicy/downloads/SCHIPEverEnrolledYearGraph.pdf.
42
Henry J. Kaiser Family Foundation, “Health Insurance Coverage of Children,” The Kaiser Family
Foundation, (2008),
http://facts.kff.org/uupload/relatedtable/Health%20Insurance%20Coverage%20of%20Children,%202006.xls.
43
Henry J. Kaiser Family Foundation, “Medicaid/SCHIP: Low Income Families,” The Kaiser Family
Foundation, (2008), http://www.kff.org/medicaid/lowincome.cfm. Some States have used this flexibility to
cover adults, the vast majority of whom are not CHIP eligible unless they have incomes below 100 percent of
the Federal poverty level and minimal assets.
44
Henry J. Kaiser Family Foundation, “Foundation Resources on the State Children’s Health Insurance
Program and Reauthorization,” The Kaiser Family Foundation, (2007),
http://www.kff.org/medicaid/schipresources.cfm.
45
Edwin Park and Matthew Broaddus, “Fourteen states face SCHIP shortfalls this year totaling over $700
million,” Center on Budget and Policy Priorities, (2007).
46
See, for example, H.R.976, Children's Health Insurance Program Reauthorization Act of 2007; H.R.3963,
Children's Health Insurance Program Reauthorization Act of 2007; H.R.3162, Children's Health and
Medicare Protection Act of 2007; and S.1893, Children's Health Insurance Program Reauthorization Act of
2007.
47
Indian Health Service, “Indian Health Service Introduction,” IHS, (2008)
http://www.ihs.gov/PublicInfo/PublicAffairs/Welcome_Info/IHSintro.asp.
48
Congressional Research Service, “Indian Health Service: Health Care Delivery, Status, Funding, and
Legislative Issues,” CRS, (2008): 1.
49
Ibid., 10.
50
Ibid., 2-3.
51
Indian Health Services, “IHS Fact Sheets,” IHS, (2008), http://info.ihs.gov/Profile08.asp.
52
Congressional Research Service, “Indian Health Service: Health Care Delivery, Status, Funding, and
Legislative Issues,” CRS, (2008): 14-16.
53
42 CFR §§136.11(c), 136.23(e).
54
Chronic Disease Prevention and Health Promotion, “Chronic Disease Overview,” CDC,
http://www.cdc.gov/nccdphp/overview.htm.
55
Centers for Disease Control and Prevention, “Chronic Disease Prevention and Health Promotion,” CDC,
(2004), http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5311a1.htm.
56
Ross DeVol and Armen Bedroussian, “An Unhealthy America, The Economic Burden of Chronic
Disease,” The Milken Institute, (2007).
57
Robert Mollica and Jennifer Gillespie, “Care Coordination for People with Chronic Conditions,”
Partnership for Solutions, (2003): 3.
58
Kenneth E. Thorpe et al., “The Impact of Obesity on Rising Medical Spending,” Health Affairs, (2004),
(published online 20 October, 2004; 10.1377/hlthaff.w4.480).
59
Robert Beaglehole, World Health Organization’s Director of Chronic Diseases and Health Promotion,
(Keynote Address before the Philip Hauge Abelson Advancing Science Seminar, December 8, 2005).
60
Task Force on Community Preventive Services, “Community Guide,” (2008),
http://www.thecommunityguide.org/about/.
61
Kenneth E. Thorpe, “Reforming Medicare: A New Focus on Primary Prevention and Chronic Care
Management: working paper,” Emory University, (2008). These community care teams would include social
34

and mental health workers, care coordinators and other community resources that would work with primary
care provider practices to prevent and manage chronic disease.
62
Kenneth E. Thorpe, (Testimony before the House Appropriations Subcommittee on Labor, Health and
Human Services, Education and Related Agencies, U.S. House of Representatives, February 14, 2008).
63
Julie Hudman and Molly O’Malley, “Health Insurance Premiums and Cost Sharing: Findings from the
Research on Low-Income Populations,” The Kaiser Commissions on Medicaid and the Uninsured, (2003),
http://www.kff.org/medicaid/upload/Health-Insurance-Premiums-and-Cost-Sharing-Findings-from-the-
Research-on-Low-Income-Populations-Policy-Brief.pdf..
64
Partnership to Fight Chronic Disease, “Roadmap to Successful Program Development,” (2008),
http://promisingpractices.fightchronicdisease.org/uploads/roadmap.pdf.
65
Jack Hadley, and Timothy Waidmann, “Health Insurance and Health at Age 65: Implications for Medical
Care Spending on New Medicare Beneficiaries [Abstract],” Health Services Research: The Global Journal
for Improving Health Care Delivery and Policy, 41, no. 2, (2006): 429-451.
66
The Centers for Disease Control and Prevention has identified elements of successful evidence-based
workplace wellness programs. Senator Tom Harkin has proposed providing a tax credit for qualified
wellness programs in the Healthy Workforce Act of 2007 (S.1753).
67
S.3674, The 21
st
Century Wellness Trust Act, introduced by Senator Hilary Rodham Clinton; S.3584, The
Obesity Prevention, Treatment and Research Act of 2008, introduced by Senator Jeff Bingaman.
68
Henry J. Kaiser Family Foundation, “Key Facts: Race, Ethnicity, and Medical Care,” The Kaiser Family
Foundation, (2007) http://www.kaiserfamilyfoundation.org/minorityhealth/upload/6069-02.pdf.
69
Ibid.
70
CIA, “The World Fact Book,” CIA, (2008) https://www.cia.gov/library/publications/the-world-
factbook/rankorder/2091rank.html.
71
Brian D. Smedley, Adrienne Y. Stith, and Alan R. Nelson, Unequal Treatment: Confronting Racial and
Ethnic Disparities in Health Care, (Institute of Medicine, 2003): 29-30.
72
Agency for Healthcare Research and Quality, “Health Disparities Report,” AHRQ, (2008)
http://www.ahrq.gov/qual/nhdr07/nhdr07.pdf.
73
Ibid.
74
Ibid.
75
Henry J. Kaiser Family Foundation, “Key Facts: Race, Ethnicity, and Medical Care,” The Kaiser Family
Foundation, (2007) http://www.kaiserfamilyfoundation.org/minorityhealth/upload/6069-02.pdf.
76
Agency for Healthcare Research and Quality, “Health Disparities Report,” AHRQ, (2008)
http://www.ahrq.gov/qual/nhdr07/nhdr07.pdf.
77
S.764, Proposed provision in the Legal Immigrant Children’s Health Improvement Act (ICHIA) 2007,
introduced by Senator Hillary Clinton.
35
CHAPTER III BAUCUS PLAN: IMPROVING VALUE BY
REFORMING THE HEALTH CARE DELIVERY
SYSTEM

Ensuring access to meaningful health coverage is a fundamental goal of health care reform,
but there are also other vital priorities we must pursue. Among them is the critical need to
improve the value of care provided in our health care system. We must take steps to
ensure patients receive higher quality care, and do so in a way that reduces costs over the
long-run. In short, the U.S. must get better value for the substantial dollars spent on health
care.

Our nation’s health care providers — physicians, nurses, hospitals, and others — work
hard to provide life-saving and life-improving care to millions of Americans. The level of
care provided is often excellent, but it has become increasingly evident that the way care is
delivered and paid for in our health system does not always encourage the right care at the
right time for each and every patient.

The Baucus plan includes initiatives to reorient America’s health care delivery system
toward services and activities that improve patient care and “bend the curve” of growth in
national health care spending. At the same time, the plan invests in the health care
infrastructure that is necessary for delivery reform to succeed. Many of the proposals in the
plan are based in the Medicare program because of its unique ability to lead the way for
system-wide changes. The expectation, however, is that public and private insurers will
follow and continue to innovate as well. The Baucus plan considers delivery system
reform with four key goals in mind:

! Strengthening the role of primary care and chronic care management.
Primary care is the keystone of a high-performing health care system. Access to
primary care that successfully manages and coordinates patient care, particularly
for the chronically ill, is a proven determinant of high-quality, cost-effective care.
Yet America’s current system undervalues primary care relative to specialty care.
This has caused fewer medical students to choose careers in primary care, and has
created access problems that will only worsen as more Americans get health care
coverage. Increasing the supply of primary care practitioners and redefining their
role in the health system — by using Federal reimbursement systems and other
means to improve the value placed on their work — is a necessary step toward
meaningful reform.

! Refocusing payment incentives toward quality. Today’s payment systems
reward providers for delivering more care rather than better care. Under the current
system, the more visits, tests, images and services providers deliver, the more they
are paid — regardless of the quality or the health outcomes of the patient. The
health system should refocus payment incentives toward improving the quality of
care patients receive. Movement toward quality-based payment must start with
fixing the unstable and unsustainable Medicare physician payment formula. The
36
current Sustainable Growth Rate (SGR) formula is fatally flawed and must be
replaced.

! Promoting provider collaboration and accountability. Delivery system reform
should also encourage providers in different settings — physician offices, inpatient
hospitals, post-acute care settings, and others — to collaborate and provide patient-
centered care in a way that improves quality and saves money. Under current
payment systems, hospitals, physicians, and other health care providers are not
encouraged to work together to improve patient care throughout the course of a
patient’s illness. In fact, they may be penalized financially — through lower
revenues — if they successfully help patients avoid the need for additional health
services. Congress should modify current payment systems to encourage — rather
than discourage — collaboration and accountability among health care providers
across treatment settings and sites of care.

! Improving the health care infrastructure. Efforts to improve the health care
delivery system cannot succeed without taking other steps to modernize our
system. These steps include investing in new research and tools, as well as the
health care workforce. A national approach to comparative effectiveness research
can help provide systematic, unbiased information about what treatments,
technologies, and procedures work best. Health information technology (IT) can
put comparative effectiveness research and other clinical decision-support tools at
providers’ fingertips in real time, as well as improve the delivery of care across
settings and help providers to better coordinate patient care. Health IT can also
facilitate initiatives to improve quality performance and data collection and
aggregation. But gains from new research and health IT will be shallow unless we
reinvest in the training of a 21
st
century health care workforce.

Like many other reforms, changes to the health care delivery system will take time.
Moreover, these efforts will require continuing evaluation as the health system — and the
health care needs of Americans — evolve.

A. STRENGTHENING THE ROLE OF PRIMARY CARE AND CHRONIC CARE
MANAGEMENT

A strong emphasis on primary care is a common element of high-performing health
systems.
1
International systems, and even parts of our own country, that deliver cost-
efficient, high-quality care tend to have robust access to and use of primary care
services.
2,3
Among other things, primary care practitioners should provide preventive
care, help patients make informed medical decisions, and serve a critical care management
and coordination role — especially for those with multiple chronic conditions who are the
least healthy and most costly to our system. Yet today’s payment systems place higher
value on specialty care than primary care.

4
Strengthening the role of primary care will require a multi-pronged approach. To this
end, the Baucus plan includes several initiatives to improve our primary care system:
37
ensuring accurate prices for primary care services in Medicare, providing an add-on bonus
payment for primary care services, and encouraging further testing and implementation of
the medical home model. The plan would also ensure the viability of community health
centers and rural health clinics that provide vital safety net functions and serve as a true
medical home for thousands of patients across the country.

Ensuring Accurate Payments for Primary Care Services. Payments for primary care
physician visits are undervalued, particularly compared to procedures and services
furnished by specialists. In fact, the overvaluation of procedures in the Medicare physician
fee schedule has both created financial incentives to provide unnecessary services and
served as a disincentive for physicians to become primary care physicians. Primary care
physicians are not trained in — and do not have the opportunity to bill for — procedures
that generate extensive revenues for non-primary care physicians.
5

In 1989, Congress enacted Medicare physician payment reform, which required a fee
schedule based on relative values for approximately 7,000 services covered by the
program. Private insurers often adopt the relative values set by Medicare, although they
may use different payment rates for determining actual fees paid. The 1989 law also
required periodic review — at least every five years — to ensure that the payment system
reflects changes in the relative resources involved in furnishing physician services.
Adjustments to relative values reflect changes in medical practice, coding changes,
experience with new procedures, and other variables. Rapid growth in the volume of a
service provided often represents evidence that the relative value for that service should be
reviewed.
6


The Centers for Medicare and Medicaid Services (CMS) has relied heavily on
recommendations from the American Medical Association (AMA) Relative Value Update
Committee (RUC) to determine needed changes to the value of services in the physician
fee schedule. The RUC process has resulted in changes that have increased relative values
in many areas but decreased values in very few. This result has worked against primary
care services because primary care physicians bill for a relatively smaller and more static
set of codes than non-primary care physicians. A recent increase in the relative values for
primary care services by the RUC was a step in the right direction. The Baucus plan
would seek a continued focus on the high value of primary care-related services, with
corresponding reductions in relative values for overvalued services. Fee schedule rates
must accurately reflect priorities that the health care system must adopt to bend the health
care cost curve and improve quality over time.

Additional Payments for Primary Care Providers. The undervaluation of primary care
services might also be addressed by the Baucus plan with increases in Medicare payments
for services furnished by practitioners focused on delivering primary care.
7
Payments
must be well-targeted, starting with careful identification of the list of services that qualify
as primary care services — primarily evaluation and management visits. A second step
involves identification of Medicare providers, including physician and non-physician
practitioners, who truly focus on delivering primary care. Using claims history — rather
than self-identification — is a more accurate approach to identifying appropriate providers.
38
In addition, bonus payments should also take into account the complexity of the provider’s
patient panel to ensure that underserved populations are not left behind. Finally, the task
of setting a threshold for these services is best left to CMS, which can collaborate with
stakeholders and other experts to strike the right balance.

To avoid cost inflation, this proposal should be made budget-neutral. Budget-neutral
changes to Medicare payments mean that any increase to primary care providers requires a
corresponding cut to specialist services. This approach has the potential to create
significant controversy among physicians, however. Any reforms along these lines must
be crafted in collaboration with the entire physician community and other practitioners to
ensure appropriate valuation of, and access to, primary care services. Other means of
redefining the value that the health system places on primary care, such as revisions to the
SGR formula, are discussed below.

Patient-Centered Medical Home. Expanding Medicare’s role in testing the medical home
model — in which practitioners are paid explicitly for comprehensive care management
services — is another way that the Baucus plan would promote quality and efficiency. A
growing body of evidence suggests that medical homes may improve patient health and
reduce costs.
8,9
In 2006, Congress required CMS to establish a demonstration program to
test the medical home model in fee-for-service Medicare.
10
More recently, Congress
provided additional funding for this demonstration and granted CMS authority to expand
the program if quality and cost targets are met.
11

Medical home expansions in Medicare should focus only on providers who are committed
to ensuring that patients truly receive the primary care and care management services that
the medical home is designed to deliver. Providers seeking to participate in a Medicare
medical home expansion program should meet a set of stringent service and capacity
criteria in order to qualify, such as those proposed by MedPAC,
12
and be willing to have
additional payments based in part on the quality of care they deliver. The National
Committee for Quality Assurance (NCQA) has also developed an assessment tool that tiers
medical homes based on the implementation of particular capacities and patient services.
13


In addition, careful consideration should be paid to the role of non-physician providers,
such as nurse practitioners and home health aides, in the medical home model. Medical
home expansions should also target the patient populations most in need of comprehensive
care management and coordination, particularly those with multiple chronic conditions.
As with other components of the medical home, though, these tools and criteria will evolve
as results from ongoing demonstrations and input from patients, providers, other
stakeholders, and experts are received and incorporated into the medical home model.

This plan would expand the medical home model by requiring collaboration between
Medicare and ongoing demonstration sites that include private payers and Medicaid.
Aligning incentives created by disparate payment models — for example, private payers
and public programs — is crucial to achieving significant delivery system reform.

39
Building a qualified medical home may not be feasible for all providers, however. The
required medical home criteria (particularly the necessary investments in infrastructure and
staffing) can be challenging for the 36 percent of physicians who work in solo or very
small-group practices, many of which are located in rural areas. One option is to invest in
community health teams that include nurses, nutritionists, and social and mental health
workers. These teams could link primary care practices with additional resources that
would allow small or rural offices to participate in the medical home. The state of North
Carolina has achieved preliminary success with the community health team model in its
state Medicaid program.
14
Going forward, Medicare could join with other payers
(Medicaid, private plans) in funding states to develop this capacity throughout the state, or
in conjunction with other states in their region. Financial assistance for smaller primary
care practices to adopt health information technology would also provide a strong incentive
to collaborate with community health teams. Another option is to explore alternative
payment models that do not require specific practice improvements but instead offer
shared-savings bonuses for meeting aggressive cost and quality benchmarks.

In addition to the medical home, Medicare should test other primary care models that
promote comprehensive care management and coordination, particularly for the
chronically ill. Recent proposals to focus on caring for the sickest patients in their home,
or those that rely on a geriatric assessment to qualify patients for comprehensive care
coordination programs, show promise and should be examined in more detail.
15

Vendor-based disease management programs, which typically involve phone-based care
planning and follow-up by nurses, have found some success in the private market but have
not fared as well in recent Medicare demonstrations.
16,17
While these approaches should
not be jettisoned without consideration of new evidence from state and private payer
programs, it remains an open question whether Medicare should make direct payments to
vendors outside of a comprehensive care management model, such as the medical home.

The medical home and other care management concepts are works in progress, and the
involvement of patient groups is critical to ensuring that these models remain patient-
centered. A true medical home should serve as a central resource for a patient’s ongoing
care. Care management expansions under the Baucus plan will require ongoing evaluation
to ensure they are truly patient-centered. And to encourage patient participation, co-
payments for services provided in medical homes, for instance, could be reduced or
eliminated. These models will only improve health care quality and efficiency if patients
find that they provide needed health services in a consumer-friendly way.

Community Health Centers and Rural Health Clinics. Efforts to reestablish primary care
as the backbone of the health care system should build on existing systems that work. For
example, community health centers, which serve low-income and medically underserved
populations, perform well on quality indicators, provide efficient care, and have in many
cases implemented critical components of the medical home model.
18


To shore up this important component of our nation’s safety net, the Baucus plan would
modernize the outdated Medicare system for paying Federally Qualified Health Centers
40
(FQHCs). The Baucus plan would establish a prospective payment system for qualifying
FQHCs, mirroring the successful model that the Medicaid program uses for paying these
centers and expand the role of health centers in providing preventive services. To qualify
for PPS payments, FQHCs will be required to report on quality metrics and make
investments in the infrastructure necessary to qualify as a medical home.

Mechanisms for compensating rural health clinics (RHCs) also are deficient and should be
improved. In Montana and across the country, these facilities are instrumental in meeting
the needs of patients when other access points to care are unavailable or inadvisable — for
example, reliance on an emergency department. For these reasons, health reform should
include policies that bolster community health centers, RHCs, and FQHCs as part of the
larger effort to improve patient access to critical primary care services.

B. REFOCUSING PAYMENT INCENTIVES TOWARD QUALITY

Efforts to restructure provider payment systems to improve quality also represent a critical
component of delivery system reform. Many private and public organizations have echoed
the need to re-direct the health care system to reward higher quality and more efficient
care. In its landmark 1999 report, To Err is Human: Building a Safer Health Care System,
the Institute of Medicine (IOM) urged a heightened focus on quality initiatives.
19

Subsequent reports called for increasing payments for providers offering high-quality
care
20
and the establishment of a national system for performance measurement and
reporting.
21
MedPAC has also made multiple recommendations to Congress regarding the
need for payment incentives based on quality for hospitals, physicians, home health
providers, Medicare Advantage plans, and outpatient dialysis providers.
22,23

Based on these recommendations, Congress and CMS have enacted and implemented
policies to increase the focus on quality in the Medicare payment systems, particularly in
the areas of inpatient hospital care and physician services. The Baucus plan will build on
these efforts by establishing a pay-for-performance program for hospitals in Medicare and
further strengthening physician programs that are focused on quality improvement. The
plan will also encourage efforts to test pay-for-performance models related to home health
and nursing home care, as well as bring pay-for-performance to the Medicare Advantage
program.

Hospital Quality Reporting and Next-Generation Quality-Based Payment Reforms.
In 2003, Congress set the Medicare program on a path toward quality improvement by
establishing a hospital pay-for-reporting program.
24
As part of this effort, Congress asked
hospitals to track and report to CMS their performance on a set of ten defined quality
measures, such as how frequently a heart attack patient received aspirin upon admission.
To encourage participation, Congress provided higher payments to hospitals that reported
this information, and penalized those that did not. Ninety-eight percent of hospitals chose
to participate.
25


41
In 2005, Congress permanently extended the reporting program, directed CMS to
incorporate additional performance measures into the initiative,
26
and increased penalties
for non-participating hospitals.
27

By most accounts, the Medicare hospital pay-for-reporting program has been an important
first step in improving the quality of care provided to Medicare beneficiaries in the
inpatient hospital setting. It provides better insight into the quality and performance of
America’s hospitals for policymakers and patients alike.

Alongside the Medicare pay-for-reporting program, CMS has been testing a more
aggressive move to a “pay-for-quality” model. In October 2003, CMS contracted with
Premier, Inc., a nationwide alliance of not-for-profit hospitals and health systems, to
conduct a demonstration linking payment to the achievement of quality goals. This project,
the Hospital Quality Incentive Demonstration (HQID), has involved more than 260
hospitals across the nation
28
. Under the demonstration, hospitals were asked to report
process and outcome measures in five clinical areas related to heart attack, heart failure
and pneumonia. Hospitals in the top 20 percent in each clinical area received a financial
incentive payment.

Results from the HQID project demonstrate dramatic quality improvements in every
measured clinical area, with an 11.8 percent average quality improvement among
participating facilities over two years. These statistics translate into actual results for
patients: 1,284 fewer heart attack deaths for patients who received more clinically
appropriate care
29
. Based on these results, the HQID demonstration was extended for
another three years (through 2009) and will be expanded to test other innovative pay-for-
performance models.

The next step in quality-based payment reform is the adoption of a value-based purchasing
(VBP) program in the hospital inpatient setting. In its November 2007 Report to Congress,
CMS provided a roadmap for moving Medicare from pay-for-reporting to pay-for-
performance.
30
In establishing a pay-for-performance program, providers would not only
be rewarded for reporting quality activities, but their payment would also be increased or
decreased depending on how well they perform on these quality measures.

Building on these recommendations and the other efforts outlined above, the Baucus plan
includes provisions to improve quality care in the inpatient hospital setting through
establishing a hospital pay-for-performance program, which is sometimes also referred to
as value-based purchasing, in Medicare. The Baucus plan uses the following principles to
guide this effort:

! Transitions to value-based purchasing should be gradual. Linking payments to
performance represents a major shift in how Medicare pays for services. The plan
would phase in value-based purchasing so that the amount of payment at risk would
gradually increase to no more than two percent of base hospital operating
payments.

42
! A value-based purchasing program should build on the current reporting
program. A hospital value-based purchasing program should start with a set of
quality measures that hospitals have already been reporting on through the pay-for-
reporting program. Over time, the quality reporting program should continue to be
a testing ground for evaluating new measures before they are subjected to pay-for-
performance rules.

! Quality measures should be endorsed by relevant stakeholders. All measures
must be evidence-based, statistically valid, and field-tested to ensure that they
represent the best practices in improving quality. Measures should be selected
through rulemaking and endorsed or considered by consensus-building
organizations whenever possible.

! Rewards should be provided to hospitals that achieve quality goals as well as
to those that make significant improvements. The value-based purchasing
program should reward facilities that meet quality benchmarks and those who have
made substantial quality gains in performance relative to prior years.

! Every effort must be made to align hospital and physician quality goals. As
new quality measures for hospital and physician performance continue to be
developed, every effort must be made to encourage providers to work together
toward common quality improvement goals.

! Safety net, low-volume, and rural hospitals should be given special
consideration. The hospital value-based purchasing program must be structured in
a way that would allow smaller, rural facilities to participate and include
protections for safety net hospitals that may face unique challenges in meeting the
requirements of a value-based purchasing program.

! Quality performance and the process to reward hospitals must be transparent.
Hospital performance in the value-based purchasing program should be publicly
reported and available to consumers. The CMS methodology for determining
hospital performance scores and calculating payments for facilities must also be
transparent and public.

! The value-based purchasing program should be subject to ongoing monitoring
and evaluation. The Secretary, GAO, MedPAC, and others should help Congress
monitor the value-based purchasing program and provide specific input on any
unintended consequences of the program.

These principles would serve as guideposts for efforts to establish a hospital value-based
purchasing program in Medicare and are a key component of this plan.

Physician Quality Reporting Initiative. As Congress seeks to reward hospitals that
provide high-quality care, steps must also be taken to improve quality and resource
efficiency in the Medicare physician payment systems. To further improve patient care,
43
the Baucus plan would build on the Physician Quality Reporting Initiative (PQRI) and the
provider feedback program as a next step in improving patient care.

Despite substantial concerns regarding PQRI, the program is on its way to achieving the
goals set by Congress when the program was enacted in 2006: engaging clinicians and
other health care stakeholders in developing meaningful quality metrics to evaluate care;
putting Federal resources on the table to promote and partially fund quality improvement
activities; and expediting the development of data collection processes that will lead to
meaningful and actionable information flowing to providers, patients, and payers.

The first round of PQRI was executed in the second half of 2007. More than 100,000
clinicians attempted to participate in the program, and performance results and incentive
payments were delivered to participants this summer. At the same time, considerable
confusion lingers regarding the reporting mechanism, and reports indicate delays in the
delivery of incentive payments and difficulty in accessing feedback reports.

Congress and CMS have recently acted to address these technical challenges and expand
provider outreach and education programs so that the foundation of this program remains
strong, and physicians are not discouraged from participating. Reforms enacted in MIPPA
permit physicians to report on condition-specific groups of measures, such as those
addressing diabetes and heart failure, permitting more comprehensive analysis of a
physician’s ability to care for patients with these chronic illnesses.

In addition, MIPPA requires the establishment of a pathway for physician groups to report
quality information on an aggregated basis, reducing administrative burdens and fostering
clinician-to-clinician sharing of expertise that will be much more effective in improving
quality than purely governmental interventions.

Finally, Congress required CMS to expedite approval of clinical registries to which
physicians report performance data. These registries, such as the National Cardiovascular
Data Registry spearheaded by the American College of Cardiology, are often operated by
clinician groups or medical boards and are capable of collecting richer data sets than can
be accessed through claims forms. And physician recognition programs like those
sponsored by NCQA are also important conduits for quality reporting. Under MIPPA,
registries and recognition programs — once they are approved by CMS — will now be
able to submit data to CMS on behalf of participants.

Medical boards in particular are striving to meet the professional needs of physicians while
also fostering gains in quality of care. Boards such as the American Board of Internal
Medicine (ABIM) are including some quality reporting in their maintenance of
certification process. In order to retain ABIM certification every ten years, physicians
must not only pass a traditional exam testing their knowledge, judgment, and analytical
skills, but they also must participate in at least one quality reporting program. Going
forward, PQRI should work in conjunction with medical boards to encourage more
frequent and more aggressive recertification processes, including those that go beyond
quality reporting to focus on how physicians actually perform.
44

Before Medicare can transition from pay-for-reporting to pay-for-quality, physicians must
be able to successfully participate in PQRI and receive appropriate incentives to do so.
The reforms in MIPPA demonstrate a commitment by Congress to keep PQRI a flexible
program that responds to provider feedback and capitalizes on developments outside of
Medicare (e.g., clinical registries).

Ultimately, Medicare must put physicians on a similar course as the plan described above
for hospitals and transition PQRI to a true value-based purchasing program. As a next
step, the Baucus plan focuses on improving the clinical importance and validity of the
measures that physicians report to PQRI. The program may also require that physicians
report the results of patient experience surveys in order to receive a full bonus. Finally,
once the recent program improvements are fully implemented, the Baucus plan calls for the
current positive financial incentives for physician participation in PQRI to eventually be
matched with payment penalties for those who do not report. A report from CMS, required
in MIPPA, will give Congress additional guidance on how best to reinvent the Medicare
physician payment system from one that rewards quantity to one that focuses financial
incentive on high-quality, evidence-based care, and healthy outcomes for patients.

Provider Feedback Program and Episode Groupers. Congress also recently required
CMS to begin providing feedback to practitioners regarding their resource use. CMS is
authorized to explore different methods, including evaluating resource use on a per capita
basis or using episode grouper technology. The per capita method — which essentially
examines physician resource use per beneficiary — can be particularly helpful in
identifying outliers whose practice patterns fall outside an acceptable “bell curve” of
variation.
31
However, this method is less effective in giving providers actionable
information by which to change their practice patterns and improve their care for specific
patients and particular diagnoses.
32


An alternative methodology that may hold greater promise, particularly for specialists who
tend to perform discreet procedures for a specific illness, is the use of episode grouper
software. This technology evaluates the resources used to treat a patient during a specific
episode of illness, which may encompass multiple interventions over a period of time and
care furnished by multiple providers.
33
While most versions of this technology rely strictly
on insurance claims, eventually they could be adapted to include clinical data generated
from electronic health records and other sources.

Ultimately, episode groupers could give providers and payers more specific, actionable
information that could lead to meaningful reductions in inappropriate care patterns.
Medicare should develop its own open-source technology platform that includes
information on both episodes of care and per-capita resource use. This will help ensure
that episodes of care are both necessary and efficient. Finally, Medicare’s physician
feedback program should include information regarding quality of care — the health
outcomes of patients should not be compromised by efforts to reduce costs in treating
specific illnesses.

45
Quality Improvement for Other Providers and Private Plans. As Congress moves
forward on efforts to improve the quality of care provided by hospitals and physicians,
efforts to strengthen quality in other care settings must not be left behind.

CMS is currently developing a pay-for-performance demonstration project aimed at home
health and nursing home care. For home health care, CMS proposes to test a pay-for-
performance model in seven states using quality measures based on the Outcome and
Assessment Information Set (OASIS) that agencies have been using to report quality
activities since 2000. For nursing homes, CMS is also working to develop a demonstration
project that would offer financial incentives to facilities that meet certain conditions for
providing high-quality care. This project would be tested in five states. Both of these
projects must move forward to help CMS and Congress gain much needed information on
how to appropriately increase the focus on quality in the home health and nursing home
settings.

Congress should also explore a pay-for-performance requirement for private plans that
participate in Medicare. Health plans in the Medicare Advantage program have been
reporting a standard set of valid performance measures to CMS for over a decade. CMS
should move health plans beyond reporting so that payments reflect plan performance.
Additionally, CMS should provide for the development of valid performance measures for
prescription drug plans and begin to bring pay-for-performance to these plans, too.

As these efforts to collect, report, and appropriately pay for quality and efficiency move
forward, provider concerns regarding the number of methodologies, metrics, and
misaligned payment incentives must also be addressed. Clinicians are often subject to
several pay-for-performance programs that use different quality measures for similar
patients and require different data collection approaches. While significant efforts are
underway at the National Quality Forum (NQF) and other quality alliances and industry
groups to achieve uniformity, more work needs to be done to standardize measures and
administrative approaches and to minimize the burden on providers.

Congress provided substantial funding to NQF in MIPPA to facilitate the endorsement of
standardized measure sets and bring stakeholders together to agree on priorities for
performance measurement.
34
But Congress can go further by fostering, through the
Independent Health Coverage Council, alignment among the insurance plans participating
in the Health Insurance Exchange.

Reforming the Sustainable Growth Rate Formula. Moving toward a more value-driven
physician payment system in Medicare must start with reform of the current system used to
update physician payments. Enacted as part of the Balanced Budget Act of 1997, the
Sustainable Growth Rate (SGR) was designed to control spending for physician services
provided under Medicare Part B.
35
The statutory formula sets a target amount for
spending for certain services including physician services, lab tests, imaging, and
physician-administered drugs that are furnished in connection with physician services. If
overall spending exceeds the target set by the SGR, payments under the fee schedule are
46
automatically adjusted downward. If overall spending is less than the target, then
payments are adjusted upward.

Since 2002, the formula has called for automatic reductions in the payment update, but
Congress has enacted legislation to override the formula each year. These legislative
overrides, as CBO has observed, suggest that the current SGR formula is not a viable
mechanism to control spending for physician services.
36
However, Congress has struggled
to find a viable alternative to the SGR.

The most immediate obstacle to reforming the SGR is budgetary. The flawed formula
which is the basis of the SGR, combined with multiple years of Congressional
intervention, has left a nearly $300 billion discrepancy over ten years between what
physicians are projected to be paid under the formula and what a modest inflationary
update over those years would provide.
37


These projected reductions in physician reimbursement are unrealistic and, if implemented,
may have disastrous consequences for the Medicare program. They could likely cause
physicians to exit the program and Medicare beneficiaries to lose access to needed care.
The now-yearly cycle of Congressional intervention to block these SGR cuts consumes
attention and resources that should be directed to other challenges posed by Medicare and
other Federal programs. And, because the timing of Congressional action is often
unpredictable, it also puts enormous pressure on physician practices across the country as
they try to set budgets and meet payroll each month.

As Congress takes steps to resolve the budgetary shortfall posed by the SGR, CMS should
use its discretion to define the items and services that are included in the SGR formula’s
calculations. CMS should use its administrative authority to remove physician-
administered drugs, for which payment is based on the average sales price methodology,
from the formula in a shared effort to reverse the annual cycle of fixing the SGR.

In addition to the massive budgetary shortfall, there are also substantive obstacles to SGR
reform. The fundamental flaw of the SGR is that the behavior of an individual physician,
even a large group practice, cannot affect a formula driven by the practice habits of more
than 800,000 providers who are paid under the physician fee schedule.

When MedPAC presented its analysis of the substantive options for reforming the SGR in
March 2007, it identified two paths: (1) jettison the expenditure target approach and focus
on proposals that encourage higher quality care at lower cost; or (2) pursue value-based
payment reforms while replacing the SGR with a new expenditure target system for all
Medicare providers based, for example, on geographical location or type-of-service.
38

The first path would explicitly reorient physician payment toward high-value care. It
would also avoid further investment of Federal resources in a target-based formula that
may not influence individual physician behavior as Congress intends. Applying
expenditure targets to other aspects of Medicare — as MedPAC’s second path suggests —
could create additional administrative burdens without ensuring payment stability.
47

Eliminating the expenditure target altogether would likely exacerbate the SGR’s budgetary
shortfall and some in Congress have asserted a strong interest in revising the SGR
formula.
39
As we attempt to move beyond the ongoing SGR predicament, it may be
necessary to replace it with an alternative expenditure target approach.

One such approach would be the development of a revised SGR formula that creates
multiple expenditure targets based on sub-sets or categories of services. This has the
advantage of reallocating resources from high-growth, potentially overpaid aspects of
health care to underutilized, potentially more valuable services such as primary care and
prevention. Careful attention must be paid to appropriately clustering services so that new
prices generated by the SGR do not produce excessive increases or reductions in any
particular service. Consideration should also be given to whether GDP growth should
remain the short-term basis of SGR expenditure targets as medical inflation is expected to
outpace GDP growth at least until the reforms proposed in this paper take full effect.

Finally, in constructing a fee schedule based on multiple targets, careful consideration
must be given to ensure that the price outputs of the formula apply to the practitioners
responsible for the rate of growth of particular services. For example, in the case of a
separate target based on utilization and growth in imaging services, physicians who refer
patients for imaging services usually do not receive payment for the performance or
interpretation of those services.

Nonetheless, SGR reform should closely examine the growing costs to the Medicare
program of advanced imaging utilization and fees. A recent report by GAO found that the
significant recent growth in imaging costs is attributable in large part to physicians
increasingly providing imaging services in their offices as a means for revenue-
generation.
40
MedPAC analysis points to imaging utilization as a factor in the significant
regional variation of cost and quality discussed elsewhere in this paper; according to their
report, regional use of imaging services can vary by as much as three times.
41
Physician
payment reform should pay particular attention to the cost and quality implications of the
growing practice of physicians self-referring for diagnostic imaging services. Medicare
should also consider establishing a process for the identification and surveillance of high-
growth services. If the evidence suggests that prices are distorting physician behavior,
then modest reductions in prices that can elicit desirable behavioral changes without
impacting beneficiary access could be pursued administratively.

C. PROMOTING COLLABORATION AND ACCOUNTABILITY

While we take steps to improve the quality of care provided to patients, we must also
provide new incentives that encourage health care providers to work together to offer
patients the best possible care. Today, hospitals, physicians and other health care
providers are each paid separately, which creates little incentive for them to work together
to effectively manage patient care. Lack of collaboration can have a particularly
detrimental impact on patients with chronic or multiple illnesses who can most benefit
48
from well-coordinated care. Medicare should use payment incentives to drive more
collaboration among physicians, hospitals, and other health providers.

The disadvantages of care fragmentation are particularly evident for patients who
experience a hospitalization. Discharge from a hospital is a particularly critical and
vulnerable time for patients. In many cases, hospital patients are abruptly transitioned to
home or post-acute care, and discharges that occur over a weekend mean patients are
suddenly expected to assume a self-management role for their recovery with little support
or preparation.
42
In addition, the physicians who treat a patient during their hospital stay
are often not the same physicians who see the patient once they leave the hospital.
Payment systems, including the Medicare program, do not encourage these providers to
communicate or work together to ensure patients receive the proper medication and other
follow-up that is necessary post-hospitalization.

While lack of care coordination around a hospitalization episode can have a detrimental
impact on patients’ health and well-being, it also has a significant financial impact,
particularly on the Medicare program. According to some estimates, 18 percent of
Medicare hospital admissions result in readmissions within 30 days post discharge. These
readmissions accounted for $15 billion in spending in 2005, and according to MedPAC,
$12 billion of this spending is potentially avoidable.
43
Not only can a reduction in
readmissions result in Medicare savings, but it could also reduce geographic variations in
health spending. The 30-day readmission rate for Medicare beneficiaries ranges from 14
percent in some states to 22 percent in others.
44
New Medicare payment policies should
encourage hospitals and other providers to work together to provide the best possible care
to hospital patients both during and immediately following their hospital stay.

As we work to improve patient care around hospitalizations, we must take steps to
encourage further collaboration among multi-specialty physicians who treat patients in the
community. In the Medicare program, physicians who are paid on a fee-for-service basis
have little financial incentive to work together to improve the quality and efficiency of care
provided to patients. Any savings they achieve through better care coordination accrue not
to their practice but to Medicare. A Medicare demonstration project, called the Physician
Group Practice demonstration, is succeeding at slowing cost growth and improving quality
by allowing physician groups to share in savings from reduced health spending and should
be expanded.

Delivery system reforms should also encourage innovative organizational models that
allow for patient care across the treatment spectrum. Health care delivery systems that
treat patients throughout the continuum of care — from primary care to hospitalization to
post-acute rehabilitation — should be paid in a way that rewards them for improved
quality and efficiency. One model that should be tested in this area, and is described in
more detail below, is the concept of accountable care organizations (ACOs), which
encourage health care providers across the treatment setting to work together to improve
patient care.

49
Reducing Hospital Readmissions. Discouraging unnecessary readmissions by
restructuring Medicare payments is good policy. It is better for patients and better for
taxpayers. The Baucus plan would take a three-step approach to reduce hospital
readmissions and improve care coordination for patients who have experienced a
hospitalization.

First, the plan requires CMS to provide confidential feedback to hospitals and physicians
regarding resource use for select hospitalization episodes. This data would need to be
detailed enough to help providers understand spending and resource consumption,
particularly for higher-cost beneficiaries. Once providers better understand how they
perform relative to their peers, they could begin to address problem areas. The plan would
then require hospital-specific information on readmissions be made available to the public.

Second, the plan would create new financial incentives in Medicare to encourage providers
to take greater responsibility for the coordination of care for hospital inpatients. Under
current law, Medicare pays the same for hospital stays regardless of whether it is a
patient’s first inpatient stay or a readmission for the same condition. The plan would adopt
MedPAC recommendations as a starting point for creating new financial incentives to
reduce hospital readmissions in the Medicare program. These changes would mean
reduced payment rates for hospitals with readmission rates above a certain benchmark.
This benchmark will need to be defined, but ideas that have been put forward include
setting the benchmark as the average readmission rate across similar hospitals or using a
higher standard that ties the benchmark to the top performing facilities. In the initial years,
this plan would focus on reducing re-hospitalizations for a limited number of conditions
that are known to have a high rate of readmissions, such as congestive heart failure,
chronic obstructive pulmonary disease (COPD), and coronary artery bypass graft. But
over time, the program would be expanded. In circumstances where a readmission is
unavoidable, hospitals would not be penalized.

Bundled Payments. The third step will involve testing other models to improve patient
care related to hospitalizations. One concept that offers promise for greater efficiency and
care coordination is the idea of allowing Medicare to pay bundled or global payments for
all services provided to a patient during hospitalization and for some amount of time post
discharge.

Using its administrative authority, CMS has taken steps toward bundled payments by
establishing the Medicare Acute Care Episode (ACE) demonstration. Currently under
development at CMS, this demonstration project would allow hospitals and physicians to
receive a global payment for services provided to patients who receive certain cardiac and
orthopedic procedures. In the first year, this bundled payment would cover all hospital and
physician services provided during a patient’s hospital stay. At this point, it does not
appear that the demonstration will include services provided post-hospitalization. The
project is expected to be implemented early next year and would involve up to 15
demonstration sites. Medicare beneficiaries who receive care as part of the demonstration
would receive a partial refund on their Part B premium for agreeing to participate in the
project.
50

A similar project, the Medicare Participating Heart Bypass Center demonstration, was
tested in the early 1990s. Under this demonstration, Medicare paid a bundled rate for
hospital and physician services around hospitalizations for cardiac bypass graft surgery. In
this demonstration, the bundled payment included services provided during the hospital
stay as well as services provided immediately following the hospitalization. Results
showed increased efficiency and reduced Medicare spending. In particular, CMS found
that most participants were able to achieve reduced lab, pharmacy, and intensive care unit
spending. Spending on post discharge care also decreased, while quality remained high.

45,46


More recently, bundled payment initiatives have been tested in the private sector,
specifically at the Geisinger Health System. Glenn Steele, Geisinger’s President and CEO,
discussed the ProvenCare
SM 47
program at a Finance Committee hearing in September. The
program offers a bundled payment for the package of services provided to patients
receiving cardiac bypass graft surgery. This bundled payment covers the first physician
visit that determined surgery was necessary, all hospital costs for the surgery, and all costs
for related care post surgery, including cardiac rehabilitation. As long as all care was
provided at Geisinger, the patient pays only one charge for this set of services.

The results of the ProvenCare
SM
initiative have been impressive. Within three months of
instituting the program, roughly 86 percent of patients were receiving all recommended
best practices related to cardiac surgery care.
48
Based on this success, Geisinger recently
expanded this model to other high-volume procedures, such as hip replacement, cataract
surgery, obesity surgery, care for babies, and heart catheterization.

Building on these efforts, the Baucus plan would develop and test other models for
bundled payments. As part of this effort, the plan would allow the current CMS bundling
demonstration to expand to other sites and to focus on other clinical conditions if certain
criteria are met. In addition, this plan would encourage CMS to include services that are
provided post-hospitalization as part of the bundling payment model.

Moving toward bundled payments is a complex process that would require time and
resources. The Baucus plan would seek to limit unintended consequences, such as
inappropriate reductions in care to increase profit. In addition, bundling models must also
include appropriate risk adjustment to ensure health care providers are not penalized for or
discouraged from treating sicker patients. Finally, this plan would work to ensure that
efforts to expand payment bundling for hospital and physician services is done in way that
is workable for non-integrated and smaller health care providers.

Physician Group Practice Demonstration and Accountable Care Organizations.
A reformed delivery system should also do a better of job of rewarding providers,
particularly physicians, who work together to offer high-quality, cost-effective care to
patients. The Medicare program is currently testing a project in this area, called the
Physician Group Practice (PGP) demonstration. Now in its fourth year, the PGP
demonstration includes ten large physician groups that receive enhanced payments for
51
improving the quality and efficiency of the care delivered to Medicare beneficiaries.
Groups that meet quality targets and achieve cost reductions beyond a two percent
threshold are permitted to share in the savings that they generate to Medicare. In the
second year, all participants demonstrated improvements in quality and achieved below-
average growth in costs; four were awarded with incentive payments for reducing costs
significantly.
49

Preliminary results from the demonstration and reports from participants suggest that the
program has achieved its goals of better coordination of care for the chronically ill, careful
attention to hospital discharge processes, expanded role for non-physician providers, and
investments in IT.
50
While some design challenges of this demonstration remain —
including the identification of a control group for cost comparison purposes, selection of
meaningful quality measures, and timely generation of feedback to participants — the
results to date merit expansion. The Baucus plan calls for CMS to establish a framework
for reforming and expanding the PGP demonstration after its fifth year, which would end
in March 2010. The plan for expansion should give providers a pathway toward
accountability and shared savings, but should not restrict beneficiary choice. This effort is
consistent with other delivery system reforms proposed in this paper, including expansion
of the medical home, greater adoption of health IT, and transparency regarding provider
quality and costs.

While the current PGP demonstration focuses on large physician group practices,
considerable work has been done to explore the possibility of accelerating broader delivery
system integration by expanding the PGP model to encourage provider collaboration and
accountability on a larger scale.
51


Ideal candidates for expansion are organizations that span the continuum of care in a
community. Integrated health systems, such as Billings Clinic in Montana, InterMountain
in Utah, and Geisinger in Pennsylvania, offer patients access to a range of providers and
settings, including hospitals, post-acute, facilities, and the local physician community.
Due in large part to their innovative organizational model, these systems are providing
high-quality integrated care that is more cost-effective than their competition.

The term accountable care organizations (ACOs) has been used to describe these and other
provider groups that are optimal candidates for payment based on improvements in quality
and savings achieved through improved care processes.
52
Based on the results from the
current PGP demonstration, the Baucus plan would create a new Medicare pilot program to
test the cost and quality opportunities of value-based payments to ACOs.

Organizations eligible to participate in this new project should include integrated delivery
systems, hospitals that employ their own physician staff, academic medical centers and
their affiliated faculty practices, multispecialty group practices, physician hospital
networks or independent practice associations, and primary care physician groups able to
identify the other providers from whom their beneficiaries receive their care. The new
ACO pilot should be implemented in part in communities and regions where meaningful
integration does not yet exist — such as in rural areas and small group practices.
52

As part of this project, ACOs would be subject to group level reporting on a list of quality
measures endorsed by the National Quality Forum (NQF). CMS would establish a
timeline to phase in reporting on these measures, so that within five years, participating
ACOs would be reporting on at least the following classes of measures: (a) risk-adjusted
health outcomes and improvement on specified ambulatory chronic conditions as well as
common inpatient chronic conditions, and (b) patient experience measures for both
ambulatory and inpatient care. CMS would establish benchmarks for achievement and
improvement that ACOs would have to meet in order to qualify for incentive payments.
ACOs that successfully report on measures in a manner consistent with the Physician
Quality Reporting Initiative (PQRI) would qualify for the incentive payment under that
program as well, as is the case for existing PGP demonstration participants.

To determine whether ACOs are successfully controlling costs, CMS would establish a
formula that would allow current and future years’ per beneficiary spending at the ACO to
be estimated as accurately as possible using Medicare Part A and Part B claims for the
beneficiaries it treats. Using multiple prior years of data would allow more accurate and
stable estimates of current year spending.

An issue to be resolved with input from stakeholders and other experts would be how to
establish cost trend targets for participating ACOs.
53
Several approaches to developing the
targets should be considered, balancing the following interests: encouraging providers in
both high- and low-cost regions to participate and receive shared savings payments;
reducing unwarranted geographic variations in per-beneficiary spending; and promoting
regional and ACO-level equity in the amount of increases in per-beneficiary spending
permitted under the shared savings program. Perhaps a middle ground would be to begin
with a formula using regional trends that would slowly phase in a national element to more
aggressively reduce cost growth over time.

Incentive payments would be awarded to ACOs that reduce spending significantly below
the target rate set by the formula. A threshold savings amount should be set — such as the
two percent mark used in the PGP demonstration — to avoid incentive payments being
made to ACOs based on natural variations in their year-to-year spending. Savings should
be based on real system improvements and not accidents.

The plan also calls on CMS to develop a formula for distributing shared savings payments
that would give providers a strong incentive to participate in the program, while ensuring
that a substantial share of the savings would accrue to the Medicare Trust Fund as the
magnitude of savings increases. The PGP demonstration allows participating provider
groups to recoup 80 percent of the cost reductions that they achieve beyond the two
percent threshold, with a cap on incentive payments of five percent of total Medicare
spending. An alternative approach would distribute 100 percent of first three percent of
additional savings beyond the threshold to the ACO, with the share of savings diminishing
above the five percent mark and continuing to decline up to a maximum threshold set by
CMS.

53
The development of a shared savings program building on the success of the PGP
demonstration should proceed as rapidly as possible. To achieve this goal, CMS should
implement ACO pilots on as broad a scale as is feasible, which could permit testing
variations of the model. As is the case with other areas, CMS could also use existing
authority to align payment models in specific regions or states to support similar initiatives
led by private payers and state Medicaid programs.

Gainsharing. As part of delivery system reforms, the Baucus plan would also take steps to
break down existing barriers that keep health care providers from improving patient care
through increased collaboration. Successful implementation of new payment and delivery
models to promote coordination and value-based purchasing may require changes to the
regulatory structure governing provider collaboration. For example, the Stark and anti-
kickback laws — which appropriately protect against financial conflicts-of-interest
between hospitals and physicians — have come to broadly prevent hospitals from offering
financial incentives to physicians who appropriately use imaging services or prevent
readmissions through disease management protocols.

Allowing providers to share among themselves savings from improved efficiency and
quality — also known as gainsharing — is one potential strategy to encourage provider
collaboration.
54
CMS conducted demonstration projects in the 1990s that allowed
participating hospitals to experiment with gainsharing arrangements. While these projects
proved successful at reducing costs and improving patient outcomes, subsequent decisions
by the HHS Office of the Inspector General (OIG) have significantly dampened
gainsharing efforts by allowing only limited projects to move forward.
55

More recently, Congress directed CMS to conduct two demonstration projects that would
examine whether physician-hospital collaboration is an effective method for promoting
quality and constraining costs. CMS is conducting a pair of multi-year programs that will
allow up to 24 hospitals to share with their physician partners a portion of any savings to
the Medicare program that are generated from improved quality and efficiency of care
delivered to Medicare beneficiaries. In particular, one demonstration will focus on
tracking patients beyond their hospital stay, to determine whether provider collaboration
can save money and generate efficiencies across multiple clinical episodes and settings.
56


While promising, neither demonstration has officially launched to date. Once underway,
these projects should provide valuable information on which modern gainsharing strategies
work and which do not, as well as any unintended consequences associated with provider
collaboration.

Concerns about unfettered gainsharing that does not ensure patient safety are warranted.
Therefore, the Baucus plan would strive to work with CMS, the HHS OIG, and interested
stakeholders to develop gainsharing proposals that strike the appropriate balance between
thoughtful incentives for coordination of care and careful protections against financial
conflicts-of-interest that could harm quality of care.

54
D. HEALTH CARE INFRASTRUCTURE

A health system that performs to its potential — providing high value care for every dollar
invested — requires adequate infrastructure to support it. The reforms outlined in this plan
would require new investments in our health care infrastructure. Priorities for
infrastructure investment include: comparative effectiveness research, health information
technology (IT), and the health care workforce.

Comparative Effectiveness Research. The U.S. produces some of the most
technologically advanced medical care in the world. Yet patients and their physicians can
face a daunting task choosing among treatment options. This plan envisions a national
approach to conduct and promote comparative effectiveness research, which would
ultimately improve the ability of providers to deliver the right care at the right time for
each and every patient. Such an effort would likely lower costs too, as the Congressional
Budget Office has signaled that national health spending could be significantly reduced if
more unbiased data were available and used widely by providers and patients.
57

The rapid development of medical technology and medical treatments in the U.S. poses a
challenge for our health system: can it produce evidence regarding what treatments work
best in a timely fashion? Experts agree that the U.S. lacks sufficient capacity to produce
unbiased information to compare existing treatments to determine which ones are more
effective and for which patients.
58, , , , 59 60 61 62
Providers have more diagnostic tests and
treatment options to choose from than ever before, but too often they lack knowledge as to
whether one works better, or if several lead to similar outcomes.

On a limited scale, organizations like the Technology Evaluation Center funded by the
Blue Cross and Blue Shield Association and the Veteran Administration’s Center for
Health Care Evaluation conduct research that compares the effectiveness of different
medical treatments. The National Institutes of Health (NIH) as well as the Agency for
Healthcare Research and Quality (AHRQ) have also conducted seminal research
comparing one or more medical interventions.

Despite these efforts, current funding for effectiveness research in the U.S. is inadequate to
keep pace with medical innovation. Public and private research efforts are also highly
fragmented and poorly coordinated.

Several well-respected panels—including the Institute of Medicine (IOM), the Medicare
Payment Advisory Commission (MedPAC), and the Congressional Budget Office
(CBO)—have called on Congress to create a national entity charged with conducting this
type of research.

The Baucus plan answers these calls. As first suggested in the Comparative Effectiveness
Research Act of 2008,
63
introduced earlier this year, this plan would create a new institute
charged with identifying the most pressing gaps in clinical knowledge that prevent the
health system from delivering the best outcomes for patients.

55
The Health Care Comparative Effectiveness Research Institute envisioned in the
Comparative Effectiveness Research Act of 2008 would be a private, nonprofit corporation
with a Board of Governors appointed from the public and private sectors by the U.S.
Comptroller General. The Institute would be created as an independent entity to remove
the potential for political influence on the development of national research priorities.
Comparative effectiveness research would be more credible, and more useful, if it
remained free from political influence and reflected broad stakeholder input.

In addition to setting national priorities, a new institute should provide for the conduct of
the studies that would meet its priorities. The Institute should not just recommend areas of
inquiry; it should produce the vital information needed. It should be able to contract with
experienced Federal agencies, like NIH, and AHRQ, that have robust research networks in
place and that can be put to good use here. The Institute must also have flexibility to meet
its priorities by contracting directly with private researchers as appropriate.

The comparative effectiveness Institute would need to assess the full spectrum of clinical
interventions, including pharmaceuticals, medical devices, procedures, services, and other
therapies, which have the greatest gaps in evidence and variations in practice patterns. A
broad scope would provide better evidence for existing diagnostics, treatment, prevention,
and management of health conditions. Importantly, the research should meet the goal of
helping patients, providers, and payers of health care to make more informed clinical
decisions.

In addition, the Institute would also need to disseminate its research findings to the public.
It could work in concert with government agencies (such as the Centers for Disease
Control and Prevention and AHRQ), medical societies, and patient networks. Its reports
should serve both clinical and general audiences.

Activities of the Institute should be open to public input and transparent in order to
maintain integrity of the research. For example, the Institute should publish its charter,
rules, proceedings, and reports and make them available on a public Internet site. Its
meetings should be open to the public. It should also provide for public comment periods
at key stages—including the development of research priorities and study designs—in
addition to holding public forums on controversial or complex topics.

Most importantly, the Institute should be subject to rigorous oversight of its finances and
mission in order to maintain the public trust. The Comptroller General should perform
regular audits of its activities to ensure that the Institute meets its statutory mission in a
fair, open, and credible manner.

These new endeavors would need an adequate and stable source of funding. Public funds
would be the best option to get the Institute up and running. But the information produced
by such an Institute would benefit all Americans—those who receive health care through
public and private sources—so it makes sense for a small assessment on private health
insurers to be included. A mix of public and private resources is the best long-term
56
framework for funding, and more reflective of the composition of the Institute and its
broad reach.

America must make a greater investment to generate information about what works in
health care. In the absence of sound evidence, clinical guidelines and protocols can vary
widely. Knowing more about the effect of different health interventions would help to
reduce the variability in treating disease, help to better manage and prevent illnesses, and
help to lower health costs for everyone.

Health Information Technology. Most providers in the health care system collect and
transmit information on paper, over the phone, and via fax machines. More advanced
health information technology (IT) offers tools to streamline and support the process of
collecting and analyzing the data needed to provide the best and most efficient care
possible. Clinical IT comprises multiple applications that can support different functions
in health care, such as:

! Tracking patient care;
! Allowing physicians to order medications, lab work, and other tests electronically,
and then access test results;
! Reporting to chronic disease registries; and
! Providing evidence-based decision support to physicians.

Encouraging more rapid adoption and use of health IT systems will improve health care
quality and make our health care system more efficient.
64,65
Automating the collection of
clinical data will also be a vital component of better quality performance measurement and
reporting.
66
Technology can facilitate richer data sets for comparative effectiveness
research,
67
and help providers use comparative effectiveness findings in their own clinical
practices. The Baucus plan provides Federal-level leadership to spur the modernization
necessary to support a truly patient-centered delivery system.

Health IT adoption by providers has been low to date, especially for physicians in small-
group practices.
68
Providers, particularly physicians, cite as obstacles the cost of
purchasing and implementing systems, a fear of investing in systems that may soon be
obsolete, as well as a lack of a clear return on investment.
69,70
Some providers, especially
in smaller settings, lack the resources or expertise to navigate the large and complex
market of health IT products or to maintain such a system over time. Implementing health
IT also requires changes in office organization, processes, and culture that clinicians and
office staff may resist. Safeguards must be put in place to ensure that patient privacy is
protected. And existing payment incentives discourage health IT adoption. Reductions in
office visits, hospital admissions, and other services that could be achieved through the use
of health IT would accrue to the benefit of payers and patients but not to providers
themselves.

Despite these challenges, there is a growing consensus among patient advocates, providers,
and payers that a path forward that drives adoption and protects patient privacy must be
found.
57

Consistent with recommendations made by MedPAC and others, the Baucus plan proposes
three strategies to encourage the adoption and use of health IT: (1) financial incentives, (2)
assistance to providers in navigating the health IT market and implementing systems, and
(3) promotion of information sharing among providers.

Direct grants, loans, and financial incentives provided through Medicare pay-for-
performance initiatives could promote adoption of health IT. Congress recently
established bonus payments in Medicare for physicians using qualified e-prescribing
systems. These bonus payments phase down over five years and become a requirement
(enforced through payment reductions). A similar model could be employed to encourage
the use of electronic health records if other obstacles are addressed.

Helping providers navigate the health IT market and implement qualified systems could
also aid widespread adoption. The Baucus plan will accelerate efforts to certify software
products by setting a deadline for the establishment of harmonized interoperability
standards; if the private sector does not find timely consensus, then the Office of the
National Coordinator for Health IT would immediately promulgate standards. The plan
also calls for additional technical assistance to help providers assess products, understand
their needs, and manage implementation and ongoing maintenance.

Promoting the sharing of information among providers also would improve coordination of
care and efficiency, getting more out of health IT. Efforts at the community level to
increase this exchange have seen limited success in some areas, but stronger leadership at
the Federal level will be necessary to initiate nationwide adoption of advanced,
interoperable health IT systems.

Health Care Workforce. Today, health care workers represent roughly 12 percent of the
American labor force.
71
While these workers strive to provide high-quality care and make
important contributions, there are growing concerns that the U.S. does not have a sufficient
supply of health care professionals to meet the demands of a changing and aging
population.

Various studies suggest that the country is facing a health professional shortage.
According to the American Association of Medical Colleges (AAMC), there have been at
least 35 studies published since 2002 demonstrating current or future physician workforce
needs.
72
Among these is a report by the Health Resources and Services Administration
(HRSA), which predicts that demand for physician services will exceed supply by 2020.
73

Other studies by HRSA warn of a nursing shortage in the coming years.
74


As the population continues to age, a shortage of health care workers will become
increasingly problematic. Between 2005 and 2020, the number of Americans over age 65
is projected to increase by 50 percent.
75
During the same period, the number of physicians
is projected to grow only 16 percent.
76
An inadequate physician supply will not only
affect the elderly, but also the 20 percent of Americans who live in underserved
communities and already struggle to obtain access to medical care.
58

The Federal government plays a key role in training future health care professionals
through the Medicare Graduate Medical Education (GME) program. Included in the 1965
legislation that created Medicare, the GME program provides subsidies to help teaching
hospitals and other entities cover the direct costs associated with medical training in
accredited teaching programs. The program has served as a major funding source for
medical training for most teaching hospitals. In 2007, Medicare spent roughly $8.8 billion
on GME activities.

While the Medicare GME program has provided essential resources for training America’s
physicians, it needs to be reexamined. In recent years, the AAMC and other stakeholders
have raised concerns about rules in the current Medicare program that place a cap on the
number of medical residency slots that can be supported by the GME program. The
residency cap was established as part of the Balanced Budget Act of 1997 in response to
what many considered an oversupply of physicians in the pipeline.
77
Since this rule took
effect, the landscape of physician supply relative to demand has shifted, and roughly 6,500
medical training positions have been created that do not receive support from Medicare.
78

Also of concern has been the question of whether the Medicare GME program should
place a greater emphasis on providing training in critical focus areas, such as primary care,
geriatrics, and preventive services. There is also discussion about allocating GME funds
toward nurse practitioners and physician assistants who also play a role in managing
patients’ primary care needs. In addition, others have recommended that training programs
place a greater emphasis on preparing providers to practice in an organized delivery system
or team-based environment.
79
Similarly, GME funding should be used to train residents
outside traditional hospital settings, such as in community-based primary care offices.
80

These policies represent a shift in the structure and focus of the GME program, but are
worth serious Congressional consideration.

In addition to direct payments for GME, Medicare also subsidizes the indirect costs of
patient care associated with graduate medical training. Indirect medical education (IME)
payments under Medicare are based on the ratio of residents to beds — the higher the ratio,
the higher the payment. These payments are not well targeted and are set at a level that is
twice as high as what can be justified empirically. According to MedPAC, more than $3
billion in extra payments are made to teaching hospitals with no accountability for how
these funds are used.
81
Congress should increase accountability around how these and
other GME funds are spent.

As we work to strengthen graduate medical education programs, we must also take steps to
increase the number of racial and ethnic minorities who enter our health workforce.
Minorities are underrepresented among our nation’s health care workers. Among
physicians, African-American and Latino physicians comprise only three and a half and
five percent, respectively, of the physician workforce compared to 11 and 13 percent,
respectively, of the general population. Native Americans/Alaska Natives comprise only
two percent of the physician workforce. The same degree of disparity is also evident in the
59
area of nursing care. Racial or ethnic minorities represent only 14 percent of the nursing
workforce while they represent 34 percent
82
of the general population.

Strategies to improve the racial and ethnic diversification of our health workforce include
increasing the number of pipeline education programs at the high school and college level
and providing funding for scholarship and loan programs that support racial diversification
among health workers and medical faculty. Many of these programs, such as Title VII and
Title VIII of the Public Health Service Act, merit re-examination as we work to improve
our health care infrastructure. Loan assistance and forgiveness programs for caregivers
who choose to practice in underserved areas should also be expanded to make sure that
patient needs are met, especially as we expand access to insurance for millions of
Americans.

Significant work must be done in these areas, and Congress must dedicate the time and
attention to graduate medical education that it deserves. Policy solutions in this area
should be considered as part of health care reform. Next steps could include:

! Evaluating whether changes are needed to the number of allowable GME training
slots;
! Exploring options to increasing the residency cap for certain specialty areas;
! Determining ways to modernize the GME benefit through policies to allow training
in other treatment settings and encouraging a focus on care coordination;
! Increasing accountability of indirect medical education (IME) funding; and
! Working with the Senate Health, Education, Labor and Pensions (HELP)
Committee to address workforce shortages and support increased racial and ethnic
diversity within the health care workforce by strengthening public health programs
in these areas.

These efforts are critical if we are to place our nation’s workforce on sound footing to
address the health care needs of current and future generations.


1
Barbara Starfield, Leiyu Shi, and James Macinko, “Contribution of Primary Care to Health Systems and
Health,” Milbank Quarterly 83, no. 3 (2005): 457-502.
2
Katherine Baicker and Amitabh Chandra. 2004, “Medicare Spending: The Physician Workforce, and
Beneficiaries’ Quality of Care,” Health Affairs, no. 10 (2004):184-196 (published online 7 April, 2004;
10.1377/hlthaff.w4.184).
3
Barbara Starfield, Leiyu Shi, and James Macinko, “Contribution of Primary Care to Health Systems and
Health,” Milbank Quarterly 83, no. 3 (2005): 457-502.
4
Medicare Payment Advisory Commission, “Report to Congress: Reforming the Delivery System,” (2008).
5
Ibid.
6
Medicare Payment Advisory Commission, “Report to Congress: Reviewing the Work Relative Values of
Physician Fee Schedule Services,” (2008): 135.
7
Medicare Payment Advisory Commission, “Report to Congress: Reforming the Delivery System,” (2008)
8
Richard J. Baron and Christine K. Cassell, “21
st
-Century Primary Care: New Physician Roles Need New
Payment Models,” Journal of the American Medical Association, 299, no. 13, (2008): 1595-1597.
60

9
Stephen Wilhide and Tim Henderson, “Community Care of North Carolina: A Provider-Led Strategy for
Delivering Cost-Effective Primary Care to Medicaid Beneficiaries,” American Academy of Family
Physicians, (2006).
http://www.aafp.org/online/etc/medialib/aafp_org/documents/policy/state/medicaid/ncfull.Par.0001.File.tmp/
ncfullreport.pdf
10
The Tax Relief and Health Care Act of 2006, Public Law 109-432.
11
The Medicare Improvements for Patients and Providers Act of 2008, Public Law 110-275.
12
Criteria for provider participation in the medical home program should, at minimum, include the
following: Provision of primary care services (including coordinating appropriate preventive, maintenance,
and acute health services); active care management; use of health information technology for active clinical
decision support; implementation of a formal quality improvement program; implementation of a rapid
access, 24-hour patient communication system; ability to maintain up-to-date records of beneficiaries’
advance directives; and a maintenance of a written understanding with each beneficiary designating the
provider as a medical home.
13
National Committee for Quality Assurance, www.ncqa.org
14
Stephen Wilhide and Tim Henderson, “Community Care of North Carolina: A Provider-Led Strategy for
Delivering Cost-Effective Primary Care to Medicaid Beneficiaries,” American Academy of Family
Physicians, (2006).
http://www.aafp.org/online/etc/medialib/aafp_org/documents/policy/state/medicaid/ncfull.Par.0001.File.tmp/
ncfullreport.pdf
15
S.3613, the Independence at Home Act, introduced by Senator Ron Wyden, September 2008, and S.1340,
the Geriatric Assessment and Chronic Care Coordination Act, introduced by Senator Blanche Lincoln, May
2007.
16
RTI International, “Report to Congress: Evaluation of Phase I of Medicare Health Support (Formerly
Voluntary Chronic Care Improvement) Pilot Program Under Traditional Fee-for-Service Medicare,” (2007).
17
Mathematica, “Third Report to Congress on the Evaluation of the Medicare Coordinated Care
Demonstration,” (2008).
18
National Association of Community Health Centers, “Access For All America Quality of Care Statistics”,
NACHC, www.nachc.org/aaa-statistics.cfm
19
Institute of Medicine, “To Err is Human: Building a Safer Health Care System,” National Academy Press,
(1999).
20
Institute of Medicine, “Crossing the Quality Chasm: A New Health System for the 21
st
Century,” National
Academy Press, (2001).
21
Institute of Medicine, “Performance Measurement: Accelerating Improvement,” National Academy Press,
(2006).
22
Medicare Payment Advisory Commission, “Report to the Congress: New Approaches in Medicare,”
(2004).
23
Medicare Payment Advisory Commission, “Report to the Congress: Medicare Payment Policy,” (2005).
24
Medicare Prescription Drug, Improvement and Modernization Act of 2003 (P.L. 108-173), section 501(b).
25
Congressional Research Service, “Report to Congress: Pay-for-Performance in Health Care,” CRS, (2006):
18.
26
Deficit Reduction Act (P.L. 109-171), section 5001 (a).
27
Centers for Medicare and Medicaid Services, “Medicare Fact Sheet, Fiscal Year 2009 Quality Measure
Reporting for 2010 Payment Update,” CRS, http://www.cms.hhs.gov/apps/media/fact_sheets.asp.
61

28
Premier, “Value-based Purchasing: HQID and Premier’s P4P Leadership,” Premier,
http://premierinc.com/quality-safety/tools-services/p4p/index.jsp.
29
Premier, “CMS/Premier Hospital Quality Incentive Demonstration: Year 2 results,” Premier, (2007),
http://www.premierinc.com/about/news/jan-07/hqid-year2.jsp
30
Centers for Medicare and Medicaid Services, “Report to Congress: Plan to Implement a Medicare Hospital
Value-Based Purchasing Program,” CMS, (2007).
31
Government Accountability Office, “Focus on Physician Practice Patterns. Can Lead to Greater Program
Efficiency,” GAO, (2007).
32
Medicare Payment Advisory Commission, “Report to Congress: Assessing Alternatives to the Sustainable
Growth Rate System,” (2007).
33
Mark C. Hornbrook et al., “Health Care Episodes: Definition, Measurement, and Use,” Medical Care
Review, 42, no. 2, (1985): 163.
34
Medicare Improvements for Patients and Providers Act of 2008 (P.L. 110-275), section 183.
35
Balanced Budget Act of 1997, Public Law 105-33.
36
Congressional Budget Office, “The Sustainable Growth Rate Formula for Setting Medicare’s Physician
Payment Rates,” CBO, (2006).
37
Congressional Budget Office, “Estimated Changes in Net Federal Outlays from Alternative Proposals for
Changing Physician Payment Rate,” CBO, (2008).
38
Medicare Payment Advisory Commission, “Report to Congress: Assessing Alternatives to the Sustainable
Growth Rate (SGR) Formula,” (2007).
39
H.R.3162, Children’s Health and Medicare Protection Act of 2007, introduced by Congressman John
Dingell, July 2007.
40
Government Accountability Office, “Medicare Part B Imaging Services: Rapid Spending Growth and Shift
to Physician Offices Indicate Need for CMS to Consider Additional Management Practices,” GAO, (2008).
41
Medicare Payment Advisory Commission, “Report to Congress: Assessing Alternatives to the Sustainable
Growth Rate System,” (2007).
42
Eric A. Coleman, and Robert A. Berenson, “Lost in Transition: Challenges and Opportunities for
Improving the Quality of Transitional Care,” Annals of Internal Medicine 141, no. 7 (2004): 533-536.
43
Medicare Payment Advisory Commission, “Report to Congress: Reforming the Delivery System,” (2008).
44
The Commonwealth Fund, “Why Not the Best? Results from the National Scorecard on the U.S. Health
System Performance” The Commonwealth Fund, (2008),
http://www.commonwealthfund.org/usr_doc/StateScorecard.pdf?section=4039.
45
Jerry Cromwell et al., “Medicare Participating Heart Bypass Demonstration: Final Report,” Waltham, MA:
Health Economics Research, Inc., (1998).
46
Medicare Payment Advisory Commission, “Report to Congress: Reforming the Delivery System,” (2008):
90.
47
Glenn Steele, “Aligning Incentives: The Case for Delivery System Reform,” (Testimony before Senate
Committee on Finance, U.S. Senate, September 16, 2008).
48
Ibid.
49
Centers for Medicare and Medicaid Services, “Medicare Demonstrations,”
http://www.cms.hhs.gov/DemoProjectsEvalRpts/MD/itemdetail.asp?filterType=none&filterByDID=-
99&sortByDID=3&sortOrder=descending&itemID=CMS1198992&intNumPerPage=2000
62

50
Michael Trisolini et al., “The Medicare Physician Group Practice Demonstration: Lessons Learned on
Improving Quality and Efficiency in Health Care,” The Commonwealth Fund, (2008).
51
Elliot S. Fisher et al., "Creating Accountable Care Organizations: The Extended Hospital Medical Staff,"
Health Affairs, 26, no. 1 (2007).
52
Stephen M. Shortell and Lawrence P. Casalino, “Health Care Reform Requires Accountable Care
Systems,” Journal of the American Medical Association, 300, (2008): 95-97.
53
The PGP demonstration program uses a control group to evaluate whether participants are reducing
spending. While this approach has some strengths and some weaknesses, it is not feasible to implement on a
national scale and thus should not be employed in the next iteration of the PGP approach.
54
Gail R. Wilensky, Nicholas Wolter, and Michelle M. Fische, “Gain Sharing: A Good Concept Getting A
Bad Name?” Health Affairs 26, no. 1, (2007): 58-67.
55
Ibid.
56
The Centers for Medicare and Medicaid Services, “Details for DRA 5007 Medicare Hospital Gainsharing
Demonstration,” CMS,
http://www.cms.hhs.gov/demoprojectsevalrpts/md/itemdetail.asp?filterType=none&filterByDID=0&sortByD
ID=3&sortOrder=descending&itemID=CMS1186805&intNumPerPage=10.
57
Congressional Budget Office, “Research on the Comparative Effectiveness of Medical Treatments,” CBO,
(2007), http://www.cbo.gov/ftpdocs/88xx/doc8891/12-18-ComparativeEffectiveness.pdf.
58
Gail Wilensky, “Developing A Center For Comparative Effectiveness Information,” Health Affairs, 25, no.
6 (2006): 572-585.
59
Kathy Buto and Peter Juhn, “Can A Center For Comparative Effectiveness Information Succeed?
Perspectives From A Health Care Company,” Health Affairs, no. 6 (2006): 586-588.
60
IOM Roundtable on Evidence-Based Medicine, “Learning What Works Best,” (2007).
61
Medicare Payment Advisory Commission, “Report to Congress: Reforming the Delivery System,” (2008).
62
Paul B. Ginsburg, “Rising Costs, Low Quality in Health Care: The Necessity for Reform,” (Testimony
before the Senate Committee on Finance, U.S. Senate, June 2, 2008).
63
S.3408, The Comparative Effectiveness Research Act of 2008, Introduced by Senator Baucus and Senator
Conrad.
64
Richard Hillestad, James Bigelow, Anthony Bower, Federico Girosi, Robin Meili, Richard Scoville, and
Roger Taylor, “Can Electronic Medical Record Systems Transform Healthcare? An Assessment of Potential
Health Benefits, Savings, and Costs,” Health Affairs, 24, no. 5, (2005): 1103-1117.
65
Medicare Payment Advisory Commission, “Report to Congress: New Approaches in Medicare,” (2004).
66
Richard Hillestad, “The Right Care at the Right Time: Leveraging Innovation to Provide Quality Care for
All Americans,” (Testimony before the Senate Committee on Finance, U.S. Senate, July 17, 2008).
67
Gail Wilensky, “The Right Care at the Right Time: Leveraging Innovation to Provide Quality Care for All
Americans,” (Testimony before the Senate Committee on Finance, U.S. Senate, July 17, 2008).
68
David Gans et al., “Medical Groups’ Adoption of Electronic Health Records and Information Systems,”
Health Affairs, 24, no. 5, (2005): 1323.
69
Medicare Payment Advisory Commission, “Report to Congress: New Approaches in Medicare,” (2004).
70
Richard Hillestad, “The Right Care at the Right Time: Leveraging Innovation to Provide Quality Care for
All Americans,” (Testimony before the Senate Committee on Finance, U.S. Senate, July 17, 2008).
71
Health Resources and Services Administration, “The United States Health Workforce Profile,” HRSA,
(2006), http://bhpr.hrsa.gov/healthworkforce/reports/#medicine.
63

72
Edward Salsberg, “Healthcare Workforce Issues for the Future,” (Testimony before the Committee on
Health, Education, Labor and Pensions, U.S. Senate, February 12, 2008).
73
Health Resources and Services Administration, “Physician Supply and Demand: Projections to 2020,”
HRSA, (2008),
http://bhpr.hrsa.gov/healthworkforce/reports/physiciansupplydemand/default.htm.
74
Health Resources and Services Administration, “Towards a Method for Identifying Facilities and
Communities with Shortages of Nurses,” HRSA, (2007), ftp://ftp.hrsa.gov/bhpr/nursing/nurptsummary.pdf.
75
Health Resources and Services Administration, “The United States Health Workforce Profile,” HRSA,
(2006), http://bhpr.hrsa.gov/healthworkforce/reports/#medicine.
76
Ibid.
77
The Balanced Budget Act of 1997 (P.L 105-33, Chapter II).
78
John K. Iglehart, “Health Policy Report: Medicare, Graduate Medical Education, and New Policy
Directions,” New England Journal of Medicine 359, no. 6 (2008): 645.
79
The Commonwealth Fund, “Organizing the U.S. Health Care Delivery System for High Performance,” The
Commonwealth Fund, (2008).
80
Edward Salsberg, “Healthcare Workforce Issues for the Future,” (Testimony before the Committee on
Health, Education, Labor and Pensions, U.S. Senate, February 12, 2008).
81
Medicare Payment Advisory Commission, “Report to Congress: Reforming the Delivery System,” (2008).
82
U.S. Census Bureau, “Nation’s Population One-Third Minority,” U.S. Census Bureau, (2006),
http://www.census.gov/Press-Release/www/releases/archives/population/006808.html.
64
CHAPTER IV BAUCUS PLAN: FINANCING A MORE EFFICIENT
HEALTH CARE SYSTEM

The U.S. spends $2.3 trillion a year — more than 16 percent of the U.S. economy — on
health care, and economists warn that rising health care costs represent a serious threat to
our long-term fiscal security.
1,2
We spend more than any other country on health care —
both per capita and as a percentage of gross domestic product — yet the Congressional
Budget Office (CBO) estimates that up to one-third of that spending does not improve
Americans’ health outcomes.
3
That means we spend over $700 billion more than we need
to get the outcomes that we receive today. Clearly, excess spending must be eliminated
and dollars put to better use — not only to correct the imbalances of the current health care
system, but to offset the high costs of much-needed comprehensive reform.

Americans deserve a health care system in which everyone has affordable coverage, no
matter their age, income, employment, or health status. This will require an investment.
Some experts predict that a health system covering all Americans would necessitate $100
billion to $150 billion in new Federal spending per year.
45
But savings from the reforms
proposed earlier in this Call to Action and the financing mechanisms in this section can
make the net cost of reform much smaller.

National spending on health care can be lowered, and quality improved, by realigning the
health care system toward prevention and primary care, rewarding providers that deliver
quality, evidence-based care, and investing in critical research and health information
technology that can lead to higher-value care. Beyond these measures, the Baucus plan
endorses even further, more direct steps in these five areas to curb excess health care
spending.

! Fraud, Waste, and Abuse. New initiatives should be implemented immediately to
better detect and eliminate financial fraud and abuse in our public programs.
Taxpayer dollars should cover needed benefits and not fraudulent medical claims.

! Increased Transparency. Public reporting of the costs and quality of care — as
well as the relationships between providers and drug or device makers that may
lead to biased decision-making — can encourage providers to pursue better
outcomes and help patients choose better, more efficient providers and treatments
when they are able to do so. Information about the full value of employer-
sponsored health care could help employees make better coverage decisions for
themselves and their families. Greater transparency in these areas can help
eliminate waste and drive better value throughout the health system.

! Medical Malpractice. Careful reforms of medical malpractice laws can lower
administrative costs and health spending throughout the system, while ensuring that
injured patients are compensated fairly for their losses.

! Private Insurance Plans in Medicare. If private insurers participate in Medicare,
they must bring value to the program and beneficiaries. Overpayments to private
65
insurers in the Medicare Advantage program must be eliminated so that spending is
put on a level playing field with traditional Medicare. Payments should also be
modified to promote the best of what plans have to offer beneficiaries, without
financial giveaways to insurers. Price discounts for prescription drugs of the dual-
eligibles in Medicare’s prescription drug plans should reflect discounts in
Medicaid.

! Long-Term Care Services and Supports. The current long-term care system is
expensive, fragmented, and does not encourage the delivery of high-quality care.
Further expanding home and community-based care, testing new models of care
delivery and coordination, and better supporting family caregivers are essential to
improving the quality and efficiency of the system. These ends cannot be
accomplished without a stronger investment in a more robust workforce.

! Tax Incentives for Health Coverage. Congress should also explore targeted
reforms of the tax code to make incentives work better within the current system.
Since the mid-1950s, tax incentives for employer-sponsored health benefits have
made employer coverage more affordable for millions of workers. Similar but
smaller tax incentives increase access to coverage for the self-employed and ease
the burden of health expenses for people with no employer coverage. Such tax
provisions have been and will continue to be the main tool used to foster employer-
based health insurance coverage in the U.S. But it is time to explore ways in which
tax incentives can be modified to distribute benefits more fairly and effectively. At
the same time, targeted reforms can promote smarter, more efficient spending of
health care dollars by consumers themselves.

In the short term, health care reform will likely cost taxpayers more than the government
can achieve in savings from all reforms and financing changes. Much of the savings from
reforms, such as comparative effectiveness research and malpractice reform, would not
accrue until policies have been in place for several years.

Congress and the public must be realistic about the timeframe in which the fiscal success
of reform is measured. If we fail to act, however, the current national expenditure on
health care will double from over $2 trillion to $4 trillion, tens of millions will continue to
be uninsured, poor quality will continue to contribute to nearly 100,000 deaths each year,
and the nation’s entitlement programs will consume a greater portion of the Federal
budget. In short, the costs of inaction, both in human and financial terms, would
eventually be far greater than any initial outlays. America must choose to invest now in a
health care system that will richly repay the nation with greater health and economic
stability in the long term.

A. FRAUD, WASTE, AND ABUSE
Fraud, waste, and abuse cheat the taxpayer, can harm beneficiaries, and threaten the
financial integrity of essential Federal health care programs. Many payment errors are the
result of honest mistakes unrelated to providers or suppliers trying to take advantage of
66
Medicare, Medicaid, and CHIP. However, some providers and suppliers purposefully
manipulate these programs for financial gain.
There are clear differences between fraud, waste, and abuse. Fraud and abuse connote
some level of culpability in that they involve billing practices or behaviors that include
misrepresentation of or overcharging for services delivered. Fraud is willful or intentional,
and abuse is a deviation from acceptable business and medical standards. Both lead to
unnecessary costs to the payer.
6


In 1994, the Health and Human Services Inspector General, June Gibbs Brown, said in
testimony before the Senate Appropriations Committee that, “Fraud is the obtaining of
something of value through intentional misrepresentation or concealment of material facts.
Abuse is any practice that is not consistent with the goals of providing patients with
services which (1) are medically necessary, (2) meet professionally recognized standards,
and (3) are fairly priced. Waste is the incurring of unnecessary costs as a result of deficient
practices, systems, or controls.”
7
The full magnitude of health care fraud, waste, and abuse cannot be determined with
precision, but evidence of the problem is everywhere. For instance, the U.S. spends more
than $2 trillion on health care every year. Of that amount, the National Health Care Anti-
Fraud Association estimates conservatively that at least three percent — or more than $60
billion each year — is lost to fraud. The Secretary of Health and Human Services (HHS),
acting through the Department’s Office of Inspector General (OIG), and the Attorney
General, run the Health Care Fraud and Abuse Control (HCFAC) program, which
coordinates Federal, state, and local law enforcement activities to prevent health care fraud
and abuse. In the ten years since its inception, HCFAC has returned over $10.4 billion to
the Medicare Trust Fund alone.
8

The amount of money wasted on billing errors and other mistakes is also staggering. Last
year, the Medicare program reported a fee-for-service payment error rate of 3.9 percent,
which means that Medicare paid over $10.8 billion incorrectly.
9
Many of the
improvements to the delivery system discussed in the preceding chapter would help reduce
wasteful spending. Better alignment of incentives and value-based purchasing in particular
would reduce waste because they will cut down on instances in which Medicare pays for
something beneficiaries do not need.
While the efforts to fight fraud, waste, and abuse have been commendable, we need to do
more. Outlays for Medicare and Medicaid almost doubled between 2000 and 2008, but the
outlays for fighting fraud and abuse in these programs have not kept pace. We can provide
more and better care for our beneficiaries if we do more to reduce fraud, waste, and abuse.
Medicare, Medicaid, and CHIP must have flexibility to quickly deliver high-quality, low-
cost services while minimizing providers’ administrative burdens. More can be done to
combat unnecessary spending. The Baucus plan, which includes ideas articulated by HHS
OIG,
10
would focus on preventing fraud, waste, and abuse before they happen, and
aggressively detecting them when prevention fails. A five-part strategy will effectively
67
fight fraud, waste, and abuse, while allowing the programs to effectively serve
beneficiaries.

First, the government must do a better job of screening those allowed to become providers
and suppliers in Medicare, Medicaid, and CHIP. Ensuring that only well-intentioned and
law-abiding people and companies have the privilege of providing health care items and
services to beneficiaries is an important initial step. For example, in January of 2005, an
individual arrived in Miami-Dade County from Cuba and soon thereafter enrolled as a
Medicare provider. From April until June, his new company billed over $4.1 million in
fraudulent claims and was paid $1.65 million. He has since disappeared. This person
should never have been allowed to become a supplier.

Second, government payment methodologies should discourage, rather than encourage,
providers or suppliers from engaging in fraud, waste, or abuse. For example, in 2006,
Medicare allowed an average $7,215 for rental of a piece of durable medical equipment
that costs about $600 to purchase new.
11
As a result of these excessive fees, beneficiaries
also incurred $1,443 in coinsurance charges for this equipment. The competitive bidding
program for durable medical equipment, prosthetics, and orthotics has been temporarily
delayed. Competitive bidding is a proven method for saving money and reducing fraud in
this area, however, and the program should move forward.
12


Third, working with providers and suppliers to promote compliance with program
requirements and quality and safety standards could actually increase it. Most health care
providers and suppliers intend to act in accordance with program requirements, but need
help doing so. The same is true for quality and safety standards applicable in Medicare,
Medicaid, and CHIP.

Fourth, the Federal government has an absolute duty to conduct vigilant oversight of
Medicare, Medicaid, and CHIP and continuously monitor for evidence of fraud, waste, and
abuse. Improvements and enhancements in the collection and review of data,
establishment of internal controls, investigation of providers and suppliers, mandated
reporting of violations, and penalties and sanctions would enable better detection and
punishment of inappropriate or unlawful behavior.

Finally, responses to detected fraud must be swift and strong. Punishments must be
sufficient to deter others from considering the same behavior. Program vulnerabilities that
are revealed by the fraudulent conduct must be remedied to prevent repeated abuse. For
example, Florida’s Miami-Dade County is home to many companies that claim to be
durable medical equipment suppliers, infusion clinics, and other Medicare providers and
suppliers. In May 2007, the Department of Justice and HHS OIG created a strike force
whose primary goal was to attack the fraud problem by decreasing the amount of time
between the government’s detection of a fraud scheme and the arrest and prosecution of
the offenders. That effort has lead to over 76 convictions and criminal fines and civil
recoveries in excess of $140 million.

68
Success demands that the resources devoted to fighting fraud, waste, and abuse be
sufficient to respond to this growing problem. The Baucus plan would invest much needed
resources to carry out this fight because it takes time, manpower, and money to effectively
monitor and detect fraudulent, wasteful, or abusive practices. Effective elimination of
fraud provides a significant return on investment. According to the Office of Management
and Budget, the HHS OIG demonstrated a return on investment of 16:1 for these efforts.
13


Watchdog and advisory agencies like the HHS OIG, Government Accountability Office,
state Medicaid Fraud Control Units, the Medicare Payment Advisory Commission, and law
enforcement agencies must be provided with the resources that they need to combat fraud,
waste, and abuse. We also need to work with the HHS and CMS program managers
responsible for protecting and effectively managing these programs.

B. INCREASED TRANSPARENCY

Making more information available to health care providers and consumers would remove
much of the mystery that currently shrouds our health care system. It is often too difficult
for Americans to understand what services they receive or why they receive them, what
they pay for relative to their insurer, or what their insurer is charged — not to mention
what a service actually costs. Providers suffer from some of this same confusion. This
lack of understanding leads to frustration.

Increasing transparency — providing more and better information — would improve the
level of understanding. With better information, consumers, providers and payers would
gain a better understanding of how the system works and would be able to see how health
care dollars are spent. Providing meaningful and useful information would alleviate much
of the frustration and suspicion.

The Baucus plan focuses on three areas that would benefit from greater transparency:
physician-industry relationships, physician self-referral, and cost and quality information.

Physician-Industry Relationships. Harvard’s Eric Campbell told the Finance Committee:
“A physician-industry relationship exits whenever a physician accepts anything from a
pharmaceutical or device company such as dinners at fancy restaurants, pens, drug
samples, lunches, trips and paid consultancies.”
14
Though these relationships may lead to
advancements in medical technology and a better understanding of medical procedures,
“this practice likely results in substantial increases in the costs of health care.”
15
These
higher costs occur because industry gifts, “may also result in physicians prescribing higher
priced, brand-name drugs instead of cheaper, equally effective alternatives.”
16
These types
of relationships are common throughout the physician community.

According to a Harvard Medical School study, “most physicians (94 percent) reported
some type of relationship with the pharmaceutical industry, and most of these relationships
involved receiving food in the workplace (83 percent) or receiving drug samples (78
percent). Thirty-five percent received reimbursement for costs associated with
professional meetings or continuing medical education, and more than one quarter (28
69
17
percent) received payments for consulting, giving lectures, or enrolling patients in trials.”
In 2005, pharmaceutical companies spent $7 billion on sales representative visits to
physicians and provided $18 billion worth of free samples.
18

To dissuade inappropriate relationships, both the American Medical Association (AMA)
and the Pharmaceutical Research and Manufacturers of America (PhRMA) adopted or
revised their codes of conduct involving industry relationships. The AMA “allows
physicians to accept gifts as long as the gifts primarily benefit patients and are not of
substantial value.”
19
The PhRMA code states such relationships “are intended to benefit
patients and to enhance the practice of medicine,” and should be used, “solely on each
patient’s medical needs.”
20
Though these updated guidelines are a step in the right
direction, “there is also evidence that interactions prohibited by voluntary codes continue
to occur.”
21

Four states (Minnesota, Vermont, Maine, and West Virginia) and the District of Columbia
have enacted laws that require drug manufacturers to report any cash and in-kind payments
made to physicians.
22
Many advocate more detailed reporting of gifts between industry
and physicians on a national level. National legislation has been introduced that would
require drug and device companies to disclose all gifts of $25 or more to physicians and
other medical providers.
23

A recent MedPAC report to Congress outlined several advantages of such a requirement.
It may discourage inappropriate arrangements between physician and industry, allow the
media to explore potential conflicts of interest, enable payers to examine physician
practices that may be influenced by particular relationships, and highlight those physicians
who have decided not to take part in inappropriate relationships.
24

Unfortunately, data collection alone may not prevent inappropriate relationships.
However, once national, system-wide data is available, the extent of industry influence and
the wasteful spending that it leads to can be better determined. With this information,
stronger enforcement can be put into place, so that regardless of provider relationships, we
can be sure physicians are recommending and performing medical care based on sound
medical science rather than heavy-handed industry influence.

For these reasons, the Baucus plan would require disclosure of gifts and other transfers of
value made by drug and device companies to physicians and other health care
professionals. Only with this information can potential bias be known. And the
requirement to disclose may deter inappropriate behavior. Disclosure is the only way to
know if there are inappropriate influences on the delivery of care and use of taxpayer
dollars.

Physician Self-Referral. Physicians, like most professionals, expect to get paid for the
work that they perform. Some physicians, however, have found a way to game the system
so that, in addition to getting paid, they reap additional financial benefits from the
provision of certain health care services. Physicians can accomplish this by having
ownership or other financial interests in equipment or facilities — such as an MRI machine
70
or a hospital — that provide health services. When those physicians refer their patients for
services from which the physician reaps the additional financial benefits — a practice
known as self-referral — there is reason to be concerned about the physician’s motives.

Physician self-referral is generally prohibited by Federal law when the patient is covered
by Medicare or Medicaid.
25
Self-referral creates conflicting incentives for physicians,
because the financial incentive to increase utilization of the financially-rewarding services
may conflict with otherwise sound medical and professional judgment. Ultimately, this
practice often results in an “increased use of services and higher payments from third party
payers.”
26


Congress has enacted several laws to confront this problem. In 1972, Congress enacted the
Anti-Kickback Statute, which “broadly prohibits the purposeful offer, payment, or receipt
of anything of value to induce the referral of patients from services reimbursable by a
federal health care program.”
27
Few prosecutions occurred, however, and referrals to
imaging facilities or medical laboratories were not deterred.
28

In 1989, Congress enacted the Ethics in Patient Referrals Act (known as Stark I), which
prohibits physicians from “referring Medicare or Medicaid patients for clinical laboratory
services to labs with which the physician has a financial relationship…unless the
relationship fits within a specified exception.”
29
In 1993, Congress enacted amendments
(known as Stark II) expanding the prohibited services to “physical and laboratory therapy,
radiology, radiation, home health care, hospital, outpatient prescription drugs, and many
types of medical equipment and supplies.”
30

The Baucus plan would scrutinize physician self-referral to ensure that physicians are not
engaged in financial arrangements that place financial interests ahead of the needs of
patients and the American taxpayer. Physicians deserve fair pay for providing services,
but they should not be able to game the system unfairly. Increased transparency to both
patients and payers in the form of disclosure of physicians’ financial interests is first step.

One example is physician ownership of hospitals. There is concern that physician
ownership of hospitals leads to cherry-picking the patients who are healthiest and most
able to pay, while leaving the patients who are sickest and least able to pay for community
hospitals to treat, often without much compensation, if any. This cherry-picking only
exacerbates the cost shifting to those Americans with insurance. This concern is
heightened by the fact that the patient often is unaware of a physician’s financial interest in
providing services at a hospital in which he or she has an ownership interest.

Physician-owned hospitals are often smaller and more specialized than community
hospitals. They tend to focus on lucrative lines of service. Community hospitals, on the
other hand, tend to provide all service lines, including emergency departments.
Community hospitals find it difficult to compete with their more cash-rich physician-
owned counterparts. Over time, the trend of increasing physician ownership of hospitals
jeopardizes the continued viability of community hospitals.

71
The issue of self-referral must be reviewed in light of how health care is and will be
delivered. No serious effort at reform can ignore the potential gaming that financial
conflicts may create.

Cost and Quality Transparency. Rising health care costs have fueled an interest in greater
public availability of price and quality information. Public reporting and transparency can
aid patients in making more informed decisions about their treatment options. Such
information could also spur providers to make improvements by benchmarking their
performance against their peers. And health care price and quality information can be used
by private health plans and public programs to reward quality and efficiency.

The demand for more transparent price and quality information has been driven primarily
31
by employers and health plans. But consumers believe they have much to gain from
greater transparency, too. A recent survey, for example, found that 84 percent of
32
Americans want hospitals, physicians, and pharmacies to publish their prices.
Additionally, 90 percent of health care consumers want to partner with their physician in
making health care decisions, and more than 60 percent claim to have searched for
33
information to help make health care decisions.

Public programs have also embraced greater transparency. An August 2006 Executive
Order directed Federal health programs ! including the Federal Employees Health Benefit
Program, Medicare, programs operated by the Indian Health Service, and TRICARE ! to
make quality and pricing information available to beneficiaries and enrollees by January 1,
34
2007.

Pursuant to this order, and building on existing programs, Medicare currently posts
hospital quality measures online at the Hospital Compare website. Hospital-specific
process measures include those related to heart failure and heart attack care, pneumonia
care, and surgical care improvement. Information is also available for risk-adjusted
mortality rates and patient satisfaction. The Centers for Medicare and Medicaid Services
(CMS) has also started making available comparative price information for common
outpatient procedures, such as wrist fracture pinning, colonoscopy, and hernia repair.

While public availability of Medicare price information is novel and has been hailed as a
first step, the information is based on an average, and it is not current or hospital-specific.
In addition, the price and quality information is not linked, which undermines the value of
any comparison by patients and beneficiaries.

At the state level, recent legislation has required public reporting of hospital retail charges.
Most experts agree, however, that this information is too detailed and not meaningful,
35
because it contains unit prices rather than episodes of care. Trying to estimate a hospital
stay based on charge data is “like shopping for a car by adding up the prices suppliers
36
charge for all the nuts and bolts that go into one.”

The value and usefulness of cost and quality information may be limited by practical
factors. Decisions about health care are often involuntary — made under emergency
72
conditions or emotional distress. Patients also may not have the opportunity to choose
among hospitals if a referring physician is not on staff at the preferred hospital. Even for
non-urgent elective procedures like LASIK vision-correction surgery, variation in quality,
misleading advertising, and inconsistent bundling of services that makes apples-to-apples
37
price comparisons difficult, all contribute to imperfect market conditions.

Medicare’s recent experience with making cost and quality information available online,
combined with real-life examples from the private sector, provide valuable lessons for
making information meaningful. Some of these lessons, also described in recent
38
congressional testimony by the Commonwealth Fund, include:

Information currently available is inadequate. Although progress has been !
made even in the past two years, cost and quality information is rarely available to
patients, and physicians lack comparative information on the quality of the care
they provide or the care provided by physicians to whom they refer their patients.

! Price and quality information should be provided together. Information on the
price of a specific health care service provides little value. Knowing the total cost
of caring for a condition is more meaningful, particularly if combined with
information on the quality or outcomes of the care.

Transparency alone is not likely to transform health care. Shopping for the !
best physician or hospital is impractical for very sick patients and patients with
chronic conditions, particularly when care is sought under emergency conditions.
Yet, these patients incur most health care costs. Moreover, purchasers, payers, and
providers — not patients — are in a better position to demand greater quality and
efficiency. And providing price information without a clear use could lead to
collusion instead of competition.

To promote greater transparency in ways that would be meaningful and reliable to
consumers and providers, the Baucus plan would leverage Medicare’s ability to play a
leading role. Medicare can and should release more information about the price and
quality of covered services. For example, the current price information available for
outpatient procedures should be paired with information on quality measures and expanded
to other sites of care.

Medicare should also make its data more widely available, with significant regulation of its
use, so that it can be combined with similar data from other payers (such as health plans
that serve employers and Medicaid) to build more robust profiles of clinicians’ care that
are based on a broad spectrum of their patients. The Department of Health and Human
Services has started down this path by initiating Charter Value Exchanges in select
communities. These initiatives allow stakeholders in a community to combine their data
with Medicare data with the goal of releasing a single set of cost and quality measures for
the entire community. To access the Medicare data, stakeholders must agree on a common
set of performance measures.

73
With appropriate privacy protections, Medicare data can be instrumental in promoting
greater cost and quality transparency within the health system. This data must be used in
ways that build consistency around cost and quality measures, however, as done through
the Charter Value Exchanges.
39
While the prospect of data sharing generates concern
among clinicians, Medicare data can be used to generate more meaningful, accurate and
consistent information across the health system so that, ultimately, reporting is acceptable
and less burdensome for the provider community.

This plan also would require health plans offered through the Health Insurance Exchange
to provide uniform cost and quality metrics. The Independent Health Coverage Council
would work with health plans and purchasers to develop consistent definitions and
principles. Plans would also be encouraged to incorporate this information into pay-for-
performance systems.

As a further step in greater transparency of health care costs, information about the full
cost of employer-provided health care should be transparent to employees. Currently,
employers must inform employees of the amount of wages paid by the employer, along
with the taxes withheld from such wages during the calendar year. The information,
provided on the Form W-2, must be given to each employee by January 31 of the
succeeding year. But no such requirement exists for the amount an employer pays for
health insurance coverage. Some employers voluntarily report the value of the health
benefits they provide, either in an annual statement to their employees or in box 14 of the
Form W-2. This plan would require employer health costs to be fully disclosed to all
employees. Better educating workers about the full cost of their health care coverage
could encourage them to seek or demand lower premiums, which in turn could help
contain growth in spending.

The push for increased transparency highlights the need for greater adoption of health
information technology (IT) and evidence-based medicine. This plan proposes to invest in
health IT and comparative clinical effectiveness research. Taken together, these tools can
help drive the U.S. health system toward greater efficiency and increased engagement in
health care decision making among consumers.

C. MEDICAL MALPRACTICE REFORM

Medical malpractice insurance premiums have risen steadily over recent decades, at times
increasing an average of 15 percent a year.
40
Some states have seen even more dramatic
increases. Pennsylvania, for example, experienced increases ranging from 26 to 73 percent
in 2003.
41
While the Government Accountability Office has found that access to medical
care is not “widely affected” by large premium increases,
42
and malpractice costs account
for less than two percent of health costs,
43
physicians and other health care providers
contend that the current legal environment leads to the practice of defensive medicine.
Ordering more tests, procedures, or visits primarily to avoid liability rather than to benefit
patients may contribute to unnecessary health care spending.

74
A serious effort at comprehensive health care reform, then, should address medical
malpractice.

Reducing malpractice premiums alone would not have a substantial effect on overall health
spending. CBO estimates that a 25 to 30 percent reduction in malpractice costs “would
lower health care costs by only about 0.4 to 0.5 percent, and the likely effect on health
insurance premiums would be comparably small.”
44
But helping patients and providers to
cooperate rather than participate in time-consuming and expensive legal battles may help
to shift America’s health care system away from the costly practice of defensive medicine
and toward the best quality care and adherence to standards of care.

The current litigation system does not do a good job of compensating victims of
malpractice or of reducing the occurrence of medical malpractice. In fact, “research
typically shows Americans rarely take their disputes to court. Of every one hundred
Americans injured in an accident, only ten make a liability claim, and only two file a
lawsuit.”
45
Yet, the large number of malpractice claims filed still overwhelms the legal
system, and only 30 percent of claims filed result in payments to victims of medical
malpractice.
46
Alternatives to civil litigation need to be utilized so that administrative
costs associated with litigation, which account for 60 percent of malpractice premiums,
47

can be reduced, while simultaneously allowing credible claims to be compensated fairly
and quickly.

Malpractice reform could address money and time spent on litigation, as well as improve
patient and provider satisfaction with the resolution of complaints or grievances.
Additionally, changes made as part of reforming the health care system would affect
medical malpractice. For example, damages awarded for care necessary as a result of
malpractice would be reduced because the cost of care would decrease across the board.
Also, improvements in preventive care and care coordination would reduce the likelihood
of risky procedures that are a source of malpractice claims.

The Fair and Reliable Medical Justice Act, introduced in the 109
th
Congress and again in
the current Congress, includes ideas for ensuring safe and effective medical care, while
working to limit malpractice insurance premiums.
48
This legislation would provide grants
to states to create alternatives to current tort litigation in an effort to increase access to
recovery for patients with low-dollar value claims and improve satisfaction with claims
resolution for patients and provides. States would have flexibility in developing
alternatives to civil litigation, with three specific models outlined in the bill: (1) the early
disclosure and compensation model, (2) the administrative determination of compensation
model, and (3) the health court model.

The early disclosure model offers health care providers tort liability immunity after an
offer, in good faith, to pay compensation to any patient injured or harmed as a result of
care. The compensation would have to include any economic loss to the patient, non-
economic damages (as determined by the state) and reasonable attorney fees. The
University of Michigan Health System (UMHS) implemented this system in 2002 with
astounding results. Three years after the program was established, UMHS had reduced its
75
annual litigation costs by $2 million and reduced the number of lawsuits, as well as the
time it took to resolve the suits, by more than half.
49
That is one of the goals of the early
disclosure model. Fostering communication about medical errors and awarding
appropriate compensation in a non-adversarial setting are the hallmarks of this approach.

By increasing communication about medical errors, and doing so in a non-adversarial
setting, the collection of medical error data will increase, leading to improved patient
safety. Data collection is essential to preventing errors by enabling providers to better
understand how errors occur. “Accurate information also provides a baseline measurement
for further assessment of the effectiveness of the changes made.”
50
Unfortunately, under
the current system, data collection remains limited because of the lack of incentives.
Alternatives to litigation, such as early disclosure, provide incentives to disclose medical
errors, while continuing to protect the provider and improve patient safety.

The second approach, the administrative determination of compensation model, calls for
the establishment of an administrative board to designate classes of avoidable injuries.
Based on these classes, the board would determine the level of compensation awarded to
the patient. An appeals process would also be established to review decisions made by the
board.

Under the third alternative, a specialized health court would be established. The court
would be presided over by judges with expertise in health care with the ability to hire
outside experts. The judges’ decisions regarding compensation would be binding but
subject to an appeals process.

The Fair and Reliable Medical Justice Act serves as a foundation for an important element
of this health reform plan. Like the legislation, the Baucus plan would call on states to
take the opportunity to develop alternatives for resolving conflicts and compensating
patients who are the victims of medical errors. In addition to receiving Federal assistance
to establish an alternative model, states would also receive assistance to collect data about
medical errors, which would help keep patients better informed and create an opportunity
for providers to learn from each other. In fact, the systems developed by the Department
of Defense and the Veterans Health Administration that successfully track such data could
serve as models. Patients and providers should have the chance to cooperate, rather than
participate in a time-consuming and expensive legal battle. This plan would help achieve
that important objective.

D. PRIVATE INSURANCE PLANS IN MEDICARE

Medicare beneficiaries can obtain benefits through the traditional fee-for-service program
or by enrolling in private insurance plans that are approved to offer Medicare benefits.
Private insurance plans are paid a monthly amount by the government for each beneficiary
whom they enroll. In return, insurers agree to provide coverage for the range of Medicare
benefits that their enrollees need. The program allowing private insurers to serve Medicare
beneficiaries is called Medicare Advantage (MA).

76
The Medicare Payment Advisory Commission (MedPAC) estimates that Medicare Advantage
(MA) insurers are currently paid 13 percent more than the amount Medicare would pay if the
same beneficiaries remained in the traditional fee-for-service program.
51
Current estimates
indicate that these excess payments will total $62 billion over the next five years, and $169
billion over the next ten years.

52
MedPAC has called for Medicare Advantage payments to be set equal to traditional Medicare.
The health insurance industry defends these payments by pointing to extra benefits that low-
income MA enrollees receive relative to traditional Medicare, like eyeglasses, dental coverage,
and lower copayments. But delivering these extra benefits through Medicare Advantage is not
as efficient as delivering them directly through traditional Medicare. Moreover, MedPAC
reports that MA plans are less efficient at delivering Medicare Part A and B benefits than the
traditional fee-for-service program.
53
Private insurers’ higher overhead and added
administrative costs — including profits — mean that fewer benefits are passed along to
beneficiaries. CBO and the U.S. Comptroller General estimate the administrative costs of
private plans serving Medicare beneficiaries are in the range of 11 to 13 percent, compared to
estimates of 2 to 5 percent for the traditional Medicare program.
54, , , 55 56 57


The majority of Medicare beneficiaries have multiple chronic conditions that could be treated
more effectively through interdisciplinary care teams, and the insurance industry contends that
private plans better coordinate care and improve quality oversight in the Medicare program.
There is no solid evidence that supports this assertion. Not all Medicare Advantage plans are
designed to integrate or coordinate care across the spectrum of providers, and not all use
electronic medical records to better manage care. Even so, all Medicare Advantage payments
are based on the same rates — whether or not the plan uses advanced methods of coordinating
and delivering care.

Congress must act to level the playing field between traditional Medicare and Medicare
Advantage payments and the Baucus plan would do so. Enacted in July 2008, MIPPA took
modest steps to reduce overpayments to private plans beginning in 2010. There are a number of
ways to complete this. One is to set MA payments on par with traditional Medicare in every
county in the country. However, Medicare costs can be low in some areas of the country and
extraordinarily high in others. Simply setting MA payments equal to traditional Medicare could
maintain overpayments in some areas and create severe underpayments in other areas relative to
insurers’ costs.

The Baucus plan would seek to better understand how insurers’ costs differ by region of the
country in designing new policies to eliminate the remaining excess spending in the Medicare
Advantage program. MIPPA has already directed MedPAC to compare Medicare and private
insurance costs and develop alternative ways of setting MA payments. MA payments should be
reformed to achieve neutrality with traditional Medicare at the national level. But the
benchmarks against which MA plans are paid should have more to do with plans’ own costs.
58

One option is to base MA payments on a blend of local and national Medicare costs, reducing
MA payments in high-use areas and increasing payments in low-use areas.

77
Alternatively, insurers’ payments could be based on a blend of their own costs per enrollee with
Medicare’s costs per beneficiary at the local or national level. Competitive bidding is another
option that could be considered or tested for MA plans. At a minimum, Congress should repeal
the “premium support” demonstration included in the MMA of 2003 because it unfairly ties Part
B premiums to how much insurers’ costs differ from traditional Medicare. Finally, Congress
must seek ways to eliminate excess spending that results from differences in the ways MA plans
and traditional Medicare code diagnoses in patients’ medical records.

In addition to determining and adopting mechanisms to reduce overpayments, Congress
should consider paying Medicare Advantage plans for delivering coordinated, cost-
effective care to beneficiaries with the highest risk of complications and spending. One
option is to pay MA plans more if they meet medical home criteria defined by NCQA and
specific performance measures. If MA plans do not meet these criteria, their payments
would be reduced over a defined period of time. As with proposals involving traditional
fee-for-service Medicare, paying MA plans for such care could increase the quality of care
provided to beneficiaries in MA plans and could possibly lower Medicare spending by
reducing complications from chronic illnesses.

Private insurance plans also deliver Medicare’s prescription drug benefit and are paid by
the government for each beneficiary they enroll. Insurers in the program contract with
pharmacies to dispense drugs, and they negotiate with drug manufacturers for discounted
prices. Current law allows insurers to use their own formularies to negotiate prices with
manufacturers and to manage the quality of the drug benefit. Recent studies suggest that
the price breaks negotiated by Medicare prescription drug plans are not as high as those
legislated through the Medicaid drug rebate program.
59
This means Medicare pays more
than Medicaid for the prescriptions of the dual-eligible population, which was switched
from Medicaid to the Medicare drug benefit in 2006.

Congress should consider extending the Medicaid price discounts to the drugs consumed
by the dual-eligible population in the Medicare program in order to maintain the previous
price breaks. Insurers would continue to negotiate prices on behalf of the other
beneficiaries who enroll in their plans. Congress should also be apprised of Medicare’s
price breaks in the aggregate, relative to Medicaid and other sectors, in order to gauge the
performance of the prescription drug program.

E. LONG-TERM CARE SERVICES AND SUPPORTS

Long-term care differs from other types of health care in that the goal is not to cure an
illness, but to provide patients with the highest level of functioning possible and improve
quality of life. The need for long-term care affects individuals of all ages: children born
with disabling conditions, working-age adults with inherited or acquired conditions !
many of whom are able to work ! and the elderly with chronic illnesses. Care for these
individuals is most often provided by informal caregivers ! family or friends ! who
provide care with little or no compensation. More than 50 million informal caregivers
currently tend to the needs of individuals and family members of all ages.
60


78
Today, about 9.4 million adults, five percent of the adult population, receive long-term
care services in the community or in institutions;
61
and about 1.1 million children living in
the community have long-term care needs.
62,63
An estimated 69 percent of people turning
65 years old will need some form of long-term care assistance before they die.
64


The current system for delivering long-term care is expensive, inefficient, and does not
encourage the delivery of high-quality care. In 2005, national spending on long-term care
was estimated to be nearly $207 billon.
65
States and the Federal government are the
largest payers of these services. Medicaid alone accounts for as much as 49 percent of
long-term care spending ! most of which was provided in an institutional setting.
66


Medicare covers a limited amount of post-acute care in skilled nursing facilities and in the
home for certain beneficiaries. And Medicare benefits are not coordinated with Medicaid
! even though the Federal government bears much of the cost for these programs.
Likewise, conflicting incentives may increase costs and diminish the quality of care.
67

Divergent characteristics, program goals, eligibility requirements, and covered services for
Medicare and Medicaid programs often lead to uncoordinated care and a fractured delivery
system for individuals needing long-term care and assistance.

The cost for nursing home care is extremely expensive, about $70,000 per year on average.
Without financial assistance from Medicaid or private insurance, most people simply
cannot afford extended nursing home care.
68
Home or community-based care is more
cost-effective,
69
and most patients would prefer care in these settings to institutional
care.
70,71


In recent years, Congress has taken some steps to reform the long-term care system. The
Deficit Reduction Act of 2005 provided new flexibility for states to offer home and
community-based long-term care services in Medicaid.
72
Despite this progress, the
program maintains a strong bias toward institutional care due to payment and access rules.
Congress has considered innovative, alternative approaches to institutional care,
73
but
reform has remained elusive due to a lack of consensus on both policy and financing.

Home and Community Based Services (HCBS) have become a popular way to support
individuals who want to remain in their own homes and communities. HCBS options are
generally provided through Medicaid waivers, but beneficiaries must have a significant
level of disability to qualify.
74
And even those who qualify often have difficulty accessing
care; by 2005 there was a waiting list of more than 207,000 Medicaid beneficiaries for
HCBS waiver services.
75


The Baucus plan would consider options to further expand access to HCBS in Medicaid.
These options include providing states with new tools and incentives to make them more
available to more beneficiaries and exploring options to better coordinate care for dual-
eligible individuals under Medicare and Medicaid.

The plan would also encourage states to explore new options that improve access to long-
term care services and supports to prevent the progression of disability and to help
79
individuals remain in their own homes. By intervening earlier with targeted assistance,
states can help prevent or delay costly institutionalizations and provide a more patient-
centered benefit. In addition, exploring inefficiencies and conflicting incentives within
Medicare and Medicaid could improve the quality of care and decrease costs.

Providing support for family caregivers should also be an important part of any reform
plan. The plan would provide assistance to individuals, families and caregivers in
navigating the complex and fractured long-term care services and supports system. With
this help, individuals in need of care and their families would be better able to make the
most appropriate care choice.

Family caregivers cannot be expected to fill all the gaps in our current system. Long-term
care reform should include options to recruit, train, and retain a robust workforce that can
ensure high-quality care. One concept that has been put forward to address these shortages
is providing educational and training opportunities to adults who are participating in the
Temporary Assistance for Needy Families (TANF) program, who represent a pool of more
than 900,000 individuals who could provide an important resource in meeting our nation’s
workforce needs.

Institutional or residential care is appropriate in some cases; however, it should be a choice
for individuals and families. This plan would pilot new models of institutional care, such
as the Green House model,
76
that has shown promise for both improving the quality of life
and care in these settings. In addition, this plan incorporates several options to reform the
delivery system to provide better care coordination and chronic disease management.
Others may include investment in aging and disability resource centers (ADRCs) and
programs that limit secondary disabilities by promoting nutrition, exercise and fall
prevention. Because almost 25 percent of deaths occur in long-term care settings, ways to
provide the best quality care at the end of life should be considered.
77


In the long run, fundamental reform of the long-term care system will be necessary.
Achieving ultimate success will require both public and private solutions. While we
consider options to improve the care in our public programs, we should also explore
policies that make quality long-term care insurance products more affordable and
accessible.

F. TAX INCENTIVES FOR HEALTH COVERAGE

Tax breaks for health insurance premiums and other health expenses are among the largest
tax expenditures in the Federal budget. In 2007, the total value in foregone revenue for
health tax benefits was more than $300 billion.
78
Congress should explore ways to
restructure the current tax incentives to encourage more efficient spending on health and to
target our tax dollars more effectively and fairly.

Current tax law favors individuals who receive health insurance through their employer.
The employer’s contribution to health care and premiums is excluded from an individual’s
income for both income and payroll tax purposes. In addition, an employee’s share of the
80
premium cost can be excluded if it is made through what is called a cafeteria benefit plan.
This means workers are not taxed on the value of their health premiums, even though the
premiums are part of the worker’s total compensation package. There is no limit on the
amount of premiums that can be excluded from wages. The tax exclusion fosters
employment-based health coverage, because it lowers the cost of buying insurance through
an employer.

In addition to the employee exclusion, other incentives to purchase health care and health
coverage are available through the tax code. An employee’s pre-tax contributions for
health insurance or medical expenses through a Flexible Spending Account (FSA) are
excluded from income and therefore not subject to tax. There are no limits on the amount
of wages an employee can contribute on a pre-tax basis to an FSA. For individuals who
qualify to contribute to a Health Savings Account (HSA) by enrolling in a high-deductible
health plan, up to $2,900 of those contributions for individuals and $5,800 for families are
deductible in tax year 2008.

Self-employed individuals can deduct the cost of health insurance premiums for
themselves, their spouse, and their dependents for income tax purposes, but they must pay
self-employment tax on these amounts. This is less favorable treatment than employer-
provided health insurance. And finally, those who purchase health insurance through the
individual market, and those who have out-of-pocket medical expenses, may deduct their
spending to the extent that it exceeds 7.5 percent of their adjusted gross income and they
itemize their deductions.

Most economists argue there are problems with the current set of tax incentives for heath
care.
79, , , 80 81 82
First, they argue that the incentives are inequitable because the amount of
tax benefit received differs based on how health coverage is received: those covered
through their employers are rewarded with the largest tax breaks, while those who must
obtain coverage on the individual market receive a much smaller tax break, or none at all.
Current incentives are also regressive because they are, for the most part, more valuable to
taxpayers who are subject to higher marginal rates. As such, they give larger subsidies to
higher-income workers, instead of to the lower-income Americans who need more help
buying insurance.

Second, many economists argue that the unlimited employee tax exclusion leads to
increased health spending. The unlimited tax benefit for the exclusion encourages workers
to purchase more expensive coverage to avoid co-payments and deductibles. This lower
cost sharing can lead to higher use of services that are considered non-urgent and
discretionary. Additionally, employees who have different health insurance options from
which to choose may spend health care dollars unnecessarily to simply buy the most
expensive plan they can afford, instead of looking at the amount of coverage that they
actually need.

Some have proposed eliminating the current tax exclusion for employer-based health
insurance premiums and converting the benefit to a tax deduction or tax credit.
83,84
This
approach goes too far because it could cause widespread disruption in employer-based
81
health benefits. Reform should not endanger coverage for the more than half of all
Americans who now have health insurance through an employer.

More targeted reforms of the exclusion might make the incentive more equitable and
reduce spending in the health care system. One option for reform is to cap the amount of
health care premiums that can be excluded from employee wages for income and payroll
tax purposes. This could be done by limiting or capping the tax exclusion based on the
value of health benefits or, as an alternative, based on a person’s income — or both.
Employees could be allowed to exclude, for example, up to a specific dollar amount in
health benefits from their wages each year. If they purchase health plans with greater
benefits, the difference between a more generous plan and the cap could be subject to
Federal and state income taxes. Alternatively, the exclusion could be available on a sliding
scale based on income: people with low wages could be allowed to exclude 100 percent of
the premiums offered through their employers, with the percent allowed phasing down or
out with income.
85

Tax incentives can be an effective way of subsidizing the cost of health insurance. New
tax incentives for small businesses and low-income individuals were discussed earlier in
this plan. Current tax policies for health coverage must promote efficient uses of care and
distribute subsidies fairly. We must also balance any tax reforms in this area with the
desire of Americans to maintain employer-based health coverage.


1
Centers for Medicare and Medicaid Services, “National Health Expenditure Data,” CMS,
http://www.cms.hhs.gov/NationalHealthExpendData/02_NationalHealthAccountsHistorical.asp.
2
C. Eugene Steuerle and Randall R Bovbjerg, “Health And Budget Reform As Handmaidens,” Health
Affairs 27, no. 3, (2008): 633-644.
3
Peter R. Orszag, “Increasing the Value of Federal Spending on Health Care,” (Testimony before the
Committee on the Budget, U.S. House of Representatives, July 16, 2008). The CBO estimate is based on an
estimate of spending variation in Medicare and the costs that could be saved — without any negative effect
on health outcomes — if high- and medium-cost areas were reduced to the level in low-cost areas. In 2007,
that potential savings in Medicare is $129 billion.
4
The Commonwealth Fund, “New Analysis: Congressional Health Care Proposals Would Cover All
Uninsured, and Reduce Total U.S. Health Spending by Up to $61 Billion,” The Commonwealth Fund,
(2007).
5
John Sheils and Randall Haught, “Cost and Coverage Analysis of Ten Proposals to Expand Health
Insurance Coverage,” The Lewin Group, (2003),
http://www.lewin.com/content/publications/CoveringAmerica.pdf.
6
Government Accountability Office, “Health Insurance: Vulnerable Payers Lose Billions to Fraud and
Abuse,” GAO, (1992) http://archive.gao.gov/t2pbat6/146547.pdf.
7
June Gibbs Brown, (Testimony before the Senate Appropriations Committee, U.S. Senate, April 22, 1994).
8
The Department of Health and Human Services and Department of Justice, “Health Care Fraud Abuse
Control Program Annual Report for FY 2006”, HHS & DOJ, (2007),
http://oig.hhs.gov/publications/docs/hcfac/hcfacreport2006.pdf.
9
Centers for Medicare and Medicaid Services, “2007 Improper Medicare FFS Payments,” CMS, (2007),
http://www.cms.hhs.gov/CERT/CR/itemdetail.asp?filterType=none&filterByDID=-
99&sortByDID=1&sortOrder=descending&itemID=CMS1205324&intNumPerPage=10.
82

10
Department of Health and Human Services, Office of the Inspector General, “OCIG Official Unveils Five-
Point Strategy to Help the Next Administration Combat Fraud”, Report on Medicare Compliance, HHS-OIG,
(2008): 1-3.
11
Department of Health and Human Services, Office of the Inspector General, “Medicare Home Oxygen
Equipment: Cost and Servicing,” HHS-OIG, (2006), http://oig.hhs.gov/oei/reports/oei-09-04-00420.pdf.
12
Department of Health and Human Services, “Final Report to Congress: Evaluation of Medicare’s
Competitive Bidding Demonstration for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies,”
(2004).
13
ExpectMore.gov, “Health Care Fraud and Abuse Control,”
http://www.whitehouse.gov/omb/expectmore/detail/10000292.2002.html#performanceMeasures.
14
Eric Campbell, “Aligning Incentives: The Case for Delivery System Reform,” (Testimony before the
Senate Committee on Finance, U.S. Senate, September 16, 2008).
15
Ibid.
16
Ibid.
17
Eric Campbell, et al., “A National Survey of Physician-Industry Relationships,” New England Journal of
Medicine 356, no. 17: 1742.
18
Julie Donohue et al., “A Decade of Direct-to-Consumer Advertising of Prescription Drugs,” New England
Journal of Medicine 357, no.7: 673-681.
19
American Medical Association, “Gifts to Physicians from Industry,” AMA, (1998).
20
Pharmaceutical Research and Manufacturers of America, “PhRMA Code on Interactions with Health Care
Professionals,” (2004), http://www.phrma.org/files/PhRMA%20Code.pdf: 3.
21
David Blumenthal, “Doctors and Drug Companies,” New England Journal of Medicine 351, no. 18: 1885-
1890.
22
Medicare Payment Advisory Commission, “Report to the Congress: Reforming the Delivery System,”
(2008): 153.
23
S.2029, The Physician Payments Sunshine Act of 2007, introduced by Senators Chuck Grassley and Herb
Kohl, September 6, 2007.
24
Medicare Payment Advisory Commission, “Report to the Congress: Reforming the Delivery System,”
(2008): 154-155.
25
Jean Mitchell, “The Prevalence of Physician Self-Referral Arrangements After Stark II: Evidence From
Advancing Diagnostic Imaging,” Health Affairs 26, no. 3 (2007): 415.
26
Ibid.
27
Medicare Payment Advisory Commission, “Report to the Congress: Physician-Owned Specialty
Hospitals,” (2005): 11.
28
Ibid.
29
Medicare Payment Advisory Commission, “Report to the Congress: Physician-Owned Specialty
Hospitals,” (2005): 12.
30
Ibid.
31
National Quality Forum, “Draft Background Paper on Hospital Cost and Price Transparency: Usable,
Audience-Specific Information on Hospital Costs and Prices,” (2007),
http://www.qualityforum.org/pdf/projects/transparency/txpricetranspforcommentJun12.pdf.
32
The Council for Affordable Health Insurance, “Memorandum: Results from Nationwide Poll on Price
Transparency,” (2006), http://www.cahi.org/cahi_contents/resources/pdf/CAHIPollResults042806.pdf.
83

33
Consumer-Purchaser Disclosure Project, “Building Health Care Value By Providing Consumers With
Better Information To Make Good Decisions,” (2007),
http://healthcaredisclosure.org/docs/files/DisclosureFactSheetsConsumerTools10-10-07.pdf.
34
Executive Order 13410, “Promoting Quality and Efficient Health Care in Federal Government
Administered or Sponsored Health Care Programs,” (2006),
http://www.whitehouse.gov/news/releases/2006/08/20060822-2.html.
35
National Quality Forum, “Background Paper on Hospital Cost and Price Transparency: Usable, Audience-
Specific Information on Hospital Costs and Prices,” NQF, (2007),
http://www.qualityforum.org/pdf/projects/transparency/txpricetranspforcommentJun12.pdf.
36
Ibid., 13.
37
Ha T. Tu, (Testimony before the Subcommittee on Health of the House Committee on Ways and Means,
U.S. House of Representatives, July 18, 2006).
38
Sara Collins, “Transparency in Health Care: the Time Has Come,” (Testimony before the Subcommittee
on Health of the House Committee on Energy and Commerce, U.S. House of Representatives, March 15,
2006).
39
S. 1507, and act that would establish a framework for the release and use of Medicare data, introduced by
Senators Grassley and Baucus, May 24, 2007.
40
Congressional Budget Office, “Limiting Tort Liability for Medical Malpractice,” CBO, (2004): 4.
41
Kenneth E. Thorpe, “The Medical Malpractice ‘Crisis’: Recent Trends and the Impact of State Tort
Reforms,” Health Affairs (2004): 4-25 (published online 21 January 2004; 10.1377/hlthaff.w4.20)
42
Government Accountability Office, “Implications of Rising Premiums on Access to Health Care,” GAO,
(2009): preface.
43
Congressional Budget Office, “Limiting Tort Liability for Medical Malpractice,” CBO, (2004): 6.
44
Ibid.
45
Thomas Burke, “Lawyers, Lawsuits, and Legal Rights: The Battle Over Litigation in American Society,”
University of California Press, (2004): 3.
46
David M. Studdert et al., “Claims, Errors, and Compensation Payments in Medical Malpractice Litigation,”
The New England Journal of Medicine, 354, no. 19, (2006): 2024-2033.
47
Kenneth E. Thorpe, “The Medical Malpractice ‘Crisis’: Recent Trends and the Impact of State Tort
Reforms,” Health Affairs (2004): 4-25 (published online 21 January 2004; 10.1377/hlthaff.w4.20)
48
S.1481, The Fair and Reliable Medical Justice Act, introduced by Senator Max Baucus and Senator
Michael Enzi, 110
th
Congress; S.1337, The Fair and Reliable Medical Justice Act , introduced by Senator
Mike Enzi and Senator Max Baucus, 109
th
Congress.
49
Hillary Clinton and Barack Obama, “Making Patient Safety the Centerpiece of Medical Liability Reform,”
New England Journal of Medicine, 354, no. 21 (2006): 2208.
50
Joanne Stow, “Using Medical-Error Reporting to Drive Patient Safety Efforts,” AORN Journal, (2006),
http://findarticles.com/p/articles/mi_m0FSL/is_/ai_n27000693, (accessed November 4, 2008).
51
Medicare Payment Advisory Commission, “Report to the Congress: Medicare Payment Policy,” (2008).
52
Ibid. This estimate is for plan year 2008 and does not take into account the effect of MIPPA of 2008.
53
Glenn M. Hackbarth, “An Examination of Medicare Advantage,” (Testimony before the Senate Committee
on Finance, U.S. Senate, April 11, 2007).
54
Congressional Budget Office, “Designing a Premium Support System for Medicare,” CBO, (2006): 1-56.
84

55
Centers for Medicare and Medicaid Services, “National Health Expenditure Data, Tables 11 and 12,”
CMS, (2008) http://www.cms.hhs.gov/NationalHealthExpendData/downloads/tables.pdf.
56
Merrill Mathews, “Medicare’s Hidden Administrative Costs: A Comparison of Medicare and the Private
Sector,” Council for Affordable Health Insurance, (2006): 1-16.
57
Government Accountability Office, “Medicare Advantage Organizations: Actual Expenses and Profits
Compared to Projections for 2005,” GAO, (2008): 1-14.
58
Robert A. Berenson, “From Politics To Policy: A New Payment Approach In Medicare Advantage,”
Health Affairs, (2008): 156, (published online 4 March, 2008; 10.1377/hlthaff.27.2.w156).
59
Richard G. Frank and Joseph P. Newhouse, “Mending the Medicare Prescription Drug Benefit: Improving
Consumer Choices and Restructuring Purchasing,” The Brookings Institute, (2008),
http://www.brookings.edu/papers/2007/04useconomics_frank.aspx.
60
The Department of Health and Human Services, “Informal Caregiving: Compassion in Action,” HHS,
(1998), http://aspe.hhs.gov/daltcp/Reports/carebro2.pdf.
61
S. Rogers and H. Komisar, “Who Needs Long-Term Care? Fact Sheet, Long-Term Care Financing
Project,” Georgetown University Press, (2003). Most but not all individuals were over 65 years of age, 6.3
million; the remaining 3.7 million were younger
62
Achintya N. Dey, Jeannine. S. Schiller, and Diane A. Tai, “Summary Health Statistics for Children:
National Health Interview Survey, 2002,” National Center for Health Statistics, Vital and Health Statistics,
10, no. 221, (2004).
63
Forum on Child and Family Statistics, http://www.childstats.gov/.
64
Peter Kemper, Harriet L. Komisar, and Lisa Alecxih, “Long Term Care Over An Uncertain Future: What
Can Current Retirees Expect?” Inquiry, 42, (2005-06): 335-350.
65
Georgetown University Long-Term Care Financing Project, “National Spending for Long-Term Care,”
Georgetown University, (2007).
66
Ibid.
67
David Grabowski, “Medicare and Medicaid: Conflicting Incentives for Long-Term Care,” Milbank
Quarterly, 85, no. 4, (2007).
68
MetLife, “The MetLife Market Survey of Nursing Home and Home Care Costs,” MetLife, (2006),
http://www.metlife.com/WPSAssets/1875695828115945575V1F2006NHHCMarketSurvey.pdf. In 2006,
annual costs for 24 hour care in a nursing home ranged from about $67,000 for a semi-private room to about
$75,000 for a private room, or from $183 a day to $206 a day for a private room.
69
Carol O’Shaughnessy, Julie Stone, Thomas Gabe, Laura B. Shrestha “Long-Term Care: Consumers,
Providers, Payers, and Programs,” CRS Report for Congress, (2007).
70
Enid Kassner, “Medicaid and Long-Term Services and Supports for Older People: Fact Sheet,” AARP
Public Policy Institute, (2005).
71
Nancy A. Miller, Charlene Harrington, Elizabeth Goldstein, “Access to Community-Based Long-term
Care: Medicaid’s Role,” Journal of Aging and Health, 14, no. 1, (2002): 138-59.
72
Public Law 109-171
73
S.1758, The Community Living Assistance Services and Supports Act or CLASS Act, introduced by
Senator Edward Kennedy, July 2007; S.3779, the Community Choice Act of 2007, introduced by Senator
Tom Harkin, March 2007; S.3227, The Empowered at Home Act of 2008, introduced by Senator John Kerry
and Senator Charles Grassley, July 2008.
74
Cynthia Shirk, “Rebalancing Long-Term Care: The Role of the Medicaid HCBS Waiver Program,” George
Washington University National Health Policy Forum, (2006). Individuals must meet a level of functional
need that qualifies them for a nursing home.
85

75
Ibid.
76
The Green House Model creates a small community for a group of elders and staff. They differ from
traditional skilled nursing homes and assisted living facilities, by altering size, interior design, staffing
patterns, and methods of delivering skilled professional services. Its primary purpose is to serve as a place
where elders can receive assistance and support with activities of daily living and clinical care, without the
assistance and care becoming the focus of their existence. Developed by Dr. William Thomas and rooted in
the tradition of the Eden Alternative, it is a model for cultural change within nursing facilities,
http://www.ncbcapitalimpact.org/default.aspx?id=148.
77
Pedro L. Gozalo and Susan C. Miller, “Hospice Enrollment and Evaluation of its Causal Effect on
Hospitalization of Dying Nursing Home Patients,” Health Services Research, 42, (2007): 2.
78
Edward D. Kleinbard, “Tax Expenditures for Health Care,” (Testimony before the Senate Committee on
Finance, U.S. Senate, July 31, 2008). For a comprehensive list of current health tax benefits for health
expenses, see Appendix A of this testimony.
79
Many economists in the public and private sector have analyzed and commented on problems with current
tax health incentives. A few examples are: Jonathan Gruber, “Subsidies to Employee Health Insurance
Premiums and the Health Insurance Market,” National Bureau of Economics Research, (2007),
http://papers.nber.org/papers/w9567.pdf.
80
Kate Baicker, “Making Health Insurance More Affordable Through Health Insurance Finance Reform,”
Business Economics, 42, no. 3, (2007),
https://commerce.metapress.com/content/f67110210634770k/resource-
secured/?target=fulltext.pdf&sid=05mdup55rn1nd055gl0gfx55&sh=www.springerlink.com.
81
Jason Furman, “Health Reform Through Tax Reform: A Primer,” Health Affairs, 27, no. 3, (2008): 622-
632.
82
Edward D. Kleinbard, “Tax Expenditures for Health Care,” (Testimony before the Senate Committee on
Finance, U.S. Senate, July 31, 2008).
83
S.334, The Healthy Americans Act, introduced by Senator Wyden, January 18, 2007.
84
Budget of the United States Government, Fiscal Year 2009, submitted by President George W. Bush to the
U.S. Congress on February 4, 2008.
85
Certain data collection issues would need to be addressed in order to implement an income cap.
86
CONCLUSION

The case for health reform is undeniable. Improving the U.S. health system is one of the
most important challenges we face as a nation, and the inability to achieve comprehensive
health reform will undermine any efforts to secure economic recovery. Health reform is an
essential part of restoring America’s overall economy and maintaining our competitiveness
at home and around the world.

Health care reform is also necessary to protect the finances of our working families. Nearly
46 million Americans lack health coverage and another 25 million are underinsured. Rising
health care costs and mounting medical bills have become a pocketbook issue for too many
families, becoming one of the biggest factors in personal bankruptcy filings.

Each of the key challenges facing our health care system ! lack of access to care, the cost
of care, and the need for better-quality care ! must be addressed in concert. Covering
millions of uninsured through a broken health system will be fiscally unsustainable.
Attempting to address the inefficiencies plaguing our system and the perverse incentives in
the delivery system without covering the uninsured will fail to alleviate the burden of
uncompensated care and cost shifting. The time for incremental improvements has passed;
health care reform must be comprehensive in scope.

This Call to Action provides a starting point for the upcoming health care reform debate. It
is a vision and not a legislative proposal. It is comprehensive but not an exhaustive
exploration of every health care issue that can or should be considered.

As a first step toward consideration of health care reform, Congressional leaders and the
public must understand that reform will likely require an initial investment. In the short
term, health care reform will cost more than can be achieved in savings from all the quality
improvement initiatives and financing changes. But these changes will improve the quality
of the health care that Americans receive and reduce the cost of that health care, ultimately
putting our system on a more sustainable path. More importantly, the costs of inaction,
both in human and financial terms, are greater than any initial outlays.

The next crucial step is a constructive dialog on policy priorities among policymakers,
stakeholders, health policy thought leaders and the public. Consensus will be difficult to
achieve, but common ground from which to build can and must be found.

87
APPENDIX
LIST OF ABBREVIATIONS

AAMC – American Association of Medical Colleges
ABIM – American Board of Internal Medicine
ACE – Acute Care Episode
ACO – Accountable Care Organizations
AFDC – Aid to Families with Dependent Children
AHRQ – Agency for Health Care Research and Quality
AMA – American Medical Association
ARDC – Aging and Disability Resource Center
BBA – Balanced Budget Act of 1997
CBO – Congressional Budget Office
CDC – Centers for Disease Control and Prevention
CHIP – State Children’s Health Insurance Program
CMS – Centers for Medicare and Medicaid Services
COPD – Chronic Obstructive Pulmonary Disease
EHR – Electronic Health Record
FEHBP – Federal Employees Health Benefit Program
FMAP – Federal Medical Assistance Percentage
FPL – Federal Poverty Level
FQHC – Federally Qualified Health Center
FSA – Flexible Spending Account
GAO – Government Accountability Office
GDP – Gross Domestic Product
GME – Graduate Medical Education
HCBS – Home and Community Based Services
HCFAC – Health Care Fraud and Abuse Control
HELP – Senate Committee on Health, Education, Labor, and Pensions
HHS – Department of Health and Human Services
HIT – Health Information Technology
HQID – Hospital Quality Incentive Demonstration
HRSA – Health Resources and Services Administration
88
HSA – Health Savings Account
IHS – Indian Health Services
IME – Indirect Medical Education
IOM – Institute of Medicine
IRS – Internal Revenue Service
MA – Medicare Advantage
MedPAC – Medicare Payment Advisory Commission
MIPPA – Medicare Improvements for Patients and Providers Act of 2008
MRI – Magnetic Resonance Imaging
NCQA – National Committee for Quality Assurance
NHCS – National Health Care Survey
NHIS – National Health Interview Survey
NIH – National Institutes of Health
NQF – National Quality Forum
OASIS – Outcome and Assessment Information Set
OIG – Office of the Inspector General
OMB – Office of Management and Budget
PGP – Physician Group Practice
PhRMA – Pharmaceutical Research and Manufacturers of America
PHSA – Public Health Service Act
PQRI – Physician Quality Reporting Initiative
RHC – Rural Health Center
RUC – Relative Value Update Committee
SGR – Sustainable Growth Rate
SSDI – Social Security Disability Insurance
SSI – Social Security Income
TANF – Temporary Assistance for Needy Families
UMHS – University of Michigan Health System
VBP – Value Based Purchasing

89

REFORMING AMERICA’S HEALTH CARE SYSTEM: A CALL TO ACTION
It is the duty of the next Congress to reform America’s health care system. In 2009, Congress must take up and act on meaningful health reform legislation that achieves coverage for every American while also addressing the underlying problems in our health system. The urgency of this task has become undeniable. In preparing to act, I led the U.S. Senate Finance Committee in holding nine hearings on health care reform this year and hosted a day-long health summit in June 2008 to explore in greater depth the problems plaguing our health system. I have spent a good deal of time talking to colleagues on both sides of the aisle and to stakeholders in the health care industry to get their perspectives on the issues that matter. And perhaps most importantly, in listening sessions across the state of Montana, I have heard from many Americans about the challenges so many patients and families face in getting access to affordable health coverage and paying medical bills. This paper — this Call to Action — represents the next step. It is not intended to be a legislative proposal. Nor is it an exhaustive exploration of every health care issue that should or needs to be addressed, or that will be considered. Rather, it details my vision for health care reform. The plan outlined here addresses health care coverage, quality, and cost. Many components would require an initial investment but, over time, would vastly improve the quality of the health care that Americans receive and reduce the cost of that health care, ultimately putting our system on a more sustainable path. The policies in this paper are designed so that after ten years the U.S. would spend no more on health care than is currently projected, but we would spend those resources more efficiently and would provide better-quality coverage to all Americans. The health system is so complex that any solution will demand time and attention to make sure that we get it right. This plan is most certainly a work in progress. But this Call to Action is intended to encourage constructive input by policymakers, stakeholders, and health policy thought leaders to move us forward. I look forward to discussing this plan with President-Elect Obama, with my colleagues in Congress, and with stakeholders in the health care system, working collaboratively with all to enact effective health reform.

Americans who care deeply about the future of our health system and our economy must take up the fight together for comprehensive health care reform. My door is open and I seek partners with “can do” spirits and open minds. I believe — very strongly — that every American has a right to high-quality health care through affordable, portable, meaningful health coverage. And I believe that Americans cannot wait any longer.

Max Baucus Chairman U.S. Senate Committee on Finance

2

..................................................................................................... 41 i ............................................ 21 E............................................. 1 COST! GROWTH IN HEALTH CARE SPENDING IS UNSUSTAINABLE FOR FAMILIES................................................... 7 BAUCUS PRINCIPLES: THE VISION FOR OUR HEALTH CARE SYSTEM ............... 3 QUALITY! POOR RETURN ON OUR HUGE INVESTMENT................. STRENGTHENING PUBLIC PROGRAMS .............................................................. 13 A....... iii CHAPTER I THE CASE FOR REFORM.................................... 8 CHAPTER II BAUCUS PLAN: INCREASING ACCESS TO AFFORDABLE HEALTH COVERAGE ................................ 37 B......................... BUSINESSES. STRENGTHENING THE EMPLOYER-BASED SYSTEM...................................................................................... INDIVIDUAL RESPONSIBILITY ................... 15 B.......TABLE OF CONTENTS EXECUTIVE SUMMARY ............... 36 A......... AND THE FEDERAL GOVERNMENT .................................................... 6 WHAT AMERICANS WANT FROM THEIR HEALTH CARE SYSTEM ................ STRENGTHENING THE ROLE OF PRIMARY CARE AND CHRONIC CARE MANAGEMENT ................... 16 C.............................. FOCUSING ON PREVENTION AND WELLNESS ............. 28 F......................... 30 CHAPTER III BAUCUS PLAN: IMPROVING VALUE BY REFORMING THE HEALTH CARE DELIVERY SYSTEM .......... 1 ACCESS!MILLIONS OF AMERICANS LACK COVERAGE ......................... GUARANTEED ACCESS TO AFFORDABLE COVERAGE FOR INDIVIDUALS AND SMALL BUSINESSES ... ADDRESSING HEALTH DISPARITIES.............................................. 17 D............................................. REFOCUSING PAYMENT INCENTIVES TOWARD QUALITY ....................................................

....... INCREASED TRANSPARENCY ............C............ 55 CHAPTER IV BAUCUS PLAN: FINANCING A MORE EFFICIENT HEALTH CARE SYSTEM.................................................. PROMOTING COLLABORATION AND ACCOUNTABILITY .............................. 78 F.......................................... 74 D................ LONG-TERM CARE SERVICES AND SUPPORTS ... 80 CONCLUSION ................... TAX INCENTIVES FOR HEALTH COVERAGE ..................................... WASTE........................... HEALTH CARE INFRASTRUCTURE................................................ 66 B.......................... FRAUD....... 87 ii ................................................... 76 E................... 48 D................................. 69 C. PRIVATE INSURANCE PLANS IN MEDICARE ............. AND ABUSE............................................................................................................ MEDICAL MALPRACTICE REFORM ............................................................ 65 A.....

Despite high levels of spending on health care. Children fare even worse. for example. And iii . manufacturers.EXECUTIVE SUMMARY The link between health care costs and the economy is undeniable. and these costs are passed on to consumers in the form of increased premiums. providers charge higher prices to patients with private coverage to make up for uncompensated care. the costs of care for the uninsured are largely borne by those with insurance. American businesses are straining to absorb rising health care costs while staying competitive at home and around the world. plans. covering all Americans is essential to effective prevention and wellness efforts and managing chronic illnesses. families are struggling to keep up with out-of-pocket costs for medical care. and they are ready for change. with 46 million uninsured and another 25 million underinsured. labor. research documents poor quality of care received by patients in the U. Insurance works because policyholders pay into their plans when healthy. health status. and far less than optimal quality and value is unsustainable and intolerable. Efforts to guard against and better manage illness are an effective tool to improve health and contain costs but.S. Requiring all Americans to have health insurance will help end the shifting of costs from the uninsured to the insured. those efforts will fall short of their full potential. to deal with our long-term fiscal challenges. and the problem of unaffordable coverage will persist. without every American in the system. health providers and plans. providers. Americans are acutely aware of problems in the country’s health care system. the nation’s economists concur that system reform is not only necessary to rationalize our health care system. businesses. and state and local governments — are signaling that they are ready and willing to engage in serious and comprehensive reform of a health system in crisis. our ability to compete internationally and. that adults receive recommended care for many illnesses only 55 percent of the time. over the long haul. unacceptable numbers of the uninsured and underinsured Americans. They recognize that the status quo of high costs. individuals. Today. but to sustain our economy. is the only developed country that does not guarantee health coverage for all its citizens. They are not alone. Wellness and prevention would be prioritized. As a result.S. notably. Reforming the health care system is essential to restoring America’s overall economy and the financial security of our working families. And. employers. and have their medical bills paid when they are sick. or medical history. quality coverage no matter their age. The U. Covering all Americans would also ensure that the insurance market functions effectively. as well as government would all bear responsibility and contribute to fulfilling the goal of covering all Americans. In a high-performing health care system. If a significant portion of Americans does not purchase coverage until sick. A high-performing health care system would guarantee all Americans affordable. then premiums for all enrollees will increase to cover insurer outlays. Finally. Studies show. The nation’s health care stakeholders — consumers. The case for reform is strong.

the Exchange would be a marketplace where Americans could easily compare and purchase the plans of their choice. the Baucus plan calls for additional funding for IHS. This policy is consistent with the original intent of Medicaid. the Baucus plan would make health care coverage immediately available to Americans aged 55 to 64 through a Medicare buy-in. Premium subsidies would be available to qualifying families and small businesses. This step is necessary for insurance market reforms to function properly and to end the cost shifting that occurs within the system.increased quality would result in lower costs so that employers could afford to continue to offer health coverage and still compete in a global marketplace. employers that choose otherwise must contribute to a fund that would help cover those who remain uninsured. Those who already have health coverage could keep what they have. guaranteed coverage. and (3) an absolute commitment to weed out waste. and it would begin to phase-out the current two-year waiting period for Medicare coverage for individuals with disabilities. eliminate overpayments. This Call to Action outlines a vision for creating that high-performing health care system. putting help within reach for more needy children. Ensuring Health Coverage for All Americans. so that Americans are no longer locked into a job based on a need to retain their health coverage. greater value. (2) an insistence that any such expansion be coupled with an emphasis on higher quality. and it is the quickest and most cost-effective way to cover every American living in poverty. Like a sturdy stool. Private insurers offering coverage through the Exchange would be precluded from discrimination based on pre-existing conditions. individuals would have a responsibility to have health coverage. and meaningful health insurance options are available to all Americans through their employers or through the Exchange. and — over time — less costly care. Except for small firms. By making health care more affordable and universally available to all Americans. Ensuring that every American has coverage would make health care truly portable. Finally. But for those who need affordable. the Call to Action has three equally important legs: (1) a policy that ensures meaningful coverage and care to all Americans. recognizing that America cannot keep its promise to provide care to Native Americans and Alaska Natives with the current level of Indian Health Service (IHS) funding. iv . and design a sustainable financing system that works for taxpayers as well as for the nation’s recipients and providers of health care. The plan would provide every American living below the poverty level with access to Medicaid. While the Exchange is being created. Once affordable. The Baucus plan would also ensure that all states use the State Children’s Health Insurance Program (CHIP) to cover children at or below 250 percent of the Federal poverty level. The Baucus plan would ensure that every individual can access affordable coverage by creating a nationwide insurance pool called the Health Insurance Exchange. the Baucus plan would take a major step toward eliminating racial and ethnic health disparities. It is expected that the vast majority of American employers would continue to provide coverage as a competitive benefit to attract employees. Our public health programs would be on a more fiscally sustainable path. high-quality.

S. The plan strengthens the role of primary care and chronic care management. The plan would promote accountability and coordination among providers by encouraging providers in different settings — physician offices. The plan would refocus payment incentives toward quality and value. A redefined health system would realign payment incentives toward improving the quality of care delivered to patients. Preventive Services Task Force. over time. Increasing the supply and availability of primary care practitioners by improving the value placed on their work is a necessary step toward meaningful reform. Improving Health Care Quality and Value. inpatient hospitals. and CHIP beneficiaries would receive recommended preventive services with little or no co-payment. not only to correct the imbalances of the current health care system. Individuals without private coverage and not eligible or enrolled in a public health coverage program. costly chronic conditions. According to the Congressional Budget Office. immunizations. lower costs. up to one-third of that spending — more than $700 billion — does not improve Americans’ health outcomes. Reinvesting in the training of a twenty-first century health care workforce is necessary for many delivery system reform goals to be realized. including services like a health risk assessment. and economists warn that rising health care costs represent a serious threat to our long-term fiscal security.S. Today’s payment systems reward providers for delivering more care rather than better care. Achieving Greater Efficiency and Sustainable Financing. The U. Health IT is needed for quality reporting and improvement and to give providers ready access to better evidence and other clinical decision-support tools. but to offset the high costs of much-needed comprehensive reform. and others — to collaborate and provide patient-centered care in a way that would improve quality and save money. To facilitate the proposed delivery system reforms. Recognizing that any attempt to cover the uninsured and reduce health care spending must address the perverse incentives fostered by current payment systems. Excess spending must be eliminated and dollars put to better use. the Baucus plan would improve the health care infrastructure by investing in new comparative effectiveness research and health information technology (IT). Those who are uninsured ! and therefore less likely to receive preventive care and treatment for major conditions ! would be given a “RightChoices” card that guarantees access to recommended preventive care. v . rather than on illness and treatment. post-acute care settings. Preventive services would be covered by all insurance options offered through the Health Insurance Exchange. the Baucus plan includes delivery system reforms that would improve quality and. but whose RightChoices screening detected and diagnosed one or more of the most common. would qualify to receive treatment on a temporary basis until viable coverage options are available under the Health Insurance Exchange. Fixing the unstable and unsustainable Medicare physician payment formula is a necessary step in this process. Medicaid. Primary care is the keystone of a high-performing health care system. physical exam. Current Medicare.The Baucus plan would immediately refocus our health care system toward prevention and wellness. and age and genderappropriate cancer screenings recommended by the U.3 trillion per year on health care. spends $2.

The plan also considers careful reforms of medical malpractice laws that could lower administrative costs and health spending throughout the system. and invest in critical research and technology.000 deaths a year. continue to witness the plight of tens of millions of our citizens without health insurance cost shifting to those who do. Congress must take up and act on meaningful health reform legislation that achieves coverage for all Americans while also addressing the underlying problems in our health system. reward quality care. distribute benefits more fairly. In short. In 2009. Conclusion. I believe it is the duty of the next Congress to reform America’s health care system. however. waste. continue to tolerate poor quality that leads to nearly 100. will eventually be far greater than any initial outlays. In the short term. the Baucus plan would endorse direct steps in five additional areas to curb excess health care spending. and abuse in public programs. The urgency of this task has become undeniable. while ensuring that injured patients are compensated fairly for their losses. Congressional leaders and the public must be realistic about the timeframe in which the fiscal success of reform is measured. health care reform would cost taxpayers more than the government can achieve in savings from all reforms and financing changes.Beyond measures to refocus the system on primary care. vi . we will double our current national expenditure on health care from $2 trillion to $4 trillion. we all must realize that the costs of inaction. Considering policies to shift the focus from institutional care to services provided in the home and community could improve the quality of care delivered and reduce costs. Long-term care services and supports are both a significant share of national health expenditures and a driver of cost. We must choose to invest now in a health care system that will richly repay the nation with greater health and economic stability in the long term. the plan would explore targeted reforms of the tax code to make incentives more efficient. The plan would address overpayments to private insurers in the Medicare Advantage program. The plan would increase transparency of cost and quality information and would require disclosure of payments and incentives to providers by drug or device makers that may lead to biased decision-making. The plan would invest more to detect and eliminate fraud. and watch our businesses become less competitive and our nation go further into debt. If we fail to act. Finally. and promote smarter spending of health care dollars by consumers themselves. both in human and financial terms.

1). 9 A majority of the uninsured has low or moderate incomes (see Figure 1. as then.4 Those without health coverage generally experience poorer health and worse health outcomes than those who are insured.3 percent of the population. on government spending. Roosevelt and the New Deal generation as they sought a path out of the Great Depression. About twothirds have family incomes less than twice the Federal poverty level (FPL). A better understanding of each of these key issues demonstrates the need for immediate action by the next Congress. Eight in ten of the uninsured come from working families.10.” 1 With a world financial crisis demanding a significant investment of government resources. health care reform is an essential part of restoring America’s overall economy and the finances of our working families. Health care reform is not a distraction from addressing our economic challenges. ACCESS!MILLIONS OF AMERICANS LACK COVERAGE The U. 6 . on U. 1 . But the link between health care costs and the economy is incontrovertible. the cost of care. or they do not qualify for employer-offered coverage.CHAPTER I THE CASE FOR REFORM At a day-long health reform summit hosted by the Senate Finance Committee this year.12 But these workers are either not offered coverage by their employer and cannot access it through a family member. and the need for better-quality care. Now. is the only developed country without health coverage for all of its citizens.000 uninsured adults die prematurely each year as a direct result of lacking access to care. The key challenges facing our health care system are lack of access to care. Federal Reserve Chairman Ben Bernanke said. 7 . or 15. 2 This moment in history is not unlike that faced by President Franklin D. lacked health insurance in 2007 — up from 38. 8 The Urban Institute reports that 22.4 million in 2000. 3 An estimated 45. And a number of studies show that the uninsured are less likely to receive preventive care or even care for traumatic injuries. For example.11 Only one in ten have incomes higher than four times the Federal poverty level.7 million Americans. Health care concerns are closely tied to economic anxiety. businesses.5. and on the country’s ability to compete globally. solving America’s economic challenges will require a multifaceted response. they might not be eligible because they work part-time. and chronic diseases. Sixty-two percent of voters in the 2008 elections agree that it is more important than ever to take on health care reform in light of the economic downturn. Twentythree percent forgo necessary care every year due to cost.S. some have asked whether the time is right for a large — and likely expensive — effort at comprehensive health care reform in the United States. Each of these challenges has a direct effect on family budgets. heart attacks. Reforming the nation’s health care system will be an essential part of shoring up the nation’s long-term economic strength.S. “Improving the performance of our healthcare system is without a doubt one of the most important challenges that our nation faces.

Unfortunately.000 annual limit. REAL REASONS FOR REFORM: In 2006.000 before it would start providing chemotherapy treatment. the policy had a $37. more than 47 million were insured when the expenses were incurred. Medical debt contributes to half of all filed bankruptcies. Ms. 2 . she learned that after being in remission for more than a year.000 each month for those bills. and affects approximately two million people a year. Anderson Cancer Center. Ms. her leukemia has returned. 16 REAL PEOPLE. another 25 million Americans are “underinsured. In addition to the uninsured. M. the hospital. Lisa Kelly was diagnosed with acute leukemia. or heating their homes.1.000 in bills incurred before February 2008. underwritten by UnitedHealth Group Inc.” without enough coverage to keep their medical bills manageable. Since her cancer was a pre-existing condition. medical debt keeps these Americans from feeding their families. with a monthly premium of $633. Kelly is still personally responsible for more than $145. Although Blue Cross started paying her new hospital bills earlier this year. And due to the flimsy coverage provided by her policy. and she is paying $2. with a monthly premium of $185.Figure 1.D. 79 million Americans are unable to pay their medical bills 14 — and of those. paying their rent. she had to wait one year for the new plan to cover her treatment. requested an up-front cash payment of $105. 15 Despite their insurance coverage. According to a recent study by The Commonwealth Fund. In June. Uninsured by Federal Poverty Level 400%+FPL 10% 300-399% FPL 8% <100% FPL 37% 200-299% FPL 17% 100-199% FPL 29% Source: KCMU/Urban Institute analysis of March 2008 CPS. Kelly enrolled in a high-risk insurance plan administered by Blue Cross Blue Shield of Texas in February 2007.13 She had insurance!an AARP Medical Advantage plan.

791 $4.325 $5. including obesity. 1999–2008 $12.680 13% 11% 8% 14% 11% 9% 8% 6% 119% increase $9.247 $1. BUSINESSES. 17 Other factors. 1999-2008. working families and individuals found their health care in jeopardy as the cost of employer-sponsored coverage rose beyond the means of businesses — particularly small businesses — and workers alike. KPMG Survey of EmployerSponsored Health Benefits.543 1999 117% increase $3. 1988.2. and productivity. demographics. 1993. Failure to address problems in the health care system could undermine current efforts to restore the economy. 1996. Bureau of Labor Statistics. 1989. As Figure 1. City Average of Annual Inflation.354 2008 Health Insurance Premiums Overall Inflation Workers' Earnings Employer Contribution Worker Contribution Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits.COST! GROWTH IN HEALTH CARE SPENDING IS UNSUSTAINABLE FOR FAMILIES.S. Congress cannot help American families’ finances or address America’s economic woes in a lasting. U. Why are premiums rising so fast? A recent synthesis of studies found that greater use of medical technology is a driving force — contributing between 38 and 65 percent to health care cost increases. Premiums have increased 117 percent for families and individuals and 119 percent for employers between 1999 and 2008. Seasonally Adjusted Data from the Current Employment Statistics Survey. 1988-2007. health insurance premiums have increased faster than wages and inflation for most years between 1988 and 2007. Consumer Price Index. 1988-2007 18% 14% 12% 9% 5% 1% 19 88 19 89 19 90 19 93 19 96 19 99 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 Average Health Insurance Premiums and Worker Contributions for Family Coverage. Bureau of Labor Statistics. American businesses are straining to absorb rising health care costs while staying competitive at home and around the world. Even before the current economic crisis. AND THE FEDERAL GOVERNMENT American families are struggling to keep up with out-of-pocket costs for health care. Illustrations of Health Insurance Premium Increases Increases in Health Insurance Premiums Compared to Other Indicators. Federal and state budgets — as well as taxpayers — are bearing an ever-increasing burden as entitlement programs such as Medicare and Medicaid consume a larger share of public expenditures. The Health Insurance Association of America (HIAA). meaningful way without health care reform. also contribute to growth in the cost of health care. 1990. 1988-2007.2 shows. Figure 1. 3 . Ultimately.

health care expenditures are expected to consume nearly 20 percent of the GDP (see Figure 1. 4 . 25 Over the same period. or providing less-than-comprehensive health coverage. 22 As rising health care costs threaten the stability and competitiveness of American businesses. is projected to increase by 114 percent in ten years. 19 Even if workers can afford their portion of a premium. 24 Spending for Medicare and Medicaid. Quotes from other plans were 2½ times higher than the current rate. By 2017. Renewing coverage in 2008 cost the company 35 percent more than in 2007. Because employers are the principal source of health insurance in the U. has appropriately noted that rising health care costs represent the “single most important factor influencing the Federal Government’s long-term fiscal balance. Small business owners have increasingly been forced to decide among several painful options to offset increasing health care costs — raising health insurance premiums. or $4. but today that figure is 62 percent. hospitals and clinics provide an estimated $56 billion in uncompensated care every year to people without health insurance. an Ohio firm. Inc. REAL PEOPLE. eliminating family health benefits. 68 percent of small to mid-size businesses (3-199 workers) offered health benefits. providing health benefits for more than 158 million people. 21 is far too common in the U.S. The story of Phoenix Products (left).20 erosion in employersponsored coverage is a serious problem. But as its employees grew older and health costs increased.3). REAL REASONS FOR REFORM: Phoenix Products. growing from a youthful start-up company into an established business with 47 employees. A study of this “hidden tax” estimated that ten percent of California health care premiums are attributable to cost shifting due to the uninsured. spends more than 16 percent of our gross domestic product (GDP) on health care — a much greater share than other industrialized nations with high-quality systems and coverage for everyone. has operated for 31 years. The company is on the verge of losing its ability to offer insurance.. Even then. Director of the Congressional Budget Office. the company had to dramatically alter the health plan benefit structure to keep providing any coverage at all.” 23 The U. Peter Orszag. employers may not be able to afford the rest. Phoenix Products could afford to provide a comprehensive health plan at a reasonable cost.3 trillion annually. they threaten to destabilize the fiscal health of the country itself. relayed to the Senate Finance Committee at a June 2008 hearing. 18 and those who have health coverage pay the bill through higher health care costs and increased premiums. premiums increased ten percent each year from 2003 to 2007. due to many of the same factors found in the private sector. In 2000. limiting raises or reducing bonus pay.. the maximum increase allowed under Ohio law.S.S.Additionally. the GDP will grow by just 64 percent. The company moved away from comprehensive benefits to a limited catastrophic coverage plan. As recently as 2003.

Finally.5 percent of total costs. compared to about 22 percent for coverage purchased in the private insurance market in the U. In Japan’s largely private system. they can raise taxes or cut spending on Medicaid and other vital services.0% 37.5% 16. 30 In a study of global health care systems. 2007) States face fiscal challenges ALSO.Figure 1. 26 One effect of rising unemployment rates will be increased eligibility for and enrollment in Medicaid.200 in the U. 28 States face limited choices in trying to meet budget shortfalls.S. 5 . Although polls show that many Americans believe the U. in the 21st century. In Switzerland.4). “Health Spending Projections Through 2017”. Health Care Spending Poses Long Term Challenges for U. at least 29 states have already taken action to reduce their budget deficits for fiscal year 2009.S. The Long Term Budget Outlook (Dec. health care system is better than other industrialized nations. 27 In response. the cost for magnetic resonance imaging (MRI) is less than $100. spends a greater percent of GDP and almost twice as much per person on health care compared to other major industrialized countries (see Figure 1. the U. the strength of our health care system is increasingly important. CBO. compared to $1.S.S. Many state governments are struggling to meet balanced budget requirements. Economy and Federal Budget 43. when the economies of the world are ever more interconnected.0% 20.3% 2007 2050 Health Care Spending as % of GDP 2007 2050 Medicare & Medicaid as % of Total Federal Budget Sources: Keehan.S.S. Our international competitiveness depends on the health of our workforce. On average. 29 the numbers do not demonstrate this to be true. administrative costs represent 5.3. As mentioned. journalist and author T. home to profitable insurance companies and influential pharmaceutical companies.R. states already spend 22 percent of their budgets on Medicaid. other countries demonstrate the possibility of success. Reid found startling cost differences with the U.31 While there must be a uniquely American answer to the question of containing health care costs.

449 $3.371 $3.082 $2.999 $3.Figure 1. Source: Organisation for Economic Co-operation and Development.oecd. and Selected Countries.349 $2.760 $6. QUALITY! POOR RETURN ON OUR HUGE INVESTMENT Despite high levels of spending on health care. OECD Health Data 2008. Total Health Expenditures Per Capita. Patients with breast cancer fared better.678 $3. United States OECD Average $2. U. Needed care for diabetes was delivered only 45 percent of the time and for pneumonia only 39 percent of the time.S.202 $4.714 $3. but still did not receive recommended care one-quarter of the time. A 2003 RAND Corporation study found that adults received recommended care for many illnesses only 55 percent of the time.250 $2.34 A recent study by the Institute of Medicine concluded that the current health care system is not making progress toward improving quality or containing costs for patients or providers. updated August 26.32 America ranks 29th out of 37 countries for infant mortality — tied with Slovakia and Poland.391 $4.606 $3. the U. 2006 Australia Austria Belgium Canada Denmark Finland France Germany Ireland Italy Japan Luxembourg Netherlands Norway Sweden Switzerland U.474 $4.D.668 $3. 33 The United States has almost double the infant mortality rate of France or Germany.311 $3.824 $2.303 Amounts in U. 6 .4. is shocking.S.488 $3.S. ranks last out of 19 industrialized countries in unnecessary deaths. 2008. 35 Research documenting poor quality of care received by patients in the U. and below Cuba and Hungary.K.S.614 $2.org/health/healthdata. http://www.

” 41 When asked whether our health system needs a complete overhaul. 90 percent of Americans respond that the system should be “completely rebuilt” or that “fundamental changes” are needed. Even more disturbing is the finding that all patients are at risk for poor quality care — gender. and pay even more when treatment results in subsequent injury or illness. Americans are not getting their money’s worth when patients receive services of little or no value 37. 42 At the same time. many more receive uncoordinated. Many people are satisfied with their personal providers or their current coverage and do not want to jeopardize those connections to the system. 44 Three out of four say that. race.The same researchers at RAND found that children received recommended care only 47 percent of the time. More than 70 percent of Americans rate our health care system as “fair” or “poor. 45 7 . better meet the health care needs of millions more American patients. or ineffective tests and treatments. 39 Providers are not consistently encouraged to coordinate patients’ care or to supply preventive and primary care services. Rewarding providers that furnish better quality care. and ready for change. Sixty-five percent of those polled admit that it is “somewhat” or “very difficult” for them to afford health care and health insurance. Medicare and most other insurers continue to pay for more visits. regardless of whether the treatment is effective or necessary. or minor tinkering. income. Beyond the known medical risks that low-quality care poses for individual Americans. The majority of Americans also believes that coverage should be provided for the uninsured. the amount of money that they have paid out of pocket for their own health care has increased. are unable to access care when needed. Polling repeatedly demonstrates that Americans want and deserve better access to care. and children with chronic illnesses received about 53 percent of needed services. duplicate tests. 43 Americans also want relief from rapidly rising premiums and medical debt. even though such actions can improve quality of care and reduce costs. or obtain care through hospital emergency departments after their condition has worsened due to lack of timely intervention. In short. those who currently have health coverage do not want to lose those benefits. 36 Recommended preventive services were provided just 41 percent of the time. over the past five years. and use resources more judiciously could reduce costs and. calling the issue of the uninsured a very serious problem. Yet the current system does little to steer providers toward the right choices. and procedures. 40 WHAT AMERICANS WANT FROM THEIR HEALTH CARE SYSTEM Americans are acutely aware of problems in the country’s health care system. the lack of quality across our health care system contributes to the problem of rising costs. better quality care. age. imaging services. and better value from their health care system. Even though more care does not necessarily mean better care. major repairs. and insurance status do not provide any advantage. fragmented care.38 — such as hospitalizations that could have been prevented with appropriate outpatient treatment. Although many patients do receive excellent care. coordinate care. tests. most importantly.

There is also agreement that our health care system must do a better job of containing costs. and reduce costs to make our system sustainable for the future. BAUCUS PRINCIPLES: THE VISION FOR OUR HEALTH CARE SYSTEM While there may be differences of opinion on the solutions. These principles form the foundation of this Call to Action.5).5. Such a system may not be viable in a country that values individuality. or a mandate that all individuals purchase coverage. A mix of public and private solutions must be found to keep our system from leaving millions of Americans behind. Moreover. some of this support erodes when respondents are asked whether they would be willing to have more government responsibility or higher taxes — though half of all surveyed in 2007 said they would support reform even under these circumstances. America’s businesses — and the economy — depend on it. a “Medicare-for-all” single-payer option. Oct 19-22. Any serious health reform proposal must include policies that will slow the rate of growth in health spending over time. This does not mean that a government program should provide the coverage. increase the quality of care for all. choice. Along with efforts to rein in 8 . 2007 Policymakers need to sift through the options and combine the best of American’s desires for a new health care system to ensure health coverage for every American. and a preference for market-based solutions. the task remains difficult because Americans do not necessarily agree on how to achieve it (see Figure 1. Although a majority of respondents would support a mandate on employers to provide coverage. The sustainability of the nation’s public programs. most Americans agree on the principles that health reform should embrace. opposition to each of these options is also somewhat substantial.46 Figure 1.Despite widespread agreement on the need for reform. There is widespread agreement that every American should have health coverage. Lack of Consensus on Reform Options Support Employer Mandate Oppose 62% 31% Medicare-for-All 53% 36% Individual Mandate Tax Breaks to Make Insurance More Affordable 51% 39% 44% 45% Source: Los Angeles Times/Bloomberg poll.

Providing coverage to all Americans would make health care truly portable and allow Americans to change jobs when they wanted. and all Americans would gain the ability to leave a job or start a new business without worrying about prospects for future coverage. Wellness and prevention would be encouraged. Employers should contribute toward health insurance choices and financing. Others. promoting better value for our dollar. Such a system would guarantee Americans the choice of a health plan that they can afford. Individuals have the responsibility to get coverage. and to play a larger role in health care treatment decisions.health spending. should help those who lack the means to buy insurance on their own and ensure that the insurance market is fair and transparent. and payment systems should better align incentives to foster a focus on providing better care rather than more care. Another critical principle in health reform is the recognition that health care is a shared responsibility. Providing coverage to all Americans would lower costs by including the healthiest individuals in the risk pool to offset the costs of the sickest individuals — and maintaining wellness rather than treating illness. assistance must be provided to small businesses. either private or public. and individuals who currently struggle to find and afford health coverage. precluding discrimination by insurers based on health status. including the uninsured. and reforming the delivery system. families. would have options. 9 . the focus should be on care coordination. Providers should improve their performance to ensure consistent. Our public health programs would be on a more fiscally sustainable path than they are today. When illness cannot be prevented. The system envisioned here guarantees access to affordable coverage for every American. high-quality health care. rather than remaining locked in by their need for health coverage. This Call to Action represents a vision for creating that highperforming health care system. modification of risk factors. individuals. Society. Our system must also encourage wellness and the prevention of disease through early detection. With these principles in mind. and providing subsidies to low-income families. and encouragement of healthy lifestyle choices. To ensure that affordable options are available to all. through state and Federal governments. Employers. Those who like their current coverage arrangements could keep what they have. individuals. The costs of health care would be more manageable so that employers could afford to offer coverage to their employees and still compete in a global marketplace. and government would all bear responsibility and contribute toward fulfilling that goal. Employers. It also aims to lower costs by improving the quality of the care that all Americans receive. The system envisioned here would ensure that every individual could access affordable coverage by creating a nationwide insurance pool. This approach will allow every American to be enrolled in some form of health care plan. and government all have a role to play — and a contribution to make — to the system. to take better care of their own health. the quality of care must improve. it is possible to envision a high-performing health care system in the future.

” (Testimony before the House Committee on Ways and Means. In 2008. Kaiser Family Foundation.” Archives of Internal Medicine. 160. Stan Dorn. “Kaiser Health Care Tracking Poll: Election 2008.pdf.” The Urban Institute.S. 4 3 U. Ayanian et al.S. http://www. “Challenges for Health-Care Reform” (Testimony before the Senate Committee on Finance Health Care Summit. Census Bureau. http://finance. 24 (2005): 5-70. Karen Davis. Senate. Kaiser Family Foundation. others finance coverage through a mix of public and private spending.html.” U. “Unmet Health Needs of Uninsured Adults in the United States. (2008).16 (2000): 2061-9. 2008).urban. “Coverage for all”.The passage and implementation of comprehensive health care reform will not happen overnight. Bernanke.org/uninsured/upload/7806. 2008). “Insurance Coverage.S.” The Kaiser Family Foundation. (2008).kff. Two hundred percent of the Federal poverty level for a family of three is $35.600 and for a family of four it is $21. 297. 5 6 Jack Hadley. Kaiser Family Foundation. The health system is so complex that any solution will demand time and attention to make sure that we get it right. Census Bureau. Henry J.11 (2000): 1746-54. House of Representatives. 100 percent of the Federal poverty level for a family of three is $17.S. http://www.gov/healthsummit2008/Statements/Chairman%20Bernanke’s%20Remarks.pdf.gov/prod/2008pubs/p60-235.S. “Income. Roetzheim et al. U. no.. no.” The Commonwealth Fund. “Five Basic Facts on the Uninsured. and Health Insurance Coverage in the United States: 2007.6 (2000): 817-23. “Payer Status and the Utilization of Hospital Resources in Acute Myocardial Infarction. 9 Henry J.senate.” The Kaiser Family Foundation.org/publications/411588. 2008).pdf. John Z.kaiserfamilyfoundation. 16 15 David Himmelstein et al.000. “47 Million & Counting: Why the Health Care Marketplace is Broken. and Short-term Health Changes Following an Unintentional Injury or the Onset of a Chronic Condition.. June 10. September 23. (2008).. http://www. June 16. “Shifting Health Care Financial Risk to Families Is Not a Sound Strategy: The Changes Needed to Ensure Americans’ Health Security. “Illness and Injury as Contributors to Bankruptcy. “Effects of Health Insurance and Race on Colorectal Cancer Treatments and Outcomes. Richard G.” Health Affairs no.10 (2007): 1073-84.” The Kaiser Family Foundation. “Health of the Private Health Insurance Market. http://www.” American Journal of Public Health 90. in this context.census.kaiserfamilyfoundation. 10 . 8 7 John G. Medical Care Use. no. Ben S. Canto et al. http://www.org/uninsured/upload/7806. means that every citizen in the country has health care coverage. no. Subcommittee on Health. (2008). U.” Journal of the American Medical Association. 284. 2 1 Henry J.org/kaiserpolls/upload/7832. But Americans without health insurance — as well as those in need of better coverage or in danger of losing their coverage — need the process to start now. “Uninsured and Dying Because Of It: Updating the Institute of Medicine Analysis on the Impact of Uninsurance on Mortality.pdf. 14 13 12 11 10 Karen Davis.200 and $42.pdf. “Five Basic Facts on the Uninsured.” (Testimony before the Senate Committee on Finance. Poverty. While many developed countries finance health care primarily through government funds. Lisa Kelly.400 for a family of four. U. Senate. It does not necessarily mean that this coverage is financed by government spending.” Journal of the American Medical Association.

Ginsburg. no. and Dawn Miller.” The New America Foundation. “The Quality of Ambulatory Care Delivered to Children in the United States. 27 National Conference of State Legislators. (2008): 399-415. Underuse. Mathews.cbpp. Marian F. Senate. Rita Mangione-Smith. MacDorman and T. (2008). (2001).” www. 35 34 33 Committee on Quality of Health Care in America. 1. Health System Performance” The Commonwealth Fund. U.” The Center on Budget and Policy Priorities. (2008). http://www.S.” Institute of Medicine.J. “47 Million & Counting: Why the Health Care Marketplace is Broken” (Testimony before the Senate Committee on Finance.org/pdf/7790. John Holahan. “The Overuse. et. “Why Not the Best? Results from the National Scorecard on the U.ncsl. 2008). 2008). 2008). (2008). 31 32 30 29 28 PBS. 26 25 24 National Association of State Budget Officers. Teresa A. http://www. and Misuse of Health Care. no.S. U.” New England Journal of Medicine.org/wbgh/pages/frontline/sickaroundtheworld.pdf.S.” Health Affairs.brief.pdf: 2. (2008).net/files/HealthIBNo3. Senate. 2007): 1515-23. Sources Of Payment. Martin McKee.kff.” Harvard University/Harris Interactive.pdf. (2006). and Incremental Costs.S. “Sick Around the World. 2008.org/pdf/7790.al. 5. “Americans’ Views on the U.” The Kaiser Family Foundation. All States. U. “The Budget and Economic Outlook: Fiscal Years 2008 to 2018.2 (2008): 145-155. 2008. Frontline. “Measuring the Health of Nations: Updating an Earlier Analysis. (2008): 58-71.Sarah Goodell and Paul B. Senate. Jason Levitis. http://ehbs..costdrivers. “Crossing the Quality Chasm: A new Health System for the 21st Century. et al. 357 (October 11. no.. (2008).” (Testimony before the Senate Committee on Finance.org/9-26-08sfp. Peter Harbage and Len Nichols. Coughlin.S. June 10. “Employer Health Benefits Survey. http://www. 21 20 19 18 17 Raymond Arth. (2008). 23 22 Peter Orszag. no.” (Testimony before the Senate Budget Committee. http://ehbs. http://www.” Health Affairs 27. (2008). “Health Spending Projections Through 2017: The Baby-Boom Generation Is Coming to Medicare.org/files/research/101508. Ellen Nolte and C. (2003). 36 11 . Health Care System Compared to Other Countries. The Commonwealth Fund. Kaiser Family Foundation and Health Research and Educational Trust.S. “Covering the Uninsured In 2008: Current Costs. Iris J. “A Premium Price: The Hidden Cost All Californians Pay in Our Fragmented Health Care System.pdf. http://www.org/Publications/PDFs/Fiscal%20Survey%20of%20the%20States%20June%202008.org/usr_doc/StateScorecard. Health Care Spending. Organization for Economic Co-Operation and Economic Development.” Health Affairs. “State Balanced Budget Requirements.” The Kaiser Family Foundation.pbs. “Employer Health Benefits Survey. “House Plan Effectively Targets Fiscal Relief to States. Jack Hadley.kff.” The Robert Wood Johnson Foundation. Harvard University School of Public Health/Harris Interactive.nasbo. “Recent Trends in Infant Mortality in the United States.” Centers for Disease Control and Prevention.pdf?section=4039.pdf. January 24.htm. 27.newamerica.org/programs/fiscal/balreqs. are constitutionally bound to balance their budgets. Kaiser Family Foundation and Health Research and Educational Trust. http://www. “OECD Health Data 2008. “The Fiscal Survey of States” National Association of State Budget Officers.” NCSL. and Edwin Park.” OECD. Sean Keehan. 27. except Vermont.pdf.commonwealthfund.policysynthesis. July 17. “High and Rising Health Care Costs: Demystifying U.rwjf. Peter Orszag. Lav.

shtml..kff.” Harvard School of Public Health. 42 CBS/NYT Poll (Conducted February 23-27. 2007). 38 39 Committee on Quality of Health Care in America. http://www.” NPR/Kaiser Family Foundation/Harvard School of Public Health.” Health Affairs 27.org/kaiserpolls/upload/7804. Ibid. http://www.cbsnews. “The Public on Requiring Individuals to Have Health Insurance. Fisher et al. Part 1: The Content.. “Crossing the Quality Chasm: A new Health System for the 21st Century.pdf Kaiser Family Foundation. no.com/stories/2007/03/01/opinion/polls/main2528357.pdf. CBS/NYT Poll (Conducted February 23-27. and Accessibility of Care.npr. 12 . 40 41 Robert J. and Kennedy School of Government.” Annals of Internal Medicine 138.org/programs/morning/features/2008/feb/insurance/summary. http://www. Donald Berwick et al.37 Elliot S. NPR/Kaiser Family Foundation/Harvard School of Public Health.shtml. Blendon. The Washington Post/Harvard University. 4 (2003): 283. “Low-Wage Workers Survey” The Kaiser Family Foundation. 2007). no. http://www. 293.com/stories/2007/03/01/opinion/polls/main2528357. 3 (2008): 768. Health and Cost. Quality.” Institute of Medicine. (2001): 1-335. (2008).cbsnews. (2008). 45 46 44 43 Ibid. “Lessons for the Next Debate: Understanding the Public on the Health Care Costs/Uninsured Issue. “The Triple Aim: Care.. “The Implications of Regional Variations in Medicare Spending.

S. A mechanism must be established to allow health care consumers to find and obtain health coverage that best meet their needs. Significant changes will take time to approve and implement. as some have proposed. the U. The lack of appropriate standards and regulation in certain markets 13 " " . and small businesses who currently struggle to find and afford health insurance. the existing insurance market must be reformed. individuals. portable. The Baucus plan incorporates six important elements as it moves towards covering all Americans: " Individual Responsibility. Reforms enacted through the Exchange could improve access to health coverage for all. the plan proposed by President Nixon in the 1970s. private or public. would upend health care for more than half the American people — 158 million in all. or national levels. But the principle of individual responsibility can be applied only when affordable options are available to all. Additional assistance must be available to families. 2 This plan envisions a role for employers to contribute to employees’ access to health care. Each was unsuccessful for its own unique reasons. regional. Guaranteed Access to Affordable Coverage for Individuals and Small Business.CHAPTER II BAUCUS PLAN: INCREASING ACCESS TO AFFORDABLE HEALTH COVERAGE Achieving health coverage for every American has proven an elusive goal for decades. dating back to the first attempt at national health reform in the early 1900s by the Progressive Party. state. and the Health Security Act proposed by President Clinton in 1993. health system has become very complex. with deeply entrenched interests. as did the Wagner-Murray-Dingell bill and attempts by President Truman in the 1940s. This mechanism — the Health Insurance Exchange — will connect individuals and employers to insurance offered at local. We must ensure the continued viability of the employer-based system — the principal source of health coverage for most Americans — to allow workers to keep the insurance that they currently have and value. Over the years. In order to make insurance affordable. Covering all Americans means the enrollment of every individual in some form of health care plan. Eliminating employer-based coverage. Insurers offering coverage through the Exchange would need to meet certain requirements established by a new Independent Health Coverage Council. Strengthening the Employer-Based System. and meaningful health insurance. But the series of changes and reforms envisioned in this Call to Action can eventually remake the current system to ensure every American has access to high-quality health care through affordable. 1 That effort failed.

In our current health care system. racial and ethnic minorities disproportionately lack ready access to high-quality medical care. or income — and that is what this Call to Action would give them. though the impact on state and Federal budgets must also be considered. rather than treating illness — which would improve quality and reduce costs across the health care system. Existing public programs represent an effective and efficient way to increase access to coverage and decrease the number of uninsured. Our system also prohibits certain legal immigrants from getting health care for five years. Focusing on Prevention and Wellness. This gives rise to differences in both health status and health care among various groups in our diverse population. These disparities must be addressed and ultimately eliminated. Americans want and deserve a system that provides equal access to health coverage and health care for all — regardless of age. Requirements of the Exchange would be extended to improve fair price and quality competition in the insurance market as a whole so that coverage would be more affordable and available to more Americans. ethnicity. Increased attention and funding for the Indian Health Service (IHS) could improve care for Native American and Alaska Native populations. Though medical advances benefit much of the population. Offering individuals approaching age 65 the chance to buy into Medicare early and eliminating the requirement that disabled individuals wait two years to enroll in Medicare would ensure coverage to populations that the private market is under-serving. 14 . Increased access to preventive care and wellness is another step that could be accomplished in the short term. health disparities continue to worsen for others. We can strengthen public health care programs promptly. The remainder of this chapter provides additional detail on these elements. " " These six elements combine to give every American a role and a responsibility in reforming our health care system to ensure coverage for every individual. " Strengthening Public Programs. Improving Medicaid and the State Children’s Health Insurance Program (CHIP) could provide coverage quickly to additional lowincome Americans while serving current beneficiaries better.fails far too many Americans who need health care. but more immediate steps could provide relief to Americans most in need of health coverage and begin to improve the health of the country overall. race. Addressing Health Disparities. Increasing the availability and effectiveness of primary care coverage could create a national focus on maintaining wellness. Creation of the Exchange would take time.

and have their medical bills paid when they are sick. If a significant portion of Americans does not purchase coverage until sick. the 15 . is how to deal with individuals who do not file a tax return due to their low tax liability. The Exchange envisioned in this plan. Every individual would receive a certificate of coverage from their insurer to demonstrate that they are meeting their responsibility. Efforts to guard against and better manage illness are an effective tool to contain costs.S. then premiums for all enrollees will increase to cover insurer outlays. If a premium subsidy for health care was administered through the tax code. Available to all. but without every American in the system. Requiring all Americans to have health coverage will help end the shifting of costs of the uninsured to the insured. Insurance works because policyholders pay into their plans when healthy. The Exchange would provide standardized information and a single. Requiring all Americans to have health coverage would also ensure that the insurance market functions effectively. high-quality. local hospitals or schools. This step is necessary to make the entire health care system function properly. the costs of care for 46 million Americans without health insurance are largely borne by those with insurance. would be the primary path for those shut out of or underserved by today’s health care system. including physicians’ offices. however. Departments of Motor Vehicles. and the problem of unaffordable coverage will persist. tax system or some other point of contact between individuals and the government. The biggest advantage is that most Americans already have contact with the IRS through the annual filing of a tax return. it will be each individual’s responsibility to have coverage. INDIVIDUAL RESPONSIBILITY Once affordable. simple form for enrollment in a plan of the consumer’s choice. Implementation of a responsibility for all individuals to have coverage would be fair as long as every consumer has a reasonable avenue to find and purchase affordable health care coverage. described more fully below.A. and these costs are passed along to consumers in the form of increased premiums. standard. providers charge higher prices to patients with private coverage to make up for uncompensated care. Monitoring health insurance coverage through the tax code would take advantage of this existing relationship. Finally. The responsibility for all Americans to obtain coverage would be enforced possibly through the U. and local Social Security Offices. Enforcement of a responsibility to have health care through the tax system has advantages. the Exchange would also allow individuals to enroll in health care plans in various convenient locations. covering all Americans is essential to effective prevention and wellness efforts and managing chronic illnesses. and meaningful health insurance options are available to all Americans. Today. One issue to be addressed. those efforts will fall short of their full potential. 3 The cost of that uncompensated care is also unnecessarily inflated because patients without insurance often wait to receive care until they have to go to the emergency room.

6 Health insurance also costs less when purchased through an employer rather than in the individual market. Premiums paid with pre-tax dollars are not subject to Federal and state taxes. Large employers — especially firms paying high wages — have the greatest capability to provide coverage to their employees. participants in employer-based coverage enjoy other advantages. the ability to pay premiums through payroll deduction provides an easy and convenient way to purchase coverage. the majority of working-age adults in Massachusetts — 71 percent —supported the state’s health reform efforts. By offering Section 125 plans.4 In fact. If these employers choose not to provide coverage. because employers provide a natural mechanism for pooling risk by covering healthy and less healthy workers. all except the smallest employers would offer a Section 125 plan under the Baucus plan. Current law prevents them from being disqualified for pre-existing conditions or charged higher premiums based on their medical histories. the health care reform effort in Massachusetts generally has been extremely popular even with the requirement for individual coverage. In the first year of Massachusetts’ individual insurance requirement.non-filer issue would be significantly decreased because a number of current non-filers would voluntarily file in order to get the assistance. The average employer contributes 84 percent of premiums for individual coverage and 73 percent of premiums for family coverage. Additionally. The Baucus plan proposes to extend and build on the tradition and success of employersponsored insurance. under the Baucus plan they 16 . Standards already in Federal law govern certain aspects of their insurance. 5 B. The vast majority of American employers in this category would probably continue to provide coverage as a competitive benefit to recruit employees. employers would make it easier and cheaper for their workers to purchase insurance. Section 125 plans allow employees to pay their health insurance premiums through their employer’s payroll deduction and with pre-tax dollars.6 percent of taxpayers required to file insurance information with their tax returns complied. 8 To strengthen the connection of insurance to the workplace. STRENGTHENING THE EMPLOYER-BASED SYSTEM American employers. 98. 67 percent of Americans said that they were either completely or somewhat satisfied with the health insurance benefits that their employer offered. as well as provide opportunities to remain covered after losing group coverage. are instrumental in providing meaningful insurance coverage to million of workers and their families. Besides lower premiums. In a recent Gallup poll. Employer involvement in the purchase of health insurance provides many distinct advantages. large and small. The Commonwealth of Massachusetts has had success with this approach. economies of scale can reduce administrative costs. 7 And because employers pool coverage for an entire group. At the end of 2007. Employers may also have greater negotiating power with insurance companies and more sophistication in evaluating benefits.

Insurance plans participating in the Exchange could operate nationally. For individuals. Health Insurance Exchange. Eligible individuals and small businesses would receive subsidies to make sure that coverage would be affordable. cost is also the most significant factor. The contribution would likely be based on a percentage of payroll that took into account the size and annual revenues of each firm. create understandable.would have to contribute to a fund that would help to cover those who remained uninsured. GUARANTEED ACCESS TO AFFORDABLE COVERAGE FOR INDIVIDUALS AND SMALL BUSINESSES Individuals and small businesses seeking health insurance on their own frequently encounter serious challenges in obtaining coverage. Mid-sized and small employers would also have the option of providing adequate coverage or paying into the general coverage fund. statewide. and develop a standard application for enrollment in a chosen plan. or locally. The Baucus plan envisions that the Health Insurance Exchange would offer a new opportunity for individuals and small businesses to easily compare private coverage options and a public plan and to purchase the policy that would work best for them. Benefit 17 .or low-benefit options. The Exchange would be an independent entity. Businesses with the fewest workers and the lowest wages would be offered a new tax credit to purchase health insurance for their employees (described below). Workers prefer the support of employers and the convenience that employer-sponsored health coverage provides. For small businesses. the primary purpose of which would be to organize affordable health insurance options. C. So that plans could be easily compared. but the required contribution would be less for them than that for larger firms. and to share the responsibility of maintaining a healthy. and would be exempt from contributions to the general coverage fund if they were still unable to offer insurance to employees. the primary obstacle is the cost of offering coverage to employees. Health care reform must enable employers large and small to continue providing coverage to workers. Insurance companies would be prohibited from denying coverage due to pre-existing conditions and from discriminating against individuals solely due to their health status. medium. productive. but individuals with pre-existing conditions may be denied coverage at any price. The Baucus plan would establish the Health Insurance Exchange through which individuals and small businesses in the market for insurance could obtain affordable health care coverage. globally competitive workforce. qualifying insurers would have to offer products that could be classified as high-. comparable information about those options. Participating employers must enroll all employees through the Exchange — not only the sickest and most costly to insure. regionally.

The Exchange would also include a new public plan option. One option for making it so is a small assessment on premiums to fund activities of the Exchange. Such a system would require oversight. This option would abide by the same rules as private insurance plans participating in the Exchange (e. The Independent Health Coverage Council.g. All plans participating in the Exchange would be subject to the same rating rules included in the insurance market reforms described later in this chapter. reserve requirements. who is eligible for it. Reforming the health care system to cover all Americans through a mix of private and public means involves complex decisions that must be responsive to rapid changes in the health system. oversight of agent practices and training. as done today by the authorizing board of the Commonwealth Connector in Massachusetts.. In addition. similar to Medicare. Plans participating in the Exchange would be subject to oversight by states with regard to consumer protections (e. Participating insurers would have to charge the same price for the same products inside and outside the Exchange. external review. The Exchange would have authority to implement mechanisms to ensure that plans enrolling sicker-than-expected people would not suffer a financial disadvantage compared to those enrolling healthier people. would inform these decisions. A number of options could be considered to determine who runs the plan. For that reason. but all structures would have to be actuarially equivalent within benefit categories in order to prevent insurers from using benefit design to discourage enrollment by people with health conditions. participating private plans would be subject to state regulation related to solvency. The President would choose Council members who were geographically diverse and have expertise in 18 . described below. Keeping insurance premiums in the Exchange affordable must be the guiding principle in setting any assessment. and premium taxes. the Baucus plan authorizes a board of directors — called the Independent Health Coverage Council — to inform decisions that would help to guarantee that affordable health insurance options were available. but it would be self-sustaining within a few years. Offsetting some of the potential risk to insurance plans is intended to limit plans’ incentives to enroll only the healthiest individuals. grievance procedures. Differences in premiums between packages would be due to the difference in benefits and not the differences in expected risk.packages could differ within reason. market conduct). staggered terms.g. Federal funds would be needed to start up the Exchange. Insurers would include the assessment as part of their premiums and could remit it on a monthly or quarterly basis. and how to ensure that the public-private insurance competition lowers costs and improves quality.. The President would appoint members of the Council with the advice and consent of the Senate for set. Independent Health Coverage Council. offer the same levels of benefits and set the premiums the same way). but Congress cannot make all necessary decisions to guide it. Rates paid to health care providers by this option would be determined by balancing the goals of increasing competition and ensuring access for patients to high-quality health care.

For example. The Council would also play a major role in ensuring that the public plan option meets its goals of delivering high-quality and costeffective care. Consistent measures of quality would make performance rating more robust and better able to help Americans make decisions about their own care. In fact. and protect enrollees against high health care expenses. The ability of insurance companies to rate on age would also be limited. In doing so. and consumer protections. provide access to necessary health services. The Council would ensure that coverage would be affordable. however. it would. Insurance Market Reforms. among other activities. plans and others. economics. Specifically. heart disease. it would define what “coverage” and “affordability” mean. 9 While states have the authority to restrict this type of discrimination. The Council would make care management and quality reporting requirements consistent with those used by Medicare to the extent practicable. previous illness. or factors that encourage healthy lifestyles — will be specified in statute after consultation with the National Association of Insurance Commissioners. insurance companies could not deny coverage to any individual nor discriminate against individuals with pre-existing conditions. Rules for rating insurance policies — which have to do with how an insurer can determine a policyholder’s premium based on various criteria such as age. income-related annual limits on out-of-pocket costs so that families were not at risk of bankruptcy by their medical expenses. business. The Council and the Exchange would both be subject to regular reviews and oversight by the Comptroller General. the Council would ensure appropriate. Insurers in the Exchange would collect and report on the performance of providers in their networks. consumer advocates. Currently. tobacco use. 19 . very few have used that authority. actuarial science. consult with the Institute of Medicine and review existing state laws. Individuals with pre-existing conditions such as cancer. The new Independent Health Coverage Council would define key terms in a reformed health system. so that Congress—and the public—can closely monitor their activities. clinically appropriate.insurance. medicine. Input by the Independent Health Coverage Council would keep the activities of the Exchange on track and insulated from the political process. insurance companies can discriminate against older and sicker patients by charging significantly higher premiums or denying coverage altogether. and asthma are at particular risk of being denied coverage by insurance companies or being offered a policy that is unaffordable. In order to avoid severe adverse selection — a scenario under which the sickest patients gravitate toward one part of the insurance market — the rating rules for the Exchange would apply in the Exchange as well as in private non-group and small group markets. The Independent Health Coverage Council would also set standards for chronic care management and quality reporting. Under the Baucus plan. a recent Commonwealth Fund study found that insurance companies turned down one out of every five people who applied for individual coverage due to pre-existing conditions. health benefit design.

To help small businesses.Small Business Tax Credit. the credit would be available to qualifying small businesses that operate in states with patient-friendly insurance rating rules. These tax subsidies would be available to individuals and families who purchased coverage through the Health Insurance Exchange. average premium in the Exchange. Both programs have an important role to play in health care reform. until the credit is fully phased-out. the Baucus plan would provide a targeted tax credit that small firms could use towards the cost of purchasing health care coverage. 10 In order to target the tax credit most efficiently. so the Baucus plan envisions specific improvements to Medicaid and CHIP that ensure these programs function effectively and efficiently in a reformed health care system. refundable tax credits would be available to individuals and families with incomes at or below four times the Federal poverty level. taking into account the reasonable percent of income to be spent on health care coverage. As health care coverage becomes more expensive. The Independent Health Coverage Council would define what an “affordable” premium is. These programs provide access to health care for approximately 67 million low-income Americans. the tax credit would be available to small businesses that purchase coverage for all of their employees in the Health Insurance Exchange and make a meaningful contribution towards the cost of the premium for their employees’ health care. D. After the initial implementation. In order to make health coverage affordable for all Americans. The smallest firms with the lowest average earnings will be eligible to receive a credit equal to half of the average total premium cost for employersponsored insurance in the firm’s state. Initially. STRENGTHENING PUBLIC PROGRAMS Medicaid and the State Children’s Health Insurance Program (CHIP) represent cornerstones of America’s health care system. This construct would encourage individuals to be prudent purchasers of health care policies. The premium subsidy would make up the difference between the amount suggested by the Council and the premium amount charged by the plan. And for this reason. This credit will be phased down as firm size and average earnings increase. The Baucus plan also would improve Medicare by providing an option to buy into the program for individuals who are near but 20 . The amount of the subsidy could be based on a benchmark that would be equal to a locally adjusted. the number of small businesses offering their employees health care coverage is declining. many small businesses simply cannot bear the additional cost of providing health coverage for their employees. The employee and earnings phase-outs work together. There are a number of ways that such a tax credit could be structured. for both individual and family coverage. Premium Subsidies. the credit would be based on a firm’s size and earnings per employee. One option is to make the tax credit available to any small business.

the plan would increase funding for the Indian Health Service.360 for single coverage in the individual market and $2. including needed surgeries. over four million people aged 55 to 64 were uninsured. Finally. People in this age group face greater risk of illness than their younger counterparts.850 for family coverage.200 for family coverage in the individual market in 2006-2007.not yet 65. The average annual premium for those aged 60 to 64 was more than $5. This new Medicare buy-in option is temporary. but health insurance offerings in that market are often unaffordable — or even unavailable to those with pre-existing health conditions.000. Those already enrolled in the Medicare buyin would have the option to remain in Medicare. those who do not have employer-sponsored benefits or retiree coverage through a former employer. And while they may require increased access to medical care. Americans 55 to 64 years old who had not obtained coverage through the Medicare buy-in would be able to buy insurance in the new marketplace.5 Uninsured individuals in this age group find it increasingly difficult to cover their medical bills as declining health can affect their ability to work and earn income. Nearly 12 percent of those aged 55 to 64 report annual medical expenditures of more than $10. they continue to have fewer and fewer affordable insurance options as retiree health care coverage erodes and pre-existing conditions make private insurance prohibitively expensive or impossible to obtain altogether. or about 12 percent of the total population in that age group. have fewer options for coverage than other age groups.000 for single coverage and $9. Medicare would charge enrollees electing the buy-in option an annual premium. The premium amount would be calculated so that the total costs for the buy-in population 21 . The plan also would allow disabled individuals access to Medicare without a waiting period. and who lack other insurance. Medicare Buy In. 12 This figure represents an increase of one million since 2000. 11 In 2007. While this age group tends to be one of the least likely to be uninsured. 13 By contrast. The Baucus plan would make health care coverage immediately available to Americans aged 55 to 64 through a Medicare buy-in. The benefits would be the same as those available to current Medicare beneficiaries. Uninsured Americans aged 55 to 64 are twice as likely as their insured counterparts to report having to delay seeking medical care. It would be available until the Health Insurance Exchange was established. the Baucus plan would allow individuals aged 55 to 64 to buy Medicare coverage. but also their pocketbooks. Once that new infrastructure is in place. coverage for a person aged 18 to 24 was $1. 14 To fill this gap in coverage. The option would be available to any individual in this age group who otherwise did not have access to health coverage through a public plan or a group health plan. The individual insurance market can provide a source of coverage for this population. Declining health status and lack of affordable health insurance affect not only the health and wellbeing of Americans aged 55 to 64.

Thus. Pregnant women with incomes below 133 percent of the poverty level. Medicaid. ultimately.000 Americans with disabilities are uninsured and many more are underinsured. 21 22 . Medicaid currently covers approximately 61 million Americans 19 and is the source of health insurance for 14 percent of non-elderly Americans (age 64 and below). Families who meet financial requirements of the former Aid to Families with Dependent Children (AFDC) cash assistance program. Established in 1965. an estimated 400. The Medicare program might also benefit through reduced costs for this population relative to what might have been spent if these individuals were uninsured in the decade prior to becoming Medicare eligible. Providing immediate assistance to the Americans aged 55 to 64 would benefit not only individuals in this age group. An option for those 55 to 64 to buy into Medicare could enable individuals to remain healthy and continue working. 18 Forcing Americans with disabilities to wait two years for Medicare coverage results in these people having inadequate health care. Congress created a “Medicare waiting period. but the Medicare program overall. As a result of the 24-month Medicare waiting period. Medicaid is a program intended to serve low-income Americans and those with serious health conditions or disabilities.15 It would also help to ensure that individuals would not experience a break in coverage during this age period. 17 At that time. this option would not create new costs for the Medicare program or for taxpayers. Elderly and poor individuals who receive cash assistance from the Supplemental Security Income (SSI) program. which could lead to improved health status upon Medicare eligibility at age 65. The mandatory beneficiary populations are: ! ! ! ! ! Children under age six who are in families below 133 percent of the poverty level. prevent disabling conditions. Children over age six in families below 100 percent of the poverty level. falling into poverty or. 16 Phase Out of Disability Waiting Period.would be budget neutral. the Congress expanded Medicare eligibility to include people with disabilities. The Baucus plan would begin to phase-out the current two-year waiting period for Medicare coverage for people with disabilities. 20 A modernized Medicaid program is an essential component of health reform. Federal law establishes certain categories of beneficiaries to which states must offer Medicaid benefits as a condition for Federal financial participation. It is anticipated that people with disabilities would also eventually be able to purchase coverage in a reformed health insurance market. in death.” which requires people with disabilities to receive Social Security Disability Insurance (SSDI) for 24 months prior to becoming eligible for Medicare coverage. In 1972. The Federal government and the states share responsibility for funding and administration of Medicaid. and provide protection from catastrophic medical costs.

Reducing the number of uninsured by increasing Medicaid enrollment has been embraced by a diverse coalition.2 16. Medicaid Enrollment in 2007 Population Children Adults Blind/Disabled Elderly Total Number enrolled (in millions) 29. Building on the existing Medicaid program is also efficient. those at the bottom of the income scale are least likely to be able to purchase coverage on their own.States have discretion to cover populations beyond those that Federal law mandates. all states provide Medicaid benefits to optional populations. but existing state Medicaid programs have not reached everyone living below the poverty level.2 9. many with different poverty levels.1. 22 Medicaid enrollment in 2007 is displayed in Table 2. least likely to be able to afford it. In fact.6 9.0 26. though coverage is very limited. All states except Alaska and Connecticut have eligibility levels for disabled optional populations of less than the poverty level. Many states cover adults as an optional population. Medicaid coverage is limited to very low-income Americans. This would result in more equitable treatment for all Americans living in poverty. 28 Determining eligibility under the Baucus plan would be much easier than in the categorical eligibility system currently in place. 24 Thus in most states. and if such coverage is offered. Federal law does not require states to cover adults under Medicaid.6 15. elderly. States currently have dozens of eligibility categories. Table 2.1 below.9 100 23 Source: Center for Medicare and Medicaid Services (CMS). The Baucus plan aims to solve that problem by extending Medicaid eligibility to every American living in poverty.9 Percent of total Medicaid enrollment 48. or pregnant — regardless of income. Establishing a national eligibility minimum of 100 percent of the Federal poverty level would help to streamline Medicaid. Moreover. 26 Making this change would provide at least 7.1 million low-income people with access to health coverage. Medicaid is a vital source of coverage for low-income Americans. least likely to have employer-sponsored coverage.0 60. 23 . unless they are disabled.5 6. and the easiest and quickest way to provide insurance to those living in poverty. including the Commonwealth Fund 25 and the insurance industry. Twenty-seven states have eligibility levels for non-working adults with incomes below the poverty level and 26 states have eligibility levels less than the poverty level for working adults.27 Providing Medicaid to everyone below the poverty level is both consistent with the original intent of Medicaid.

thereby giving states with lower-than-average income levels a higher FMAP rate and thus a higher Federal percentage match. especially in times of economic distress. Simplifying eligibility would expedite and lower the costs associated with states’ eligibility determination processes. Current Federal matching rates and other policies consistent with this policy would remain intact for any population with income eligibility that exceeds 100 percent of the poverty level. 31 As all states (except Vermont) are constitutionally bound to balance their budgets. States should get help from the Federal government to engage in outreach to potentially eligible individuals and to modernize their eligibility and enrollment data systems because the current systems are so antiquated that they are unable to meet today’s data demands. No one currently eligible would lose access to Medicaid. or FMAP. as people lose jobs and health insurance. state revenues decrease and Medicaid rolls increase. The Baucus plan includes an additional improvement to the Medicaid program. The same is true for optional populations that states have elected to cover — because states would be required to maintain current eligibility levels (even those above 100 percent of the poverty level). Each state’s FMAP rate is based on the state’s per capita income level. Existing mandatory eligibility populations would be unaffected by this plan. in which the Federal government and the state government each pay a certain percentage of total Medicaid expenses. results in an additional one million people enrolling in Medicaid. but the highest FMAP rate is 73 percent.4 billion. The financial responsibility shared by the Federal and state governments is carried out through a matching system. According to Federal law. Currently. states require help managing the costs associated with unanticipated increases in Medicaid enrollment. for example.Additional efforts to streamline Medicaid eligibility and enrollment are also part of the plan. FMAP rates range from 50 percent to 83 percent and there is no cap on the total Federal financial participation. Uniform and simplified verification and renewal rules should be established to help minimize the “churning” that typically occurs within Medicaid. called the Federal Medical Assistance Percentage.32 the strain caused by decreased revenues and greater Medicaid participation forces states to reduce spending — often cutting back safety net programs like Medicaid at a time when they are needed most. When the national economy experiences a downturn. Medicaid must be strong and stable so that eligible individuals can rely on it. 30 One million new Medicaid beneficiaries increase state Medicaid spending by $1. 29 The goal of covering all Americans is an opportunity for the Federal government to partner with states to reduce the number of low-income uninsured Americans. 33 24 . Every one-percent increase in the national unemployment rate. The Baucus plan would invest new Federal resources to help states. In order to strengthen and stabilize Medicaid. 13 states receive the minimum 50 percent match. and is committed to finding ways for the Federal government and the states to share responsibility for the costs associated with increased Medicaid enrollment.

CHIP helped to reduce the number of uninsured children by about one-third overall. so long as states agreed not to cut benefit options during the FMAP increase.95 percent. $3. more than 6. 36 Determining the specific trigger requires careful construction in order to ensure that state economic distress is measured reliably and accurately. $1. 39 CHIP has reduced by one-quarter the number of uninsured children with effective family incomes between 100-200 percent of the poverty level.” 35 The details of an economic indicator-based trigger and the level of assistance must be responsible without being too rigid or too lax. it was the largest expansion of health insurance coverage for American children in more than 30 years. In 2003. as part of the Jobs and Growth Tax Relief Reconciliation Act. on average. more than one in ten children remains uninsured. . 37 CHIP was intended to provide health insurance to children whose families cannot afford to purchase health insurance in the private market. the amount and duration of the FMAP increase must be calibrated to provide states with enough support for the right amount of time. duration. and an average of 33. Like Medicaid. In a 2006 report. When the Children’s Health Insurance Program (CHIP) was created as part of the Balanced Budget Act of 1997.5 million children were covered through CHIP. the Government Accountability Office (GAO) recommended consideration of two factors — the number of states experiencing an increase in unemployment and the magnitude of that increase — in setting a trigger. this plan would increase FMAP rates when a predetermined combination of circumstances measuring the timing. .23 million in new wages.41 Despite this progress. 42 25 . Creating this mechanism to maintain Medicaid’s stability during nationwide economic slumps or significant downturns for individual states builds on recent success in addressing tough economic situations.To ensure that Medicaid is a reliable component of a reformed American health care system. . but earn too much to qualify for Medicaid. The Federal government pays a higher percentage of the total program costs for CHIP than for Medicaid. the total Federal financial participation in CHIP is capped regardless of rising costs or increased numbers of eligible children. Similarly. and depth of an economic downturn occurs. In its first ten years. averaging about 70 percent nationally.35 million in new state business activity . . State Children’s Health Insurance Program (CHIP). from 23 percent to 14 percent. 40 In 2006. CHIP is financed jointly by the state and Federal governments. Congress temporarily increased FMAP rates by 2. . 38 Because CHIP is financed through a block grant to states. 34 A study by Families USA found that for “every million dollars a state invests in Medicaid [it] will generate.76 new jobs per state.

enforcing longer waiting periods. Currently.1. In 2007. The Federal government has several options to consider in helping the states. the Federal government and states would join together to reduce the number of uninsured children in America. but not all CHIP programs have met that goal. 14 states faced Federal funding shortfalls. and as many as 37 states were expected to face similar financial challenges for fiscal year 2008. Impact of CHIP on Uninsured Children Source: Improving Children’s Health. as our health care delivery system is modernized to improve quality and access to care. The Baucus plan would require states to use CHIP to cover all children at or below 250 percent of the poverty level and who are not Medicaid eligible. some states are forced to cut back their CHIP programs by freezing enrollment. 2007 CHIP gives states flexibility in establishing eligibility criteria. States that currently cover children above 250 percent of the poverty level would continue to do so. 44 Under these financial constraints. With an expansion of CHIP. States have used this flexibility to craft programs responsive to their unique needs. similar efforts should be encouraged in Medicaid and CHIP to assure that our 26 . putting help within reach for more needy Americans. capped Federal allotments to states combined with expanded eligibility lead some states to exhaust available Federal funding before the end of the fiscal year. Center on Budget and Policy Priorities. 46 In addition.Figure 2. and costsharing. Existing matching and other policies not inconsistent with a responsibility to have health coverage would remain in place for states with income eligibility that exceeds 250 percent of the poverty level. or lowering the income eligibility thresholds. 43 The original intent behind CHIP was to provide access to health insurance for all lowincome families who make too much to qualify for Medicaid.45 The Baucus plan would help states with the costs associated with increased CHIP enrollment. benefit structure.

about 48 percent of estimated need. IHS provided approximately 58.3 billion. IHS. 27 . making the delivery of care difficult and hindering the ability to recruit and retain health care professionals. Health Care for Native Americans and Alaska Natives.” 53 The reality of this underfunding is that money for contract health services does not last the entire year. The IHS health care delivery system is organized around 12 regional offices and 163 local service units. Native American and Alaska Native populations have unique health care concerns. Additionally.5 million Native Americans and Alaska Natives who belong to more than 562 federally recognized tribes in 35 states.” with the most critical care given first. however. This predicament is so common in Indian Country that many tribal members fear that if they need care after June. among other programs. Medicare. the U. the agency must set priorities for both direct and contract health care based on “relative medical need. 48 In a series of treaties and agreements forged with the tribes as sovereign nations. the IHS is responsible for making sure that promise is kept. when resources or funds are insufficient. and provides various medical services. 51 IHS also contracts for medical services from local providers through what is known as contract health services. government promised to provide health care to Native Americans. 49 Many members of these populations also live in physically remote areas. Funding for IHS consistently falls short of the amount needed to provide care for the populations it serves. And Native Americans suffer from tuberculosis at a rate that is six times higher than the non-Indian population. The Indian Health Service (IHS) currently provides health care services to an estimated 1. As a result. Currently. 47 IHS provides free health care to eligible Native Americans and Alaska Natives.50 In 2007. including inpatient and outpatient services. Medicaid.S. forcing IHS to limit services to circumstances involving a “loss of life or limb” circumstance. some services are “rationed. with the exception of certain urban programs or in circumstances where a tribe chooses to charge its members for health care. In fiscal year 2008. Tribal members are eligible for. 52 The IHS itself has stated that its funding does not allow it to provide all the needed care for eligible Indians. cultural concerns must be respected in providing health care for Native Americans and Alaska Natives. Department of Veterans Affairs and the Federal Employees Health Benefit Program (FEHBP). Native Americans are three times more likely to die from diabetes. and preventive health care. dental.000 inpatient admissions and over ten million outpatient visits. total funding for IHS was $4. is not the sole source of health care for Native Americans. Native Americans also may have private insurance. Current spending levels pale in comparison to those of other Federal health care programs such as the Bureau of Prisons. IHS regulations require that. emergency. they will be forced to go without.nation’s most vulnerable populations receive the same high-quality care that is available to those with Medicare or private insurance. ambulatory. and CHIP.

costs the U. and became more physically active.S.S. An estimated 80 percent of heart disease.7 million people). 55 In addition. Nearly half (45 percent) of Americans suffer from one or more chronic conditions. as well as encourage enrollment in other programs like Medicare. the number of Americans who have become obese has doubled since 1987.S. Those who are uninsured — and therefore less likely to receive preventive care and even treatment for major conditions — must be given a means to begin safeguarding and improving their health. economy more than $1 trillion annually. The system must support clinical preventive services and community-based wellness approaches at the Federal.” a temporary program to provide the uninsured with immediate access to a set of proven preventive 28 . and type-2 diabetes. 56 About 78 percent of the nation’s total health care spending is due to chronic illness. must dramatically shift its health care focus toward preventing chronic disease. stroke.59 Despite evidence that preventive services such as smoking cessation work. With a national culture of wellness. health system does little to address the underlying health problems that lead to these conditions. Guaranteed Access to Clinical Preventive Services and Referral to Community Resources. the U. accounting for nearly 30 percent of the rise in health care spending between 1987 and 2005. Medicaid. 60 our health system continues to emphasize expensive treatments. coupled with productivity losses. This approach is further complicated by a fractured delivery system in which individuals with chronic conditions often see more than one provider and take multiple medications. FOCUSING ON PREVENTION AND WELLNESS Chronic diseases — such as heart disease. This shift requires a fundamental change in the way individuals perceive and access the system as well as the way care is delivered. and CHIP for those who are eligible to defray the costs borne by IHS directly. more importantly. stroke. chronic disease and obesity will be better managed and. and local levels. the U. 54 and chronic disease accounts for 70 percent of all deaths (more than 1. and diabetes — are the most prevalent and preventable of all health problems and also the most costly. 58 Despite the human and economic cost of chronic disease. Prevention must become a cornerstone of the health care system rather than an afterthought. increased rates of obesity and chronic disease are the primary cause of disability and diminished quality of life. A Milken Institute study found that treatment of the seven most common chronic diseases. and to truly change the economics of our health care system. is staggering. adopted healthy diets. cancer.IHS desperately needs additional funding. E. For the sake of Americans’ health. This plan proposes “RightChoices. could be prevented if Americans stopped smoking. The Baucus plan would increase funding for IHS. and 40 percent of cancers.S. It is impossible to keep America’s promise to provide care to Native Americans and Alaska Natives with the current level of IHS funding. state. 57 Further. The economic impact of chronic disease in the U. reduced.

Evidence suggests that 96 cents of every Medicare dollar and 83 cents of every Medicaid dollar are used to treat chronic diseases. by reducing or eliminating co-payments for recommended preventive services under Medicare. New payment methodologies. combined with expanded use of health information technology. Preventive Services Task Force. Any individual eligible for RightChoices who is not eligible for or enrolled in a private plan or public program such as Medicaid or Medicare. The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) took a step in this direction. The Baucus plan would do more. The RightChoices card would also provide referral to community resources such as smoking cessation and nutrition programs that have demonstrated success in changing and supporting healthy lifestyle choices. and age and gender appropriate cancer screenings recommended by the U. The Baucus plan would make prevention and wellness a priority in Medicare. physical exam. 63 In addition. These grants could also support the development of models to better manage. and reduce the medical risks and costs of poor health. states would receive a three-year capped allotment based on factors such as the percentage of uninsured and the prevalence of these chronic illnesses.services such as a health risk assessment. 29 . would increase appropriate use of these recommended preventive services and better manage the care of chronically ill beneficiaries. Medicaid and CHIP beneficiaries would receive recommended preventive services without co-payments. To cover the cost of this care. costly chronic conditions would qualify to receive treatment for those conditions.5 percent decrease) compared to those not subject to a co-payment. Preventive Services Task Force for coverage under Medicare. Based on a patient’s risk.61 It could also be used for outreach to eligible. Medicaid.S. Coverage for Prevention in Federal Health Programs and Private Plan Options. uninsured Americans. monitor.62 Federal health programs must prioritize prevention to ensure that taxpayer dollars are used more efficiently and effectively. and CHIP. Medicaid enrollees subject to cost sharing of even a one dollar co-pay per service used fewer physician services and received fewer preventive services including immunizations (a 45 percent decrease) and pap smears (a 21. and treat these chronically ill individuals such as certified community care teams. Medicaid. and CHIP. Individuals with incomes below 200 percent of the Federal poverty level could receive treatment at no cost.S. immunizations. MIPPA gave the Secretary of Health and Human Services the authority to identify new preventive services recommended by the U. but whose RightChoices screening detects and diagnoses one or more of the most common. a care plan would be developed to maintain good health. Treatment would be provided on a temporary basis until viable coverage options are available under the Health Insurance Exchange. Congress should explore evidence-based approaches for obesity prevention and treatment through demonstration projects in Medicare.

the Advisory Committee on Immunization Practices. Healthier older Americans require less expensive care.Demonstrations should test approaches that have shown clinical value in functioning settings. Congress should authorize a study to identify the various federal programs that can help prevent the development of chronic disease and suggest options to more effectively coordinate efforts going forward. The plan would provide grants to states or communities to implement innovative.S Preventive Services Task Force. and heart disease than whites. 66 The support provided by targeted tax credits or other subsidies and community challenge grants would help lead individuals to make positive choices for their own health. A National Focus on Wellness. 64 Communities would be empowered and encouraged to identify and overcome barriers to healthy choices for all residents. Interventions that could improve and maintain the health of preMedicare eligible individuals aged 55 to 64 would be explored. This investment makes sense. For example. nutritious food and safe places to exercise among other factors. The programs would employ best practices identified by the Department of Health and Human Services. Disparities in the health status involve increased rates of mortality. Centers for Disease Control and Prevention. Finally. and perception of one’s health. National Institutes of Health. race or socioeconomic status. evidence-based prevention and wellness programs at the local level. 65 The plan would also support efforts by small businesses to create healthier work environments with tax credits or other subsidies for proven wellness programs. ADDRESSING HEALTH DISPARITIES Racial and ethnic health disparities are characterized by persistent gaps in both health status and health care for minority populations. and individuals to work together and support healthy lifestyles. Congressional proposals have called for a more coordinated national strategy to prevent chronic disease and reduce obesity. schools. health care systems.67 The health of Americans is affected by access to insurance. F. Such coverage would be based on recommendations by appropriate entities such as the U. and the Task Force on Community Preventive Services. employers. level of chronic disease burden. African American infants die at a rate of 13. The Health Insurance Exchange created under the Baucus plan would require participating plans to include certain preventive services in its benefit package. other community organizations. Grants would encourage local governments. regardless of health status. high blood pressure. a larger share of African Americans has diabetes.68 One of the most glaring differences in health status is reflected in infant mortality. the Institute of Medicine (IOM). and Institute of Medicine. and evidence suggests that this investment could result in less spending on future Medicare beneficiaries.6 per 1000 live births — a rate that is higher than any other racial or ethnic group and twice that of 30 .

Social determinants of health must also be addressed in the effort to eliminate health disparities. The Baucus plan would require participating plans in the Exchange to 31 . While only one-third of the U. 73 In addition. 71 African Americans are 13 percent less likely to receive coronary angioplasty as whites. a major step toward eliminating racial and ethnic health disparities. Language compatibility is also essential to ensuring quality health care for ethnically and racially diverse groups. Information must be reflected at the subpopulation level. 69 The African-American infant mortality rate is even higher than that of Slovenia. Unequal Treatment. Subsidies for low-income individuals and families. and high cost. 77 Addressing access to health insurance coverage is not the only step in addressing disparities. The waiting period should be eliminated and eligible legal immigrants should have access to Medicaid and CHIP. 75 Medicare and Medicaid cover most of those insured among communities of color. The ability for patients to communicate their needs to a provider is critical. living wages. language and cultural differences. Latinos and Asians report having poor communication with their provider at a higher rate than other groups. A lack of communication can mean an increased likelihood of medical errors and patients not adhering to a treatment plan.76 The Baucus plan would make health care affordable and universally available to all Americans. in particular. appropriate education. 72 African Americans are more likely to undergo leg amputation related to diabetes and to have complications following surgery. Kuwait. Asians are less likely to receive timely antibiotic therapy while hospitalized. Data collection must also be more reflective of the target community from which data is gathered. Poland. they represent over half of the uninsured — over 30 percent of these two racial and ethnic groups are without health care coverage. The effort to document the extent of health disparities in the U. population is made up of racial and ethnic minorities. and Russia. 74 Lack of access is also a major factor affecting health care provided to racial and ethnic minority groups. and clean environments adversely affect health status and well-being. would be critical to make health care obtainable by everyone. but it increases the number of uninsured. Not only does this exacerbate health disparities. geographic location. will require standard methods of collecting data. The landmark 2003 Institute of Medicine (IOM) study.S. Barriers to health care can result from lack of health insurance coverage. demonstrated significant quality gaps in the health care provided to African Americans and Latinos. Currently. Lack of adequate housing. 70 Disparity in health care is characterized by differences in the quality of medical care that is provided and its availability to diverse populations.S. legal immigrant children and pregnant women are subject to a five-year waiting period before they can become eligible for Medicaid or CHIP. All federal agencies that have jurisdiction over these types of social programs should collaborate together to improve the health and well-being of our communities.whites.

http://www. 11 10 Employee Benefit Research Institute.org/uninsured/upload/Health-Insurance-Coverage-of-the-Near-Elderly-Report. 2008.gov/hhes/www/hlthins/historic/hihistt2. 2795.census.org/pdf/7790. 93. 27. Coughlin and Dawn Miller.org/pdfs/Individual_Market_Survey_December_2007.kff. 2007 and based on telephone interviews with a national adult sample of 1.pdf. Long. P.” The Commonwealth of Massachusetts. http://www. 15 16 14 Ibid. 4. Teresa A. Some literature suggests that public payments also cover much of the costs associated with uncompensated care.1 (2003): 86-91. Paul B. And Incremental Costs. “Employment-Based Health Benefits Under Universal Coverage. “Individual Health Insurance 2006-2007: A Comprehensive Survey of Premiums. John Holahan. http://ehbs.pdf: 71. “Employer Health Benefits Survey. “Covering the Uninsured In 2008: Current Costs. no. Availability.) Sharon K. 27.” The Kaiser Family Foundation. 1 Anne-Emanuelle Birn. requires that employers cover at least 60 percent of their employees’ premium in order to qualify for the tax credit. http://www. Jack Hadley and Timothy Waidmann. “Employer Health Benefits Survey. “Nearly Nine of Ten Who Seek Individual Market Health Insurance Never Buy a Plan”.” Health Affairs. and Benefits.” AHIP.ahipresearch. 27. “Most Taxpayers in Massachusetts Have Health Insurance.pdf. www.org/usr_doc/660_Dale_elimination. Ginsburg.” Health Services Research: The Global Journal for Improving Health Care Delivery and Policy. 28.2 (2006): 429-451. (2008.” The Kaiser Family Foundation. “Health Insurance Coverage of the Near Elderly.pdf?section=4039 32 . (2007). (2004). 5. Census Bureau. 9 For example. (2003). 41.xls. Poverty. “Struggles for National Health Reform in the United States.S. U. 13 12 America’s Health Insurance Plans.kff. and gender. “On the Road to Universal Coverage: Impacts of Reform in Massachusetts at One Year. Jack Hadley.commonwealthfund. Department of Revenue News Release. Verdier. August 13-16. (2006). no. (2007). 8 7 6 5 4 3 2 Survey was conducted by Gallup Organization.” The Commonwealth Fund.” The Kaiser Family Foundation.” U. no.ebri. such as the National Health Interview Survey (NHIS) and the National Health Care Survey (NHCS).kff.” Health Affairs.pdf.1 (2007).” Health Affairs. S. introduced by Senators Durbin and Snowe. 3 (2008): 675-685. Census Bureau. http://ehbs. www. The Commonwealth Fund. no. no. Sources Of Payment. (2008).collect and report data based on race. (2004). “Health Insurance and Health at Age 65: Implications for Medical Care Spending on New Medicare Beneficiaries [Abstract]. ethnicity. Kaiser Family Foundation and Health Research and Educational Trust. Kaiser Family Foundation and Health Research and Educational Trust.” EBRI Notes.org/pdf/7790.” American Journal of Public Health. 2008.. the Small Business Health Options Program. and Health Insurance Coverage in the United States. The Commonwealth Fund.S. John Holahan. “Income. et al.pdf. The plan also proposes to include appropriate levels of funding to Federal agencies responsible for this type of data collection. 1994"2005. no. “Elimination of Medicare’s Waiting Period for Seriously Disabled Adults: Impact on Coverage and Costs. “Health Insurance Coverage for the Near Elderly. (2008). 17 18 The Social Security Amendments of 1972.019.org/pdf/notespdf/EBRI_Notes_01-20071.L. 92-603 Stacy Berg Dale and James M.

(2004): 3-4. 34 35 36 33 Public Law 108-27.” (Testimony before the Senate Committee on Finance. U. 22 Henry J.cfm&PageID=51052: 2. (2008) http://www. “The Medicaid Resource List. no.” CMS.org/programs/fiscal/balreqs. “Issue in Focus: Expanding Children’s Health Coverage. 40 39 38 37 33 .org/medicaid/7743.hhs.asp. http://www. 2008).org/pubs/health. “State Children’s Health Insurance Program Summary. Henry J.” GAO.htm.” The Kaiser Family Foundation. “Data Compendium.cbpp.kff. National Conference of State Legislators. Zaslavsky. (2005): 1. Robert E.gov/MedicaidGenInfo/05_SCHIP%20Information. 27 28 26 John Holahan and Alan Weil.” The Kaiser Family Foundation. www. http://www. “Medicaid: Strategies to Help States Address Increased Expenditures During Economic Downturns.” Journal of Health Care for the Poor and Underserved.htm. (2003): 5-6. Ayanian.19 Center for Medicare and Medicaid Services.S. November 4.” The New York Times. Center on Budget Policy and Priorities.” Families USA. http://www. (2003) http://www.cms.” The Kaiser Family Foundation.cms. Peter Orszag. Government Accountability Office. Senate. 2006.gao. “State Health Facts Online. “Medicaid’s Optional Population: Coverage and Benefits.org/chart.cms. “Impact of Unemployment Growth on Medicaid and SCHIP and the Number Uninsured. Families USA. (2008): 307-19. 2 (2007): 260-261 Henry J.org/medicaid/loader. Kaiser Family Foundation.gov/DataCompendium.hhs. “State Balanced Budget Requirements. Alan M.” CMS. http://www. 1.gov/DataCompendium. 25 24 Joel S. Weissman.cfm?url=/commonspot/security/getfile. Government Accountability Office. no. Henry J.cfm. “Health Insurance Industry Urges Expansion of Coverage. Wolf. (2008) http://facts. 19. Henry J. “Covering Uninsured Children: The Impact of the August 17 CHIP Directive. Kaiser Family Foundation.” The Kaiser Family Foundation.” CMS. (2005): 2. Kaiser Family Foundation. “Toward Real Medicaid Reform. Kaiser Family Foundation. (2006).kff. “State Children’s Health Insurance Program (SCHIP): Reauthorization History.” Health Affairs 26. 31 32 30 Ibid. Centers for Medicare and Medicaid Services. ‘Optional’ Populations and Services. (2008) www.” The Kaiser Family Foundation. Kaiser Family Foundation. “State Medicaid Coverage and Access to Care. Robert Pear. www. Kaiser Family Foundation.gao.” The Kaiser Family Foundation.kff.aspx?ch=360. 29 Henry J. “Medicaid: Strategies to Help States Address Increased Expenditures During Economic Downturns. “Data Compendium.” CBPP. April 9. 21 20 Henry J.gov/cgi-bin/getrept?GAO-07-97. (2005): 2.statehealthfacts. Henry J.org. 23 Centers for Medicare and Medicaid Services (CMS). (2005).” The Kaiser Family Foundation.” GAO.ncsl. (2008) http://www. Kaiser Family Foundation.” The Kaiser Commission on Medicaid and the Uninsured. (2006).” NCSL. “Medicaid: An Overview of Spending on ‘Mandatory’ vs. “Medicaid: Good Medicine for State Economies. (2008). “Medicaid’s Optional Population: Coverage and Benefits. (2008). “Medicaid’s Optional Population: Coverage and Benefits. Kaiser Family Foundation. John Z.gov/cgi-bin/getrept?GAO-07-97.hhs.

23(e). (2007).cms. (2004).976. Indian Health Services.” Health Affairs. Thorpe et al. “Indian Health Service Introduction.htm.kff. Ibid. Ross DeVol and Armen Bedroussian.kff. “Community Guide. http://www. (Keynote Address before the Philip Hauge Abelson Advancing Science Seminar.” Emory University. Children's Health Insurance Program Reauthorization Act of 2007.1893. “The Impact of Obesity on Rising Medical Spending. (2008).3162. (2008). 2-3. Status. and Legislative Issues. (2007).gov/NationalSCHIPPolicy/downloads/SCHIPEverEnrolledYearGraph.” The Kaiser Family Foundation. “Chronic Disease Overview. (2008) http://www. “Chronic Disease Prevention and Health Promotion.3963. Status. (2007). 53 54 Chronic Disease Prevention and Health Promotion. H. Kenneth E.xls.” The Milken Institute. 2004. Kaiser Family Foundation.ihs.gov/PublicInfo/PublicAffairs/Welcome_Info/IHSintro. 2005). December 8. http://www. Thorpe.1377/hlthaff. (2008).R. http://facts. “An Unhealthy America. Funding. (2004).” CRS..org/about/. (2008): 14-16.” CDC.” Partnership for Solutions. “SCHIP Enrolled In Year. 44 43 42 Henry J. Henry J. http://www. World Health Organization’s Director of Chronic Diseases and Health Promotion.cfm. 10.R.11(c). (2007).htm.cdc. Henry J. Ibid.” CMS.pdf. The Economic Burden of Chronic Disease. Centers for Disease Control and Prevention. Funding. (2003): 3. Children's Health Insurance Program Reauthorization Act of 2007.w4.cdc.org/uupload/relatedtable/Health%20Insurance%20Coverage%20of%20Children.hhs. Children's Health and Medicare Protection Act of 2007. and Legislative Issues. H. “Foundation Resources on the State Children’s Health Insurance Program and Reauthorization.gov/nccdphp/overview. “Indian Health Service: Health Care Delivery. “IHS Fact Sheets.cfm.gov/mmwr/preview/mmwrhtml/rr5311a1. 48 Congressional Research Service. http://www. “Indian Health Service: Health Care Delivery. “Fourteen states face SCHIP shortfalls this year totaling over $700 million.gov/Profile08. Kaiser Family Foundation.480).R.org/medicaid/schipresources.” CRS.%202006. Edwin Park and Matthew Broaddus. for example. Robert Beaglehole. 47 46 45 Indian Health Service. H.” CDC.” The Kaiser Family Foundation. “Health Insurance Coverage of Children.thecommunityguide. 10. the vast majority of whom are not CHIP eligible unless they have incomes below 100 percent of the Federal poverty level and minimal assets.41 Centers for Medicare and Medicaid Services.asp. “Medicaid/SCHIP: Low Income Families. 60 59 Task Force on Community Preventive Services. Children's Health Insurance Program Reauthorization Act of 2007. See.kff.org/medicaid/lowincome. “Care Coordination for People with Chronic Conditions. These community care teams would include social 61 34 . Robert Mollica and Jennifer Gillespie. (2008). http://info. 136.” Center on Budget and Policy Priorities. and S.” IHS. (2008): 1. 58 57 56 55 Kenneth E. Kaiser Family Foundation. 42 CFR §§136.” IHS.asp. (published online 20 October. http://www. “Reforming Medicare: A New Focus on Primary Prevention and Chronic Care Management: working paper.. http://www. Some States have used this flexibility to cover adults. 49 50 51 52 Congressional Research Service.” (2008).” The Kaiser Family Foundation..ihs.

72 71 Agency for Healthcare Research and Quality. http://www.S. S. “Health Disparities Report. and Alan R.ahrq. 69 70 68 Ibid. Henry J.” CIA.org/minorityhealth/upload/6069-02. 76 Agency for Healthcare Research and Quality. “Roadmap to Successful Program Development. no.” Health Services Research: The Global Journal for Improving Health Care Delivery and Policy.html.pdf. Brian D. (2003).” The Kaiser Family Foundation. Ibid. 73 74 75 Ibid. Health and Human Services. (Institute of Medicine. Stith. (2007) http://www. 2003): 29-30. The Centers for Disease Control and Prevention has identified elements of successful evidence-based workplace wellness programs.fightchronicdisease. Julie Hudman and Molly O’Malley. 64 63 62 Partnership to Fight Chronic Disease. S. Jack Hadley.pdf. Ethnicity.” The Kaiser Family Foundation. Kaiser Family Foundation. 67 66 65 S.” AHRQ. U. “Health Disparities Report.1753). care coordinators and other community resources that would work with primary care provider practices to prevent and manage chronic disease. Smedley. introduced by Senator Hilary Rodham Clinton. and Timothy Waidmann.” The Kaiser Commissions on Medicaid and the Uninsured.gov/library/publications/the-worldfactbook/rankorder/2091rank. 2008). (2008) http://www. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.3674. Kaiser Family Foundation.” AHRQ. Education and Related Agencies.kaiserfamilyfoundation.pdf. “The World Fact Book.org/uploads/roadmap.org/minorityhealth/upload/6069-02. (2008) http://www. The 21st Century Wellness Trust Act. The Obesity Prevention. (2007) http://www. Adrienne Y. Thorpe. Senator Tom Harkin has proposed providing a tax credit for qualified wellness programs in the Healthy Workforce Act of 2007 (S. CIA.pdf.” (2008).gov/qual/nhdr07/nhdr07. (2008) https://www. House of Representatives. Treatment and Research Act of 2008. Henry J. 41. “Health Insurance Premiums and Cost Sharing: Findings from the Research on Low-Income Populations. Proposed provision in the Legal Immigrant Children’s Health Improvement Act (ICHIA) 2007. and Medical Care. 2. (2006): 429-451.gov/qual/nhdr07/nhdr07. “Key Facts: Race.org/medicaid/upload/Health-Insurance-Premiums-and-Cost-Sharing-Findings-from-theResearch-on-Low-Income-Populations-Policy-Brief. introduced by Senator Hillary Clinton. “Key Facts: Race. Ethnicity.pdf. Kenneth E. “Health Insurance and Health at Age 65: Implications for Medical Care Spending on New Medicare Beneficiaries [Abstract]. and Medical Care. February 14. (Testimony before the House Appropriations Subcommittee on Labor.kff. introduced by Senator Jeff Bingaman.pdf.cia.ahrq..764. http://promisingpractices. Nelson. 77 35 .and mental health workers.3584.kaiserfamilyfoundation.

The Baucus plan includes initiatives to reorient America’s health care delivery system toward services and activities that improve patient care and “bend the curve” of growth in national health care spending. Movement toward quality-based payment must start with fixing the unstable and unsustainable Medicare physician payment formula. and has created access problems that will only worsen as more Americans get health care coverage. the plan invests in the health care infrastructure that is necessary for delivery reform to succeed. Today’s payment systems reward providers for delivering more care rather than better care. Primary care is the keystone of a high-performing health care system. but it has become increasingly evident that the way care is delivered and paid for in our health system does not always encourage the right care at the right time for each and every patient. hospitals. and do so in a way that reduces costs over the long-run.S. Refocusing payment incentives toward quality. is that public and private insurers will follow and continue to innovate as well. nurses. but there are also other vital priorities we must pursue. Under the current system. At the same time. and others — work hard to provide life-saving and life-improving care to millions of Americans. is a proven determinant of high-quality. The expectation. the more visits. The health system should refocus payment incentives toward improving the quality of care patients receive. The Baucus plan considers delivery system reform with four key goals in mind: ! Strengthening the role of primary care and chronic care management. Increasing the supply of primary care practitioners and redefining their role in the health system — by using Federal reimbursement systems and other means to improve the value placed on their work — is a necessary step toward meaningful reform. cost-effective care. We must take steps to ensure patients receive higher quality care. the more they are paid — regardless of the quality or the health outcomes of the patient. This has caused fewer medical students to choose careers in primary care. Among them is the critical need to improve the value of care provided in our health care system.CHAPTER III BAUCUS PLAN: IMPROVING VALUE BY REFORMING THE HEALTH CARE DELIVERY SYSTEM Ensuring access to meaningful health coverage is a fundamental goal of health care reform. the U. The level of care provided is often excellent. Many of the proposals in the plan are based in the Medicare program because of its unique ability to lead the way for system-wide changes. Our nation’s health care providers — physicians. tests. however. Yet America’s current system undervalues primary care relative to specialty care. must get better value for the substantial dollars spent on health care. particularly for the chronically ill. The ! 36 . In short. images and services providers deliver. Access to primary care that successfully manages and coordinates patient care.

current Sustainable Growth Rate (SGR) formula is fatally flawed and must be replaced. ! Promoting provider collaboration and accountability. Delivery system reform should also encourage providers in different settings — physician offices, inpatient hospitals, post-acute care settings, and others — to collaborate and provide patientcentered care in a way that improves quality and saves money. Under current payment systems, hospitals, physicians, and other health care providers are not encouraged to work together to improve patient care throughout the course of a patient’s illness. In fact, they may be penalized financially — through lower revenues — if they successfully help patients avoid the need for additional health services. Congress should modify current payment systems to encourage — rather than discourage — collaboration and accountability among health care providers across treatment settings and sites of care. Improving the health care infrastructure. Efforts to improve the health care delivery system cannot succeed without taking other steps to modernize our system. These steps include investing in new research and tools, as well as the health care workforce. A national approach to comparative effectiveness research can help provide systematic, unbiased information about what treatments, technologies, and procedures work best. Health information technology (IT) can put comparative effectiveness research and other clinical decision-support tools at providers’ fingertips in real time, as well as improve the delivery of care across settings and help providers to better coordinate patient care. Health IT can also facilitate initiatives to improve quality performance and data collection and aggregation. But gains from new research and health IT will be shallow unless we reinvest in the training of a 21st century health care workforce.

!

Like many other reforms, changes to the health care delivery system will take time. Moreover, these efforts will require continuing evaluation as the health system — and the health care needs of Americans — evolve. A. STRENGTHENING THE ROLE OF PRIMARY CARE AND CHRONIC CARE MANAGEMENT

A strong emphasis on primary care is a common element of high-performing health systems. 1 International systems, and even parts of our own country, that deliver costefficient, high-quality care tend to have robust access to and use of primary care services. 2,3 Among other things, primary care practitioners should provide preventive care, help patients make informed medical decisions, and serve a critical care management and coordination role — especially for those with multiple chronic conditions who are the least healthy and most costly to our system. Yet today’s payment systems place higher value on specialty care than primary care. Strengthening the role of primary care will require a multi-pronged approach. 4 To this end, the Baucus plan includes several initiatives to improve our primary care system:

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ensuring accurate prices for primary care services in Medicare, providing an add-on bonus payment for primary care services, and encouraging further testing and implementation of the medical home model. The plan would also ensure the viability of community health centers and rural health clinics that provide vital safety net functions and serve as a true medical home for thousands of patients across the country. Ensuring Accurate Payments for Primary Care Services. Payments for primary care physician visits are undervalued, particularly compared to procedures and services furnished by specialists. In fact, the overvaluation of procedures in the Medicare physician fee schedule has both created financial incentives to provide unnecessary services and served as a disincentive for physicians to become primary care physicians. Primary care physicians are not trained in — and do not have the opportunity to bill for — procedures that generate extensive revenues for non-primary care physicians. 5 In 1989, Congress enacted Medicare physician payment reform, which required a fee schedule based on relative values for approximately 7,000 services covered by the program. Private insurers often adopt the relative values set by Medicare, although they may use different payment rates for determining actual fees paid. The 1989 law also required periodic review — at least every five years — to ensure that the payment system reflects changes in the relative resources involved in furnishing physician services. Adjustments to relative values reflect changes in medical practice, coding changes, experience with new procedures, and other variables. Rapid growth in the volume of a service provided often represents evidence that the relative value for that service should be reviewed. 6 The Centers for Medicare and Medicaid Services (CMS) has relied heavily on recommendations from the American Medical Association (AMA) Relative Value Update Committee (RUC) to determine needed changes to the value of services in the physician fee schedule. The RUC process has resulted in changes that have increased relative values in many areas but decreased values in very few. This result has worked against primary care services because primary care physicians bill for a relatively smaller and more static set of codes than non-primary care physicians. A recent increase in the relative values for primary care services by the RUC was a step in the right direction. The Baucus plan would seek a continued focus on the high value of primary care-related services, with corresponding reductions in relative values for overvalued services. Fee schedule rates must accurately reflect priorities that the health care system must adopt to bend the health care cost curve and improve quality over time. Additional Payments for Primary Care Providers. The undervaluation of primary care services might also be addressed by the Baucus plan with increases in Medicare payments for services furnished by practitioners focused on delivering primary care. 7 Payments must be well-targeted, starting with careful identification of the list of services that qualify as primary care services — primarily evaluation and management visits. A second step involves identification of Medicare providers, including physician and non-physician practitioners, who truly focus on delivering primary care. Using claims history — rather than self-identification — is a more accurate approach to identifying appropriate providers.

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In addition, bonus payments should also take into account the complexity of the provider’s patient panel to ensure that underserved populations are not left behind. Finally, the task of setting a threshold for these services is best left to CMS, which can collaborate with stakeholders and other experts to strike the right balance. To avoid cost inflation, this proposal should be made budget-neutral. Budget-neutral changes to Medicare payments mean that any increase to primary care providers requires a corresponding cut to specialist services. This approach has the potential to create significant controversy among physicians, however. Any reforms along these lines must be crafted in collaboration with the entire physician community and other practitioners to ensure appropriate valuation of, and access to, primary care services. Other means of redefining the value that the health system places on primary care, such as revisions to the SGR formula, are discussed below. Patient-Centered Medical Home. Expanding Medicare’s role in testing the medical home model — in which practitioners are paid explicitly for comprehensive care management services — is another way that the Baucus plan would promote quality and efficiency. A growing body of evidence suggests that medical homes may improve patient health and reduce costs. 8,9 In 2006, Congress required CMS to establish a demonstration program to test the medical home model in fee-for-service Medicare. 10 More recently, Congress provided additional funding for this demonstration and granted CMS authority to expand the program if quality and cost targets are met. 11 Medical home expansions in Medicare should focus only on providers who are committed to ensuring that patients truly receive the primary care and care management services that the medical home is designed to deliver. Providers seeking to participate in a Medicare medical home expansion program should meet a set of stringent service and capacity criteria in order to qualify, such as those proposed by MedPAC, 12 and be willing to have additional payments based in part on the quality of care they deliver. The National Committee for Quality Assurance (NCQA) has also developed an assessment tool that tiers medical homes based on the implementation of particular capacities and patient services. 13 In addition, careful consideration should be paid to the role of non-physician providers, such as nurse practitioners and home health aides, in the medical home model. Medical home expansions should also target the patient populations most in need of comprehensive care management and coordination, particularly those with multiple chronic conditions. As with other components of the medical home, though, these tools and criteria will evolve as results from ongoing demonstrations and input from patients, providers, other stakeholders, and experts are received and incorporated into the medical home model. This plan would expand the medical home model by requiring collaboration between Medicare and ongoing demonstration sites that include private payers and Medicaid. Aligning incentives created by disparate payment models — for example, private payers and public programs — is crucial to achieving significant delivery system reform.

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many of which are located in rural areas. 14 Going forward. nutritionists. Medicare could join with other payers (Medicaid. Care management expansions under the Baucus plan will require ongoing evaluation to ensure they are truly patient-centered. And to encourage patient participation. such as the medical home. copayments for services provided in medical homes. private plans) in funding states to develop this capacity throughout the state. In addition to the medical home. or those that rely on a geriatric assessment to qualify patients for comprehensive care coordination programs. or in conjunction with other states in their region. 15 Vendor-based disease management programs. Recent proposals to focus on caring for the sickest patients in their home. provide efficient care. which typically involve phone-based care planning and follow-up by nurses. The required medical home criteria (particularly the necessary investments in infrastructure and staffing) can be challenging for the 36 percent of physicians who work in solo or very small-group practices. and the involvement of patient groups is critical to ensuring that these models remain patientcentered. These models will only improve health care quality and efficiency if patients find that they provide needed health services in a consumer-friendly way. show promise and should be examined in more detail. These teams could link primary care practices with additional resources that would allow small or rural offices to participate in the medical home. Community Health Centers and Rural Health Clinics. Efforts to reestablish primary care as the backbone of the health care system should build on existing systems that work. and social and mental health workers. The state of North Carolina has achieved preliminary success with the community health team model in its state Medicaid program. Medicare should test other primary care models that promote comprehensive care management and coordination. For example. for instance. Another option is to explore alternative payment models that do not require specific practice improvements but instead offer shared-savings bonuses for meeting aggressive cost and quality benchmarks.Building a qualified medical home may not be feasible for all providers.17 While these approaches should not be jettisoned without consideration of new evidence from state and private payer programs. Financial assistance for smaller primary care practices to adopt health information technology would also provide a strong incentive to collaborate with community health teams. however. it remains an open question whether Medicare should make direct payments to vendors outside of a comprehensive care management model. particularly for the chronically ill. which serve low-income and medically underserved populations. The medical home and other care management concepts are works in progress. have found some success in the private market but have not fared as well in recent Medicare demonstrations. One option is to invest in community health teams that include nurses. and have in many cases implemented critical components of the medical home model. A true medical home should serve as a central resource for a patient’s ongoing care. community health centers. perform well on quality indicators. could be reduced or eliminated. 16. the Baucus plan would modernize the outdated Medicare system for paying Federally Qualified Health Centers 40 . 18 To shore up this important component of our nation’s safety net.

Ninety-eight percent of hospitals chose to participate. To encourage participation. particularly in the areas of inpatient hospital care and physician services. To Err is Human: Building a Safer Health Care System. and outpatient dialysis providers. In 2003. health reform should include policies that bolster community health centers. The Baucus plan will build on these efforts by establishing a pay-for-performance program for hospitals in Medicare and further strengthening physician programs that are focused on quality improvement.23 Based on these recommendations. Congress and CMS have enacted and implemented policies to increase the focus on quality in the Medicare payment systems.(FQHCs). Mechanisms for compensating rural health clinics (RHCs) also are deficient and should be improved. In Montana and across the country. as well as bring pay-for-performance to the Medicare Advantage program. and penalized those that did not. For these reasons. 19 Subsequent reports called for increasing payments for providers offering high-quality care 20 and the establishment of a national system for performance measurement and reporting. B. To qualify for PPS payments. Medicare Advantage plans. Congress set the Medicare program on a path toward quality improvement by establishing a hospital pay-for-reporting program. REFOCUSING PAYMENT INCENTIVES TOWARD QUALITY Efforts to restructure provider payment systems to improve quality also represent a critical component of delivery system reform. FQHCs will be required to report on quality metrics and make investments in the infrastructure necessary to qualify as a medical home. 21 MedPAC has also made multiple recommendations to Congress regarding the need for payment incentives based on quality for hospitals. 22. such as how frequently a heart attack patient received aspirin upon admission. mirroring the successful model that the Medicaid program uses for paying these centers and expand the role of health centers in providing preventive services. 25 41 . In its landmark 1999 report.24 As part of this effort. The plan will also encourage efforts to test pay-for-performance models related to home health and nursing home care. these facilities are instrumental in meeting the needs of patients when other access points to care are unavailable or inadvisable — for example. the Institute of Medicine (IOM) urged a heightened focus on quality initiatives. physicians. and FQHCs as part of the larger effort to improve patient access to critical primary care services. home health providers. The Baucus plan would establish a prospective payment system for qualifying FQHCs. Congress provided higher payments to hospitals that reported this information. Congress asked hospitals to track and report to CMS their performance on a set of ten defined quality measures. Many private and public organizations have echoed the need to re-direct the health care system to reward higher quality and more efficient care. RHCs. reliance on an emergency department. Hospital Quality Reporting and Next-Generation Quality-Based Payment Reforms.

providers would not only be rewarded for reporting quality activities. Inc. 26 and increased penalties for non-participating hospitals.In 2005. CMS has been testing a more aggressive move to a “pay-for-quality” model. which is sometimes also referred to as value-based purchasing. Building on these recommendations and the other efforts outlined above. CMS provided a roadmap for moving Medicare from pay-for-reporting to pay-forperformance. with an 11. the Baucus plan includes provisions to improve quality care in the inpatient hospital setting through establishing a hospital pay-for-performance program. the Hospital Quality Incentive Demonstration (HQID). Congress permanently extended the reporting program. The plan would phase in value-based purchasing so that the amount of payment at risk would gradually increase to no more than two percent of base hospital operating payments. 42 . Under the demonstration. directed CMS to incorporate additional performance measures into the initiative. 30 In establishing a pay-for-performance program. the HQID demonstration was extended for another three years (through 2009) and will be expanded to test other innovative pay-forperformance models. This project.8 percent average quality improvement among participating facilities over two years. CMS contracted with Premier. to conduct a demonstration linking payment to the achievement of quality goals. Linking payments to performance represents a major shift in how Medicare pays for services. Based on these results.. has involved more than 260 hospitals across the nation 28 . The Baucus plan uses the following principles to guide this effort: ! Transitions to value-based purchasing should be gradual. the Medicare hospital pay-for-reporting program has been an important first step in improving the quality of care provided to Medicare beneficiaries in the inpatient hospital setting. In its November 2007 Report to Congress. 27 By most accounts. Results from the HQID project demonstrate dramatic quality improvements in every measured clinical area. It provides better insight into the quality and performance of America’s hospitals for policymakers and patients alike. hospitals were asked to report process and outcome measures in five clinical areas related to heart attack. but their payment would also be increased or decreased depending on how well they perform on these quality measures. These statistics translate into actual results for patients: 1. in Medicare. In October 2003.284 fewer heart attack deaths for patients who received more clinically appropriate care 29 . The next step in quality-based payment reform is the adoption of a value-based purchasing (VBP) program in the hospital inpatient setting. Alongside the Medicare pay-for-reporting program. a nationwide alliance of not-for-profit hospitals and health systems. Hospitals in the top 20 percent in each clinical area received a financial incentive payment. heart failure and pneumonia.

the quality reporting program should continue to be a testing ground for evaluating new measures before they are subjected to pay-forperformance rules. A hospital value-based purchasing program should start with a set of quality measures that hospitals have already been reporting on through the pay-forreporting program. To further improve patient care. MedPAC. Over time. rural facilities to participate and include protections for safety net hospitals that may face unique challenges in meeting the requirements of a value-based purchasing program. every effort must be made to encourage providers to work together toward common quality improvement goals. Hospital performance in the value-based purchasing program should be publicly reported and available to consumers. Measures should be selected through rulemaking and endorsed or considered by consensus-building organizations whenever possible. As Congress seeks to reward hospitals that provide high-quality care. Safety net. The CMS methodology for determining hospital performance scores and calculating payments for facilities must also be transparent and public. and rural hospitals should be given special consideration. Quality performance and the process to reward hospitals must be transparent. As new quality measures for hospital and physician performance continue to be developed. Every effort must be made to align hospital and physician quality goals. Rewards should be provided to hospitals that achieve quality goals as well as to those that make significant improvements. All measures must be evidence-based. The Secretary. 43 . ! ! ! ! ! ! These principles would serve as guideposts for efforts to establish a hospital value-based purchasing program in Medicare and are a key component of this plan. low-volume. GAO. The value-based purchasing program should reward facilities that meet quality benchmarks and those who have made substantial quality gains in performance relative to prior years. The hospital value-based purchasing program must be structured in a way that would allow smaller. Quality measures should be endorsed by relevant stakeholders. statistically valid. steps must also be taken to improve quality and resource efficiency in the Medicare physician payment systems. and field-tested to ensure that they represent the best practices in improving quality. Physician Quality Reporting Initiative. and others should help Congress monitor the value-based purchasing program and provide specific input on any unintended consequences of the program. The value-based purchasing program should be subject to ongoing monitoring and evaluation.! A value-based purchasing program should build on the current reporting program.

including those that go beyond quality reporting to focus on how physicians actually perform. Finally.000 clinicians attempted to participate in the program. And physician recognition programs like those sponsored by NCQA are also important conduits for quality reporting. and performance results and incentive payments were delivered to participants this summer. the program is on its way to achieving the goals set by Congress when the program was enacted in 2006: engaging clinicians and other health care stakeholders in developing meaningful quality metrics to evaluate care. The first round of PQRI was executed in the second half of 2007. reducing administrative burdens and fostering clinician-to-clinician sharing of expertise that will be much more effective in improving quality than purely governmental interventions. Congress required CMS to expedite approval of clinical registries to which physicians report performance data. registries and recognition programs — once they are approved by CMS — will now be able to submit data to CMS on behalf of participants. Boards such as the American Board of Internal Medicine (ABIM) are including some quality reporting in their maintenance of certification process. patients. and physicians are not discouraged from participating. and reports indicate delays in the delivery of incentive payments and difficulty in accessing feedback reports. but they also must participate in at least one quality reporting program. and expediting the development of data collection processes that will lead to meaningful and actionable information flowing to providers. PQRI should work in conjunction with medical boards to encourage more frequent and more aggressive recertification processes. putting Federal resources on the table to promote and partially fund quality improvement activities. More than 100. Under MIPPA. These registries. In order to retain ABIM certification every ten years. such as those addressing diabetes and heart failure. and payers. permitting more comprehensive analysis of a physician’s ability to care for patients with these chronic illnesses. MIPPA requires the establishment of a pathway for physician groups to report quality information on an aggregated basis. 44 . At the same time. Medical boards in particular are striving to meet the professional needs of physicians while also fostering gains in quality of care. are often operated by clinician groups or medical boards and are capable of collecting richer data sets than can be accessed through claims forms. considerable confusion lingers regarding the reporting mechanism. Going forward. Despite substantial concerns regarding PQRI. and analytical skills. such as the National Cardiovascular Data Registry spearheaded by the American College of Cardiology.the Baucus plan would build on the Physician Quality Reporting Initiative (PQRI) and the provider feedback program as a next step in improving patient care. In addition. judgment. physicians must not only pass a traditional exam testing their knowledge. Reforms enacted in MIPPA permit physicians to report on condition-specific groups of measures. Congress and CMS have recently acted to address these technical challenges and expand provider outreach and education programs so that the foundation of this program remains strong.

Ultimately. the Baucus plan focuses on improving the clinical importance and validity of the measures that physicians report to PQRI.Before Medicare can transition from pay-for-reporting to pay-for-quality. Provider Feedback Program and Episode Groupers. Medicare’s physician feedback program should include information regarding quality of care — the health outcomes of patients should not be compromised by efforts to reduce costs in treating specific illnesses. physicians must be able to successfully participate in PQRI and receive appropriate incentives to do so. this method is less effective in giving providers actionable information by which to change their practice patterns and improve their care for specific patients and particular diagnoses. The reforms in MIPPA demonstrate a commitment by Congress to keep PQRI a flexible program that responds to provider feedback and capitalizes on developments outside of Medicare (e. the Baucus plan calls for the current positive financial incentives for physician participation in PQRI to eventually be matched with payment penalties for those who do not report. 32 An alternative methodology that may hold greater promise. which may encompass multiple interventions over a period of time and care furnished by multiple providers. including evaluating resource use on a per capita basis or using episode grouper technology.g. actionable information that could lead to meaningful reductions in inappropriate care patterns. Congress also recently required CMS to begin providing feedback to practitioners regarding their resource use. is the use of episode grouper software. This technology evaluates the resources used to treat a patient during a specific episode of illness. particularly for specialists who tend to perform discreet procedures for a specific illness. episode groupers could give providers and payers more specific. CMS is authorized to explore different methods. Medicare must put physicians on a similar course as the plan described above for hospitals and transition PQRI to a true value-based purchasing program. A report from CMS. clinical registries). 33 While most versions of this technology rely strictly on insurance claims. required in MIPPA. evidence-based care.. This will help ensure that episodes of care are both necessary and efficient. Finally. Ultimately. once the recent program improvements are fully implemented. will give Congress additional guidance on how best to reinvent the Medicare physician payment system from one that rewards quantity to one that focuses financial incentive on high-quality. 31 However. The program may also require that physicians report the results of patient experience surveys in order to receive a full bonus. Finally. As a next step. Medicare should develop its own open-source technology platform that includes information on both episodes of care and per-capita resource use. eventually they could be adapted to include clinical data generated from electronic health records and other sources. 45 . and healthy outcomes for patients. The per capita method — which essentially examines physician resource use per beneficiary — can be particularly helpful in identifying outliers whose practice patterns fall outside an acceptable “bell curve” of variation.

report. For home health care. Health plans in the Medicare Advantage program have been reporting a standard set of valid performance measures to CMS for over a decade. and appropriately pay for quality and efficiency move forward. CMS is also working to develop a demonstration project that would offer financial incentives to facilities that meet certain conditions for providing high-quality care. and physician-administered drugs that are furnished in connection with physician services. As these efforts to collect. through the Independent Health Coverage Council. 34 But Congress can go further by fostering. This project would be tested in five states. Congress provided substantial funding to NQF in MIPPA to facilitate the endorsement of standardized measure sets and bring stakeholders together to agree on priorities for performance measurement. While significant efforts are underway at the National Quality Forum (NQF) and other quality alliances and industry groups to achieve uniformity. efforts to strengthen quality in other care settings must not be left behind. Clinicians are often subject to several pay-for-performance programs that use different quality measures for similar patients and require different data collection approaches. CMS proposes to test a pay-forperformance model in seven states using quality measures based on the Outcome and Assessment Information Set (OASIS) that agencies have been using to report quality activities since 2000.Quality Improvement for Other Providers and Private Plans. lab tests. the Sustainable Growth Rate (SGR) was designed to control spending for physician services provided under Medicare Part B. imaging. If overall spending exceeds the target set by the SGR. Congress should also explore a pay-for-performance requirement for private plans that participate in Medicare. Both of these projects must move forward to help CMS and Congress gain much needed information on how to appropriately increase the focus on quality in the home health and nursing home settings. 35 The statutory formula sets a target amount for spending for certain services including physician services. too. As Congress moves forward on efforts to improve the quality of care provided by hospitals and physicians. alignment among the insurance plans participating in the Health Insurance Exchange. Moving toward a more value-driven physician payment system in Medicare must start with reform of the current system used to update physician payments. For nursing homes. provider concerns regarding the number of methodologies. CMS should move health plans beyond reporting so that payments reflect plan performance. CMS should provide for the development of valid performance measures for prescription drug plans and begin to bring pay-for-performance to these plans. Reforming the Sustainable Growth Rate Formula. metrics. payments under the fee schedule are 46 . and misaligned payment incentives must also be addressed. Additionally. Enacted as part of the Balanced Budget Act of 1997. CMS is currently developing a pay-for-performance demonstration project aimed at home health and nursing home care. more work needs to be done to standardize measures and administrative approaches and to minimize the burden on providers.

even a large group practice. it identified two paths: (1) jettison the expenditure target approach and focus on proposals that encourage higher quality care at lower cost. because the timing of Congressional action is often unpredictable. CMS should use its discretion to define the items and services that are included in the SGR formula’s calculations. 37 These projected reductions in physician reimbursement are unrealistic and. If overall spending is less than the target. for which payment is based on the average sales price methodology. has left a nearly $300 billion discrepancy over ten years between what physicians are projected to be paid under the formula and what a modest inflationary update over those years would provide. The flawed formula which is the basis of the SGR. suggest that the current SGR formula is not a viable mechanism to control spending for physician services. When MedPAC presented its analysis of the substantive options for reforming the SGR in March 2007. on geographical location or type-of-service. there are also substantive obstacles to SGR reform. the formula has called for automatic reductions in the payment update. These legislative overrides. for example. Since 2002. It would also avoid further investment of Federal resources in a target-based formula that may not influence individual physician behavior as Congress intends. from the formula in a shared effort to reverse the annual cycle of fixing the SGR.automatically adjusted downward. The now-yearly cycle of Congressional intervention to block these SGR cuts consumes attention and resources that should be directed to other challenges posed by Medicare and other Federal programs. as CBO has observed. but Congress has enacted legislation to override the formula each year. or (2) pursue value-based payment reforms while replacing the SGR with a new expenditure target system for all Medicare providers based. Applying expenditure targets to other aspects of Medicare — as MedPAC’s second path suggests — could create additional administrative burdens without ensuring payment stability. CMS should use its administrative authority to remove physicianadministered drugs. it also puts enormous pressure on physician practices across the country as they try to set budgets and meet payroll each month. 38 The first path would explicitly reorient physician payment toward high-value care. may have disastrous consequences for the Medicare program. cannot affect a formula driven by the practice habits of more than 800. As Congress takes steps to resolve the budgetary shortfall posed by the SGR. if implemented. The most immediate obstacle to reforming the SGR is budgetary. then payments are adjusted upward. The fundamental flaw of the SGR is that the behavior of an individual physician. Congress has struggled to find a viable alternative to the SGR. In addition to the massive budgetary shortfall. They could likely cause physicians to exit the program and Medicare beneficiaries to lose access to needed care. And. 47 .000 providers who are paid under the physician fee schedule. 36 However. combined with multiple years of Congressional intervention.

If the evidence suggests that prices are distorting physician behavior. which creates little incentive for them to work together to effectively manage patient care. Nonetheless. A recent report by GAO found that the significant recent growth in imaging costs is attributable in large part to physicians increasingly providing imaging services in their offices as a means for revenuegeneration. physicians and other health care providers are each paid separately. SGR reform should closely examine the growing costs to the Medicare program of advanced imaging utilization and fees. regional use of imaging services can vary by as much as three times. in constructing a fee schedule based on multiple targets. potentially overpaid aspects of health care to underutilized. we must also provide new incentives that encourage health care providers to work together to offer patients the best possible care. Careful attention must be paid to appropriately clustering services so that new prices generated by the SGR do not produce excessive increases or reductions in any particular service.Eliminating the expenditure target altogether would likely exacerbate the SGR’s budgetary shortfall and some in Congress have asserted a strong interest in revising the SGR formula. it may be necessary to replace it with an alternative expenditure target approach. For example. C. careful consideration must be given to ensure that the price outputs of the formula apply to the practitioners responsible for the rate of growth of particular services. Consideration should also be given to whether GDP growth should remain the short-term basis of SGR expenditure targets as medical inflation is expected to outpace GDP growth at least until the reforms proposed in this paper take full effect. 41 Physician payment reform should pay particular attention to the cost and quality implications of the growing practice of physicians self-referring for diagnostic imaging services. Lack of collaboration can have a particularly detrimental impact on patients with chronic or multiple illnesses who can most benefit 48 . in the case of a separate target based on utilization and growth in imaging services. then modest reductions in prices that can elicit desirable behavioral changes without impacting beneficiary access could be pursued administratively. hospitals. according to their report. physicians who refer patients for imaging services usually do not receive payment for the performance or interpretation of those services. Finally. 40 MedPAC analysis points to imaging utilization as a factor in the significant regional variation of cost and quality discussed elsewhere in this paper. PROMOTING COLLABORATION AND ACCOUNTABILITY While we take steps to improve the quality of care provided to patients. Medicare should also consider establishing a process for the identification and surveillance of highgrowth services. Today. potentially more valuable services such as primary care and prevention. One such approach would be the development of a revised SGR formula that creates multiple expenditure targets based on sub-sets or categories of services. This has the advantage of reallocating resources from high-growth. 39 As we attempt to move beyond the ongoing SGR predicament.

Medicare should use payment incentives to drive more collaboration among physicians. 44 New Medicare payment policies should encourage hospitals and other providers to work together to provide the best possible care to hospital patients both during and immediately following their hospital stay. which encourage health care providers across the treatment setting to work together to improve patient care. 42 In addition. The disadvantages of care fragmentation are particularly evident for patients who experience a hospitalization. According to some estimates. and discharges that occur over a weekend mean patients are suddenly expected to assume a self-management role for their recovery with little support or preparation. The 30-day readmission rate for Medicare beneficiaries ranges from 14 percent in some states to 22 percent in others. 18 percent of Medicare hospital admissions result in readmissions within 30 days post discharge. While lack of care coordination around a hospitalization episode can have a detrimental impact on patients’ health and well-being. called the Physician Group Practice demonstration. 43 Not only can a reduction in readmissions result in Medicare savings. it also has a significant financial impact. In the Medicare program. These readmissions accounted for $15 billion in spending in 2005. Any savings they achieve through better care coordination accrue not to their practice but to Medicare. do not encourage these providers to communicate or work together to ensure patients receive the proper medication and other follow-up that is necessary post-hospitalization. A Medicare demonstration project. but it could also reduce geographic variations in health spending. particularly on the Medicare program. and other health providers. hospitals. and according to MedPAC. hospital patients are abruptly transitioned to home or post-acute care. 49 .from well-coordinated care. In many cases. $12 billion of this spending is potentially avoidable. Payment systems. is the concept of accountable care organizations (ACOs). and is described in more detail below. is succeeding at slowing cost growth and improving quality by allowing physician groups to share in savings from reduced health spending and should be expanded. Health care delivery systems that treat patients throughout the continuum of care — from primary care to hospitalization to post-acute rehabilitation — should be paid in a way that rewards them for improved quality and efficiency. we must take steps to encourage further collaboration among multi-specialty physicians who treat patients in the community. As we work to improve patient care around hospitalizations. the physicians who treat a patient during their hospital stay are often not the same physicians who see the patient once they leave the hospital. physicians who are paid on a fee-for-service basis have little financial incentive to work together to improve the quality and efficiency of care provided to patients. Discharge from a hospital is a particularly critical and vulnerable time for patients. including the Medicare program. One model that should be tested in this area. Delivery system reforms should also encourage innovative organizational models that allow for patient care across the treatment spectrum.

Medicare beneficiaries who receive care as part of the demonstration would receive a partial refund on their Part B premium for agreeing to participate in the project. particularly for higher-cost beneficiaries. In the first year. Second. chronic obstructive pulmonary disease (COPD). One concept that offers promise for greater efficiency and care coordination is the idea of allowing Medicare to pay bundled or global payments for all services provided to a patient during hospitalization and for some amount of time post discharge. In circumstances where a readmission is unavoidable. Bundled Payments. such as congestive heart failure. The Baucus plan would take a three-step approach to reduce hospital readmissions and improve care coordination for patients who have experienced a hospitalization. The plan would then require hospital-specific information on readmissions be made available to the public. Medicare pays the same for hospital stays regardless of whether it is a patient’s first inpatient stay or a readmission for the same condition. The plan would adopt MedPAC recommendations as a starting point for creating new financial incentives to reduce hospital readmissions in the Medicare program. Under current law. Once providers better understand how they perform relative to their peers. Using its administrative authority.Reducing Hospital Readmissions. In the initial years. and coronary artery bypass graft. At this point. CMS has taken steps toward bundled payments by establishing the Medicare Acute Care Episode (ACE) demonstration. Discouraging unnecessary readmissions by restructuring Medicare payments is good policy. hospitals would not be penalized. the plan requires CMS to provide confidential feedback to hospitals and physicians regarding resource use for select hospitalization episodes. this bundled payment would cover all hospital and physician services provided during a patient’s hospital stay. First. It is better for patients and better for taxpayers. but ideas that have been put forward include setting the benchmark as the average readmission rate across similar hospitals or using a higher standard that ties the benchmark to the top performing facilities. the plan would create new financial incentives in Medicare to encourage providers to take greater responsibility for the coordination of care for hospital inpatients. Currently under development at CMS. they could begin to address problem areas. The project is expected to be implemented early next year and would involve up to 15 demonstration sites. it does not appear that the demonstration will include services provided post-hospitalization. 50 . The third step will involve testing other models to improve patient care related to hospitalizations. This benchmark will need to be defined. This data would need to be detailed enough to help providers understand spending and resource consumption. These changes would mean reduced payment rates for hospitals with readmission rates above a certain benchmark. But over time. this demonstration project would allow hospitals and physicians to receive a global payment for services provided to patients who receive certain cardiac and orthopedic procedures. the program would be expanded. this plan would focus on reducing re-hospitalizations for a limited number of conditions that are known to have a high rate of readmissions.

Results showed increased efficiency and reduced Medicare spending. while quality remained high. the patient pays only one charge for this set of services. cost-effective care to patients. was tested in the early 1990s. such as inappropriate reductions in care to increase profit. Building on these efforts. cataract surgery. Under this demonstration. obesity surgery.A similar project. care for babies. roughly 86 percent of patients were receiving all recommended best practices related to cardiac surgery care. The results of the ProvenCareSM initiative have been impressive. discussed the ProvenCareSM program at a Finance Committee hearing in September. the Baucus plan would develop and test other models for bundled payments. bundling models must also include appropriate risk adjustment to ensure health care providers are not penalized for or discouraged from treating sicker patients. specifically at the Geisinger Health System. Glenn Steele. As long as all care was provided at Geisinger. called the Physician Group Practice (PGP) demonstration. 47 The program offers a bundled payment for the package of services provided to patients receiving cardiac bypass graft surgery. pharmacy. Now in its fourth year. In this demonstration. Spending on post discharge care also decreased. the PGP demonstration includes ten large physician groups that receive enhanced payments for 51 . including cardiac rehabilitation. 48 Based on this success. who work together to offer high-quality. Geisinger’s President and CEO. This bundled payment covers the first physician visit that determined surgery was necessary. this plan would work to ensure that efforts to expand payment bundling for hospital and physician services is done in way that is workable for non-integrated and smaller health care providers. In particular. Within three months of instituting the program. Medicare paid a bundled rate for hospital and physician services around hospitalizations for cardiac bypass graft surgery. and intensive care unit spending. all hospital costs for the surgery. the Medicare Participating Heart Bypass Center demonstration. The Baucus plan would seek to limit unintended consequences. In addition. Moving toward bundled payments is a complex process that would require time and resources. Geisinger recently expanded this model to other high-volume procedures. Finally. and all costs for related care post surgery. 45. As part of this effort. the bundled payment included services provided during the hospital stay as well as services provided immediately following the hospitalization. the plan would allow the current CMS bundling demonstration to expand to other sites and to focus on other clinical conditions if certain criteria are met. particularly physicians. Physician Group Practice Demonstration and Accountable Care Organizations. bundled payment initiatives have been tested in the private sector. In addition. and heart catheterization. A reformed delivery system should also do a better of job of rewarding providers.46 More recently. such as hip replacement. CMS found that most participants were able to achieve reduced lab. this plan would encourage CMS to include services that are provided post-hospitalization as part of the bundling payment model. The Medicare program is currently testing a project in this area.

and primary care physician groups able to identify the other providers from whom their beneficiaries receive their care. offer patients access to a range of providers and settings. including expansion of the medical home. The Baucus plan calls for CMS to establish a framework for reforming and expanding the PGP demonstration after its fifth year. and Geisinger in Pennsylvania. The plan for expansion should give providers a pathway toward accountability and shared savings. This effort is consistent with other delivery system reforms proposed in this paper. InterMountain in Utah. post-acute. considerable work has been done to explore the possibility of accelerating broader delivery system integration by expanding the PGP model to encourage provider collaboration and accountability on a larger scale. facilities. hospitals that employ their own physician staff. and the local physician community. which would end in March 2010. Integrated health systems. and timely generation of feedback to participants — the results to date merit expansion. While the current PGP demonstration focuses on large physician group practices. these systems are providing high-quality integrated care that is more cost-effective than their competition. careful attention to hospital discharge processes. Groups that meet quality targets and achieve cost reductions beyond a two percent threshold are permitted to share in the savings that they generate to Medicare. 51 Ideal candidates for expansion are organizations that span the continuum of care in a community. the Baucus plan would create a new Medicare pilot program to test the cost and quality opportunities of value-based payments to ACOs. four were awarded with incentive payments for reducing costs significantly.improving the quality and efficiency of the care delivered to Medicare beneficiaries. but should not restrict beneficiary choice. and transparency regarding provider quality and costs. and investments in IT. Organizations eligible to participate in this new project should include integrated delivery systems. In the second year. The term accountable care organizations (ACOs) has been used to describe these and other provider groups that are optimal candidates for payment based on improvements in quality and savings achieved through improved care processes. greater adoption of health IT. 50 While some design challenges of this demonstration remain — including the identification of a control group for cost comparison purposes. expanded role for non-physician providers. physician hospital networks or independent practice associations. academic medical centers and their affiliated faculty practices. Due in large part to their innovative organizational model. all participants demonstrated improvements in quality and achieved belowaverage growth in costs. 49 Preliminary results from the demonstration and reports from participants suggest that the program has achieved its goals of better coordination of care for the chronically ill. 52 Based on the results from the current PGP demonstration. such as Billings Clinic in Montana. multispecialty group practices. 52 . including hospitals. selection of meaningful quality measures. The new ACO pilot should be implemented in part in communities and regions where meaningful integration does not yet exist — such as in rural areas and small group practices.

The PGP demonstration allows participating provider groups to recoup 80 percent of the cost reductions that they achieve beyond the two percent threshold. To determine whether ACOs are successfully controlling costs. An alternative approach would distribute 100 percent of first three percent of additional savings beyond the threshold to the ACO.As part of this project. Incentive payments would be awarded to ACOs that reduce spending significantly below the target rate set by the formula. Perhaps a middle ground would be to begin with a formula using regional trends that would slowly phase in a national element to more aggressively reduce cost growth over time. balancing the following interests: encouraging providers in both high. Using multiple prior years of data would allow more accurate and stable estimates of current year spending. CMS would establish a timeline to phase in reporting on these measures. and promoting regional and ACO-level equity in the amount of increases in per-beneficiary spending permitted under the shared savings program. participating ACOs would be reporting on at least the following classes of measures: (a) risk-adjusted health outcomes and improvement on specified ambulatory chronic conditions as well as common inpatient chronic conditions. reducing unwarranted geographic variations in per-beneficiary spending.53 Several approaches to developing the targets should be considered. and (b) patient experience measures for both ambulatory and inpatient care. while ensuring that a substantial share of the savings would accrue to the Medicare Trust Fund as the magnitude of savings increases. A threshold savings amount should be set — such as the two percent mark used in the PGP demonstration — to avoid incentive payments being made to ACOs based on natural variations in their year-to-year spending. ACOs that successfully report on measures in a manner consistent with the Physician Quality Reporting Initiative (PQRI) would qualify for the incentive payment under that program as well. ACOs would be subject to group level reporting on a list of quality measures endorsed by the National Quality Forum (NQF). so that within five years. Savings should be based on real system improvements and not accidents.and low-cost regions to participate and receive shared savings payments. with a cap on incentive payments of five percent of total Medicare spending. CMS would establish benchmarks for achievement and improvement that ACOs would have to meet in order to qualify for incentive payments. The plan also calls on CMS to develop a formula for distributing shared savings payments that would give providers a strong incentive to participate in the program. as is the case for existing PGP demonstration participants. CMS would establish a formula that would allow current and future years’ per beneficiary spending at the ACO to be estimated as accurately as possible using Medicare Part A and Part B claims for the beneficiaries it treats. 53 . An issue to be resolved with input from stakeholders and other experts would be how to establish cost trend targets for participating ACOs. with the share of savings diminishing above the five percent mark and continuing to decline up to a maximum threshold set by CMS.

neither demonstration has officially launched to date. CMS could also use existing authority to align payment models in specific regions or states to support similar initiatives led by private payers and state Medicaid programs. Congress directed CMS to conduct two demonstration projects that would examine whether physician-hospital collaboration is an effective method for promoting quality and constraining costs. the Baucus plan would strive to work with CMS. the Stark and antikickback laws — which appropriately protect against financial conflicts-of-interest between hospitals and physicians — have come to broadly prevent hospitals from offering financial incentives to physicians who appropriately use imaging services or prevent readmissions through disease management protocols. 55 More recently. As is the case with other areas. 54 . Therefore. one demonstration will focus on tracking patients beyond their hospital stay. subsequent decisions by the HHS Office of the Inspector General (OIG) have significantly dampened gainsharing efforts by allowing only limited projects to move forward. the Baucus plan would also take steps to break down existing barriers that keep health care providers from improving patient care through increased collaboration.The development of a shared savings program building on the success of the PGP demonstration should proceed as rapidly as possible. CMS is conducting a pair of multi-year programs that will allow up to 24 hospitals to share with their physician partners a portion of any savings to the Medicare program that are generated from improved quality and efficiency of care delivered to Medicare beneficiaries. As part of delivery system reforms. Allowing providers to share among themselves savings from improved efficiency and quality — also known as gainsharing — is one potential strategy to encourage provider collaboration. the HHS OIG. as well as any unintended consequences associated with provider collaboration. CMS should implement ACO pilots on as broad a scale as is feasible. these projects should provide valuable information on which modern gainsharing strategies work and which do not. In particular. to determine whether provider collaboration can save money and generate efficiencies across multiple clinical episodes and settings. Successful implementation of new payment and delivery models to promote coordination and value-based purchasing may require changes to the regulatory structure governing provider collaboration. Gainsharing. which could permit testing variations of the model. Once underway. and interested stakeholders to develop gainsharing proposals that strike the appropriate balance between thoughtful incentives for coordination of care and careful protections against financial conflicts-of-interest that could harm quality of care. 54 CMS conducted demonstration projects in the 1990s that allowed participating hospitals to experiment with gainsharing arrangements.56 While promising. To achieve this goal. While these projects proved successful at reducing costs and improving patient outcomes. For example. Concerns about unfettered gainsharing that does not ensure patient safety are warranted.

as the Congressional Budget Office has signaled that national health spending could be significantly reduced if more unbiased data were available and used widely by providers and patients. 59 . Public and private research efforts are also highly fragmented and poorly coordinated. this plan would create a new institute charged with identifying the most pressing gaps in clinical knowledge that prevent the health system from delivering the best outcomes for patients. The National Institutes of Health (NIH) as well as the Agency for Healthcare Research and Quality (AHRQ) have also conducted seminal research comparing one or more medical interventions. 62 Providers have more diagnostic tests and treatment options to choose from than ever before. 60 . 58. lacks sufficient capacity to produce unbiased information to compare existing treatments to determine which ones are more effective and for which patients. but too often they lack knowledge as to whether one works better.D. 63 introduced earlier this year. The Baucus plan answers these calls. which would ultimately improve the ability of providers to deliver the right care at the right time for each and every patient. Several well-respected panels—including the Institute of Medicine (IOM). 57 The rapid development of medical technology and medical treatments in the U. Priorities for infrastructure investment include: comparative effectiveness research.S. or if several lead to similar outcomes. organizations like the Technology Evaluation Center funded by the Blue Cross and Blue Shield Association and the Veteran Administration’s Center for Health Care Evaluation conduct research that compares the effectiveness of different medical treatments.S. The U. the Medicare Payment Advisory Commission (MedPAC).S. is inadequate to keep pace with medical innovation. As first suggested in the Comparative Effectiveness Research Act of 2008. 55 . Despite these efforts. and the Congressional Budget Office (CBO)—have called on Congress to create a national entity charged with conducting this type of research. This plan envisions a national approach to conduct and promote comparative effectiveness research.S. and the health care workforce. The reforms outlined in this plan would require new investments in our health care infrastructure. Yet patients and their physicians can face a daunting task choosing among treatment options. Such an effort would likely lower costs too. 61 . poses a challenge for our health system: can it produce evidence regarding what treatments work best in a timely fashion? Experts agree that the U. HEALTH CARE INFRASTRUCTURE A health system that performs to its potential — providing high value care for every dollar invested — requires adequate infrastructure to support it. Comparative Effectiveness Research. health information technology (IT). On a limited scale. current funding for effectiveness research in the U. produces some of the most technologically advanced medical care in the world.

A mix of public and private resources is the best long-term 56 . The Comptroller General should perform regular audits of its activities to ensure that the Institute meets its statutory mission in a fair. rules. and payers of health care to make more informed clinical decisions. It should also provide for public comment periods at key stages—including the development of research priorities and study designs—in addition to holding public forums on controversial or complex topics. The Institute should not just recommend areas of inquiry. Public funds would be the best option to get the Institute up and running. The Institute must also have flexibility to meet its priorities by contracting directly with private researchers as appropriate. and patient networks. services. These new endeavors would need an adequate and stable source of funding. the Institute should be subject to rigorous oversight of its finances and mission in order to maintain the public trust. The Institute would be created as an independent entity to remove the potential for political influence on the development of national research priorities. and management of health conditions. procedures. In addition. It should be able to contract with experienced Federal agencies. Importantly.S. Comptroller General. providers. Activities of the Institute should be open to public input and transparent in order to maintain integrity of the research. Its reports should serve both clinical and general audiences. like NIH. nonprofit corporation with a Board of Governors appointed from the public and private sectors by the U. the Institute would also need to disseminate its research findings to the public. and AHRQ. Its meetings should be open to the public. treatment. Most importantly. Comparative effectiveness research would be more credible. and credible manner. and reports and make them available on a public Internet site. prevention. open. proceedings. But the information produced by such an Institute would benefit all Americans—those who receive health care through public and private sources—so it makes sense for a small assessment on private health insurers to be included. medical devices. For example. It could work in concert with government agencies (such as the Centers for Disease Control and Prevention and AHRQ). the research should meet the goal of helping patients. medical societies. and more useful. that have robust research networks in place and that can be put to good use here. The comparative effectiveness Institute would need to assess the full spectrum of clinical interventions. which have the greatest gaps in evidence and variations in practice patterns. if it remained free from political influence and reflected broad stakeholder input. In addition to setting national priorities. and other therapies. a new institute should provide for the conduct of the studies that would meet its priorities. it should produce the vital information needed. the Institute should publish its charter. including pharmaceuticals.The Health Care Comparative Effectiveness Research Institute envisioned in the Comparative Effectiveness Research Act of 2008 would be a private. A broad scope would provide better evidence for existing diagnostics.

hospital admissions. help to better manage and prevent illnesses. Safeguards must be put in place to ensure that patient privacy is protected. Reductions in office visits. Reporting to chronic disease registries. over the phone. and more reflective of the composition of the Institute and its broad reach. and help to lower health costs for everyone. and payers that a path forward that drives adoption and protects patient privacy must be found. a fear of investing in systems that may soon be obsolete. 68 Providers. providers. Health IT adoption by providers has been low to date. especially for physicians in smallgroup practices. there is a growing consensus among patient advocates. America must make a greater investment to generate information about what works in health care. particularly physicians. 69. 66 Technology can facilitate richer data sets for comparative effectiveness research. Knowing more about the effect of different health interventions would help to reduce the variability in treating disease. Most providers in the health care system collect and transmit information on paper. especially in smaller settings. and other tests electronically. and via fax machines.64.65 Automating the collection of clinical data will also be a vital component of better quality performance measurement and reporting. as well as a lack of a clear return on investment. and culture that clinicians and office staff may resist. and other services that could be achieved through the use of health IT would accrue to the benefit of payers and patients but not to providers themselves. and then access test results. Health Information Technology. and Providing evidence-based decision support to physicians.70 Some providers. lack the resources or expertise to navigate the large and complex market of health IT products or to maintain such a system over time. 67 and help providers use comparative effectiveness findings in their own clinical practices. And existing payment incentives discourage health IT adoption. Clinical IT comprises multiple applications that can support different functions in health care. lab work. 57 .framework for funding. Despite these challenges. In the absence of sound evidence. processes. Encouraging more rapid adoption and use of health IT systems will improve health care quality and make our health care system more efficient. More advanced health information technology (IT) offers tools to streamline and support the process of collecting and analyzing the data needed to provide the best and most efficient care possible. cite as obstacles the cost of purchasing and implementing systems. The Baucus plan provides Federal-level leadership to spur the modernization necessary to support a truly patient-centered delivery system. clinical guidelines and protocols can vary widely. such as: ! ! ! ! Tracking patient care. Implementing health IT also requires changes in office organization. Allowing physicians to order medications.

there have been at least 35 studies published since 2002 demonstrating current or future physician workforce needs. the number of physicians is projected to grow only 16 percent. loans. According to the American Association of Medical Colleges (AAMC). 73 Other studies by HRSA warn of a nursing shortage in the coming years. and (3) promotion of information sharing among providers. the Baucus plan proposes three strategies to encourage the adoption and use of health IT: (1) financial incentives. (2) assistance to providers in navigating the health IT market and implementing systems. then the Office of the National Coordinator for Health IT would immediately promulgate standards. 74 As the population continues to age. health care workers represent roughly 12 percent of the American labor force. Direct grants. but also the 20 percent of Americans who live in underserved communities and already struggle to obtain access to medical care. does not have a sufficient supply of health care professionals to meet the demands of a changing and aging population. interoperable health IT systems. 72 Among these is a report by the Health Resources and Services Administration (HRSA). Between 2005 and 2020. understand their needs. which predicts that demand for physician services will exceed supply by 2020. Congress recently established bonus payments in Medicare for physicians using qualified e-prescribing systems. 58 . there are growing concerns that the U. The plan also calls for additional technical assistance to help providers assess products. 71 While these workers strive to provide high-quality care and make important contributions. Helping providers navigate the health IT market and implement qualified systems could also aid widespread adoption. the number of Americans over age 65 is projected to increase by 50 percent.S. if the private sector does not find timely consensus. 76 An inadequate physician supply will not only affect the elderly. 75 During the same period. Today.Consistent with recommendations made by MedPAC and others. Various studies suggest that the country is facing a health professional shortage. Promoting the sharing of information among providers also would improve coordination of care and efficiency. Efforts at the community level to increase this exchange have seen limited success in some areas. and financial incentives provided through Medicare pay-forperformance initiatives could promote adoption of health IT. A similar model could be employed to encourage the use of electronic health records if other obstacles are addressed. The Baucus plan will accelerate efforts to certify software products by setting a deadline for the establishment of harmonized interoperability standards. a shortage of health care workers will become increasingly problematic. These bonus payments phase down over five years and become a requirement (enforced through payment reductions). and manage implementation and ongoing maintenance. getting more out of health IT. but stronger leadership at the Federal level will be necessary to initiate nationwide adoption of advanced. Health Care Workforce.

In addition to direct payments for GME. While the Medicare GME program has provided essential resources for training America’s physicians.80 These policies represent a shift in the structure and focus of the GME program. In recent years. the AAMC and other stakeholders have raised concerns about rules in the current Medicare program that place a cap on the number of medical residency slots that can be supported by the GME program. The residency cap was established as part of the Balanced Budget Act of 1997 in response to what many considered an oversupply of physicians in the pipeline. respectively. of the general population. such as in community-based primary care offices. Included in the 1965 legislation that created Medicare. Among physicians. African-American and Latino physicians comprise only three and a half and five percent. The same degree of disparity is also evident in the 59 . According to MedPAC. GME funding should be used to train residents outside traditional hospital settings. The program has served as a major funding source for medical training for most teaching hospitals. Indirect medical education (IME) payments under Medicare are based on the ratio of residents to beds — the higher the ratio. such as primary care. the landscape of physician supply relative to demand has shifted.8 billion on GME activities. more than $3 billion in extra payments are made to teaching hospitals with no accountability for how these funds are used. Minorities are underrepresented among our nation’s health care workers. Medicare also subsidizes the indirect costs of patient care associated with graduate medical training. These payments are not well targeted and are set at a level that is twice as high as what can be justified empirically. There is also discussion about allocating GME funds toward nurse practitioners and physician assistants who also play a role in managing patients’ primary care needs. 81 Congress should increase accountability around how these and other GME funds are spent. Medicare spent roughly $8.The Federal government plays a key role in training future health care professionals through the Medicare Graduate Medical Education (GME) program. respectively.500 medical training positions have been created that do not receive support from Medicare. 77 Since this rule took effect. 79 Similarly. the GME program provides subsidies to help teaching hospitals and other entities cover the direct costs associated with medical training in accredited teaching programs. it needs to be reexamined. As we work to strengthen graduate medical education programs. and preventive services. In 2007. others have recommended that training programs place a greater emphasis on preparing providers to practice in an organized delivery system or team-based environment. of the physician workforce compared to 11 and 13 percent. In addition. the higher the payment. we must also take steps to increase the number of racial and ethnic minorities who enter our health workforce. Native Americans/Alaska Natives comprise only two percent of the physician workforce. but are worth serious Congressional consideration. and roughly 6. 78 Also of concern has been the question of whether the Medicare GME program should place a greater emphasis on providing training in critical focus areas. geriatrics.

“Report to Congress: Reforming the Delivery System. 299. 10. no. no. “Report to Congress: Reforming the Delivery System. 13. “21st-Century Primary Care: New Physician Roles Need New Payment Models.184). no.” Journal of the American Medical Association. 4 5 6 Medicare Payment Advisory Commission. no.” Milbank Quarterly 83. “Report to Congress: Reviewing the Work Relative Values of Physician Fee Schedule Services. “Contribution of Primary Care to Health Systems and Health. Baron and Christine K. These efforts are critical if we are to place our nation’s workforce on sound footing to address the health care needs of current and future generations. 3 (2005): 457-502. (2008): 1595-1597. Medicare Payment Advisory Commission. 10 (2004):184-196 (published online 7 April. 3 2 Barbara Starfield. Next steps could include: ! ! ! ! ! Evaluating whether changes are needed to the number of allowable GME training slots. 3 (2005): 457-502. and Congress must dedicate the time and attention to graduate medical education that it deserves. Loan assistance and forgiveness programs for caregivers who choose to practice in underserved areas should also be expanded to make sure that patient needs are met. “Medicare Spending: The Physician Workforce. Katherine Baicker and Amitabh Chandra. especially as we expand access to insurance for millions of Americans. merit re-examination as we work to improve our health care infrastructure. Increasing accountability of indirect medical education (IME) funding. 60 . and Working with the Senate Health. Exploring options to increasing the residency cap for certain specialty areas.w4. Significant work must be done in these areas. Leiyu Shi. Policy solutions in this area should be considered as part of health care reform.” Milbank Quarterly 83. Labor and Pensions (HELP) Committee to address workforce shortages and support increased racial and ethnic diversity within the health care workforce by strengthening public health programs in these areas. Strategies to improve the racial and ethnic diversification of our health workforce include increasing the number of pipeline education programs at the high school and college level and providing funding for scholarship and loan programs that support racial diversification among health workers and medical faculty. 2004.” Health Affairs. and James Macinko. Medicare Payment Advisory Commission. Determining ways to modernize the GME benefit through policies to allow training in other treatment settings and encouraging a focus on care coordination. and Beneficiaries’ Quality of Care.” (2008): 135.” (2008). 1 Barbara Starfield. 2004.1377/hlthaff.area of nursing care. and James Macinko. Racial or ethnic minorities represent only 14 percent of the nursing workforce while they represent 34 percent82 of the general population. Leiyu Shi. such as Title VII and Title VIII of the Public Health Service Act. Many of these programs.” (2008) 7 8 Richard J. “Contribution of Primary Care to Health Systems and Health. Cassell. Ibid. Education.

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hrsa. 6 (2006): 572-585. Kathy Buto and Peter Juhn. Shortell and Lawrence P. “Health Care Reform Requires Accountable Care Systems. 6 (2006): 586-588. “Medical Groups’ Adoption of Electronic Health Records and Information Systems.” (2004). 26. “Rising Costs.” (2008).cbo. (2007): 58-67. James Bigelow. Gail Wilensky. Introduced by Senator Baucus and Senator Conrad.” Health Affairs." Health Affairs. no.” (Testimony before the Senate Committee on Finance. Elliot S.. Fische. no. Stephen M. Richard Hillestad. Paul B. 2008).gov/healthworkforce/reports/#medicine. 65 66 64 63 Medicare Payment Advisory Commission. Gail Wilensky. Richard Scoville. “Gain Sharing: A Good Concept Getting A Bad Name?” Health Affairs 26. July 17. U.” HRSA. (2007). U.” (Testimony before the Senate Committee on Finance. 1. “The Right Care at the Right Time: Leveraging Innovation to Provide Quality Care for All Americans. Medicare Payment Advisory Commission. “Report to Congress: Reforming the Delivery System. Robin Meili. 25.S. “The Right Care at the Right Time: Leveraging Innovation to Provide Quality Care for All Americans. no. June 2. (2005): 1103-1117. “Learning What Works Best. “Can Electronic Medical Record Systems Transform Healthcare? An Assessment of Potential Health Benefits. “The Right Care at the Right Time: Leveraging Innovation to Provide Quality Care for All Americans.hhs. Nicholas Wolter. 24. Fisher et al. “Details for DRA 5007 Medicare Hospital Gainsharing Demonstration. 2008).” Health Affairs. no. no.S.3408. 60 61 62 59 58 57 IOM Roundtable on Evidence-Based Medicine. Savings. http://www. it is not feasible to implement on a national scale and thus should not be employed in the next iteration of the PGP approach.gov/ftpdocs/88xx/doc8891/12-18-ComparativeEffectiveness. David Gans et al. 2008). Gail R.cms.S. Richard Hillestad. The Comparative Effectiveness Research Act of 2008. (2006).” Health Affairs. Ginsburg.S.pdf. “Developing A Center For Comparative Effectiveness Information. Senate. U. “Report to Congress: New Approaches in Medicare. Wilensky. The Centers for Medicare and Medicaid Services.” CMS. "Creating Accountable Care Organizations: The Extended Hospital Medical Staff. http://bhpr. “Research on the Comparative Effectiveness of Medical Treatments. 300. no. and Michelle M. 1 (2007). 63 . (2008): 95-97.” (2007).Michael Trisolini et al.” (Testimony before the Senate Committee on Finance. 69 70 68 67 Medicare Payment Advisory Commission. (2008). Senate. U.” (2004).” The Commonwealth Fund. While this approach has some strengths and some weaknesses.asp?filterType=none&filterByDID=0&sortByD ID=3&sortOrder=descending&itemID=CMS1186805&intNumPerPage=10. (2005): 1323. Federico Girosi. The PGP demonstration program uses a control group to evaluate whether participants are reducing spending.” (Testimony before the Senate Committee on Finance.gov/demoprojectsevalrpts/md/itemdetail. 2008). Congressional Budget Office. 71 Health Resources and Services Administration.. “The United States Health Workforce Profile. http://www. Casalino. 55 56 54 53 52 51 50 Ibid. S. and Costs. 24. “Report to Congress: New Approaches in Medicare. July 17. “The Medicare Physician Group Practice Demonstration: Lessons Learned on Improving Quality and Efficiency in Health Care.” Journal of the American Medical Association. 5. 5. Low Quality in Health Care: The Necessity for Reform.” CBO. “Can A Center For Comparative Effectiveness Information Succeed? Perspectives From A Health Care Company. and Roger Taylor. Anthony Bower. Senate..” Health Affairs. Richard Hillestad. July 17. Senate.

and New Policy Directions. 6 (2008): 645. The Balanced Budget Act of 1997 (P.hrsa.” New England Journal of Medicine 359. The Commonwealth Fund.” U. (2006). 2008). Education. Labor and Pensions. Chapter II).” HRSA. Graduate Medical Education. Health Resources and Services Administration.gov/healthworkforce/reports/physiciansupplydemand/default.hrsa. Education. February 12. http://www. Health Resources and Services Administration.S. Iglehart. Census Bureau. 81 82 80 79 Medicare Payment Advisory Commission. 75 74 73 72 Health Resources and Services Administration.htm.S.S. Senate.Edward Salsberg. “Healthcare Workforce Issues for the Future. “Healthcare Workforce Issues for the Future. “Towards a Method for Identifying Facilities and Communities with Shortages of Nurses. (2007).S.” (2008).gov/bhpr/nursing/nurptsummary. “Nation’s Population One-Third Minority. Labor and Pensions. U. U. “Organizing the U. Census Bureau. (2006). http://bhpr. “Health Policy Report: Medicare. ftp://ftp.pdf.” (Testimony before the Committee on Health. http://bhpr. (2008).” HRSA.census. 2008).html. (2008). “Physician Supply and Demand: Projections to 2020. February 12.gov/Press-Release/www/releases/archives/population/006808. Edward Salsberg.S.L 105-33.hrsa. no.” HRSA. Ibid. “Report to Congress: Reforming the Delivery System. U.gov/healthworkforce/reports/#medicine. “The United States Health Workforce Profile. 76 77 78 John K.” The Commonwealth Fund.” (Testimony before the Committee on Health. Health Care Delivery System for High Performance. 64 . Senate.

Overpayments to private 65 ! ! ! . excess spending must be eliminated and dollars put to better use — not only to correct the imbalances of the current health care system. Americans deserve a health care system in which everyone has affordable coverage. 4 5 But savings from the reforms proposed earlier in this Call to Action and the financing mechanisms in this section can make the net cost of reform much smaller. but to offset the high costs of much-needed comprehensive reform. employment. more direct steps in these five areas to curb excess health care spending. Waste. Private Insurance Plans in Medicare. Clearly. Public reporting of the costs and quality of care — as well as the relationships between providers and drug or device makers that may lead to biased decision-making — can encourage providers to pursue better outcomes and help patients choose better. evidence-based care. while ensuring that injured patients are compensated fairly for their losses. New initiatives should be implemented immediately to better detect and eliminate financial fraud and abuse in our public programs. National spending on health care can be lowered. Taxpayer dollars should cover needed benefits and not fraudulent medical claims. Careful reforms of medical malpractice laws can lower administrative costs and health spending throughout the system. more efficient providers and treatments when they are able to do so.S. they must bring value to the program and beneficiaries.3 trillion a year — more than 16 percent of the U. This will require an investment. ! Fraud. Medical Malpractice. and investing in critical research and health information technology that can lead to higher-value care. no matter their age.2 We spend more than any other country on health care — both per capita and as a percentage of gross domestic product — yet the Congressional Budget Office (CBO) estimates that up to one-third of that spending does not improve Americans’ health outcomes.S. 3 That means we spend over $700 billion more than we need to get the outcomes that we receive today. and Abuse. If private insurers participate in Medicare. income. economy — on health care. Information about the full value of employersponsored health care could help employees make better coverage decisions for themselves and their families. Beyond these measures. Some experts predict that a health system covering all Americans would necessitate $100 billion to $150 billion in new Federal spending per year. or health status. the Baucus plan endorses even further.CHAPTER IV BAUCUS PLAN: FINANCING A MORE EFFICIENT HEALTH CARE SYSTEM The U. Increased Transparency. Greater transparency in these areas can help eliminate waste and drive better value throughout the health system. and quality improved. spends $2. by realigning the health care system toward prevention and primary care. 1. rewarding providers that deliver quality. and economists warn that rising health care costs represent a serious threat to our long-term fiscal security.

would eventually be far greater than any initial outlays. AND ABUSE Fraud. would not accrue until policies have been in place for several years. such as comparative effectiveness research and malpractice reform. If we fail to act.insurers in the Medicare Advantage program must be eliminated so that spending is put on a level playing field with traditional Medicare. Much of the savings from reforms. Similar but smaller tax incentives increase access to coverage for the self-employed and ease the burden of health expenses for people with no employer coverage. In short. however. Congress and the public must be realistic about the timeframe in which the fiscal success of reform is measured. ! In the short term. ! Long-Term Care Services and Supports. poor quality will continue to contribute to nearly 100. FRAUD. tens of millions will continue to be uninsured. and threaten the financial integrity of essential Federal health care programs. targeted reforms can promote smarter. can harm beneficiaries. These ends cannot be accomplished without a stronger investment in a more robust workforce. more efficient spending of health care dollars by consumers themselves. But it is time to explore ways in which tax incentives can be modified to distribute benefits more fairly and effectively. A. tax incentives for employer-sponsored health benefits have made employer coverage more affordable for millions of workers. Tax Incentives for Health Coverage. Further expanding home and community-based care.S. without financial giveaways to insurers. and the nation’s entitlement programs will consume a greater portion of the Federal budget. health care reform will likely cost taxpayers more than the government can achieve in savings from all reforms and financing changes. fragmented. waste. Many payment errors are the result of honest mistakes unrelated to providers or suppliers trying to take advantage of 66 . and better supporting family caregivers are essential to improving the quality and efficiency of the system.000 deaths each year. Price discounts for prescription drugs of the dualeligibles in Medicare’s prescription drug plans should reflect discounts in Medicaid. the current national expenditure on health care will double from over $2 trillion to $4 trillion. Payments should also be modified to promote the best of what plans have to offer beneficiaries. the costs of inaction. and abuse cheat the taxpayer. testing new models of care delivery and coordination. Since the mid-1950s. and does not encourage the delivery of high-quality care. The current long-term care system is expensive. Congress should also explore targeted reforms of the tax code to make incentives work better within the current system. WASTE. both in human and financial terms. Such tax provisions have been and will continue to be the main tool used to foster employerbased health insurance coverage in the U. At the same time. America must choose to invest now in a health care system that will richly repay the nation with greater health and economic stability in the long term.

lowcost services while minimizing providers’ administrative burdens. and the Attorney General. We can provide more and better care for our beneficiaries if we do more to reduce fraud. The Secretary of Health and Human Services (HHS). More can be done to combat unnecessary spending. 6 In 1994. and abuse is a deviation from acceptable business and medical standards. but evidence of the problem is everywhere. which includes ideas articulated by HHS OIG. “Fraud is the obtaining of something of value through intentional misrepresentation or concealment of material facts. Medicaid. the Medicare program reported a fee-for-service payment error rate of 3. and abuse cannot be determined with precision. 10 would focus on preventing fraud. or controls. waste. Medicaid. acting through the Department’s Office of Inspector General (OIG). Abuse is any practice that is not consistent with the goals of providing patients with services which (1) are medically necessary. run the Health Care Fraud and Abuse Control (HCFAC) program. and local law enforcement activities to prevent health care fraud and abuse. spends more than $2 trillion on health care every year. A five-part strategy will effectively 67 . and abuse.S. some providers and suppliers purposefully manipulate these programs for financial gain. waste. Better alignment of incentives and value-based purchasing in particular would reduce waste because they will cut down on instances in which Medicare pays for something beneficiaries do not need. Outlays for Medicare and Medicaid almost doubled between 2000 and 2008. The Baucus plan. state.Medicare. but the outlays for fighting fraud and abuse in these programs have not kept pace. we need to do more. Fraud and abuse connote some level of culpability in that they involve billing practices or behaviors that include misrepresentation of or overcharging for services delivered.4 billion to the Medicare Trust Fund alone. Fraud is willful or intentional. (2) meet professionally recognized standards. and (3) are fairly priced. June Gibbs Brown. and abuse. In the ten years since its inception.” 7 The full magnitude of health care fraud. waste. Last year. and abuse before they happen. waste. and aggressively detecting them when prevention fails. the National Health Care AntiFraud Association estimates conservatively that at least three percent — or more than $60 billion each year — is lost to fraud. HCFAC has returned over $10. 9 Many of the improvements to the delivery system discussed in the preceding chapter would help reduce wasteful spending. which coordinates Federal. There are clear differences between fraud. which means that Medicare paid over $10.8 billion incorrectly. Medicare. and CHIP must have flexibility to quickly deliver high-quality.9 percent. Of that amount. Both lead to unnecessary costs to the payer. said in testimony before the Senate Appropriations Committee that. the Health and Human Services Inspector General. 8 The amount of money wasted on billing errors and other mistakes is also staggering. systems. For instance. the U. While the efforts to fight fraud. and abuse have been commendable. However. and CHIP. waste. Waste is the incurring of unnecessary costs as a result of deficient practices.

waste. 12 Third. Fourth. Florida’s Miami-Dade County is home to many companies that claim to be durable medical equipment suppliers. his new company billed over $4. while allowing the programs to effectively serve beneficiaries. and CHIP. rather than encourage. waste. or abuse. the government must do a better job of screening those allowed to become providers and suppliers in Medicare. beneficiaries also incurred $1. mandated reporting of violations. investigation of providers and suppliers. in 2006. responses to detected fraud must be swift and strong. and CHIP and continuously monitor for evidence of fraud. but need help doing so. Medicaid. Medicaid. the Department of Justice and HHS OIG created a strike force whose primary goal was to attack the fraud problem by decreasing the amount of time between the government’s detection of a fraud scheme and the arrest and prosecution of the offenders. an individual arrived in Miami-Dade County from Cuba and soon thereafter enrolled as a Medicare provider. and other Medicare providers and suppliers. establishment of internal controls. and orthotics has been temporarily delayed. and CHIP. That effort has lead to over 76 convictions and criminal fines and civil recoveries in excess of $140 million. and abuse. prosthetics. and penalties and sanctions would enable better detection and punishment of inappropriate or unlawful behavior. and abuse. and the program should move forward. government payment methodologies should discourage. Competitive bidding is a proven method for saving money and reducing fraud in this area. Program vulnerabilities that are revealed by the fraudulent conduct must be remedied to prevent repeated abuse. In May 2007. The competitive bidding program for durable medical equipment. Most health care providers and suppliers intend to act in accordance with program requirements. providers or suppliers from engaging in fraud. working with providers and suppliers to promote compliance with program requirements and quality and safety standards could actually increase it. Finally. Improvements and enhancements in the collection and review of data. The same is true for quality and safety standards applicable in Medicare. 11 As a result of these excessive fees. For example. This person should never have been allowed to become a supplier. infusion clinics. For example.65 million.1 million in fraudulent claims and was paid $1. waste.fight fraud. From April until June. in January of 2005. however. He has since disappeared. First. the Federal government has an absolute duty to conduct vigilant oversight of Medicare. For example. Second.215 for rental of a piece of durable medical equipment that costs about $600 to purchase new. Punishments must be sufficient to deter others from considering the same behavior. Medicare allowed an average $7. Ensuring that only well-intentioned and law-abiding people and companies have the privilege of providing health care items and services to beneficiaries is an important initial step.443 in coinsurance charges for this equipment. Medicaid. 68 .

the HHS OIG demonstrated a return on investment of 16:1 for these efforts.Success demands that the resources devoted to fighting fraud. The Baucus plan focuses on three areas that would benefit from greater transparency: physician-industry relationships. According to the Office of Management and Budget. brand-name drugs instead of cheaper. Government Accountability Office. B. Physician-Industry Relationships. Providers suffer from some of this same confusion. Harvard’s Eric Campbell told the Finance Committee: “A physician-industry relationship exits whenever a physician accepts anything from a pharmaceutical or device company such as dinners at fancy restaurants. It is often too difficult for Americans to understand what services they receive or why they receive them. Thirty-five percent received reimbursement for costs associated with professional meetings or continuing medical education. and more than one quarter (28 69 . “most physicians (94 percent) reported some type of relationship with the pharmaceutical industry. 13 Watchdog and advisory agencies like the HHS OIG. Providing meaningful and useful information would alleviate much of the frustration and suspicion. Increasing transparency — providing more and better information — would improve the level of understanding. and law enforcement agencies must be provided with the resources that they need to combat fraud. The Baucus plan would invest much needed resources to carry out this fight because it takes time. “may also result in physicians prescribing higher priced.” 14 Though these relationships may lead to advancements in medical technology and a better understanding of medical procedures. With better information. and abuse. INCREASED TRANSPARENCY Making more information available to health care providers and consumers would remove much of the mystery that currently shrouds our health care system. waste. equally effective alternatives. the Medicare Payment Advisory Commission. and most of these relationships involved receiving food in the workplace (83 percent) or receiving drug samples (78 percent). According to a Harvard Medical School study. trips and paid consultancies. or what their insurer is charged — not to mention what a service actually costs. physician self-referral. This lack of understanding leads to frustration. waste. pens. or abusive practices. manpower. “this practice likely results in substantial increases in the costs of health care. drug samples. providers and payers would gain a better understanding of how the system works and would be able to see how health care dollars are spent. what they pay for relative to their insurer. and money to effectively monitor and detect fraudulent.”15 These higher costs occur because industry gifts. wasteful.” 16 These types of relationships are common throughout the physician community. lunches. and cost and quality information. We also need to work with the HHS and CMS program managers responsible for protecting and effectively managing these programs. state Medicaid Fraud Control Units. and abuse be sufficient to respond to this growing problem. consumers. Effective elimination of fraud provides a significant return on investment.

And the requirement to disclose may deter inappropriate behavior. The AMA “allows physicians to accept gifts as long as the gifts primarily benefit patients and are not of substantial value. so that regardless of provider relationships. 18 To dissuade inappropriate relationships. expect to get paid for the work that they perform. National legislation has been introduced that would require drug and device companies to disclose all gifts of $25 or more to physicians and other medical providers. However.” and should be used. enable payers to examine physician practices that may be influenced by particular relationships. the extent of industry influence and the wasteful spending that it leads to can be better determined. With this information. allow the media to explore potential conflicts of interest.” 19 The PhRMA code states such relationships “are intended to benefit patients and to enhance the practice of medicine. the Baucus plan would require disclosure of gifts and other transfers of value made by drug and device companies to physicians and other health care professionals. like most professionals. they reap additional financial benefits from the provision of certain health care services. For these reasons. giving lectures. system-wide data is available. Physicians. we can be sure physicians are recommending and performing medical care based on sound medical science rather than heavy-handed industry influence. 22 Many advocate more detailed reporting of gifts between industry and physicians on a national level. “there is also evidence that interactions prohibited by voluntary codes continue to occur. Only with this information can potential bias be known. have found a way to game the system so that.” 21 Four states (Minnesota. Disclosure is the only way to know if there are inappropriate influences on the delivery of care and use of taxpayer dollars. 24 Unfortunately. Physician Self-Referral. Some physicians. Maine. once national. It may discourage inappropriate arrangements between physician and industry. in addition to getting paid. however. pharmaceutical companies spent $7 billion on sales representative visits to physicians and provided $18 billion worth of free samples. both the American Medical Association (AMA) and the Pharmaceutical Research and Manufacturers of America (PhRMA) adopted or revised their codes of conduct involving industry relationships. data collection alone may not prevent inappropriate relationships. and West Virginia) and the District of Columbia have enacted laws that require drug manufacturers to report any cash and in-kind payments made to physicians. or enrolling patients in trials.” 17 In 2005. Physicians can accomplish this by having ownership or other financial interests in equipment or facilities — such as an MRI machine 70 .percent) received payments for consulting. Vermont. and highlight those physicians who have decided not to take part in inappropriate relationships. stronger enforcement can be put into place.” 20 Though these updated guidelines are a step in the right direction. 23 A recent MedPAC report to Congress outlined several advantages of such a requirement. “solely on each patient’s medical needs.

while leaving the patients who are sickest and least able to pay for community hospitals to treat. tend to provide all service lines. Over time. Congress enacted the Ethics in Patient Referrals Act (known as Stark I). outpatient prescription drugs. because the financial incentive to increase utilization of the financially-rewarding services may conflict with otherwise sound medical and professional judgment.” 30 The Baucus plan would scrutinize physician self-referral to ensure that physicians are not engaged in financial arrangements that place financial interests ahead of the needs of patients and the American taxpayer. but they should not be able to game the system unfairly. Congress enacted the Anti-Kickback Statute. Ultimately. which prohibits physicians from “referring Medicare or Medicaid patients for clinical laboratory services to labs with which the physician has a financial relationship…unless the relationship fits within a specified exception. radiology.” 29 In 1993. often without much compensation. In 1972. radiation.” 26 Congress has enacted several laws to confront this problem. Physician self-referral is generally prohibited by Federal law when the patient is covered by Medicare or Medicaid.or a hospital — that provide health services. Congress enacted amendments (known as Stark II) expanding the prohibited services to “physical and laboratory therapy. They tend to focus on lucrative lines of service. or receipt of anything of value to induce the referral of patients from services reimbursable by a federal health care program.” 27 Few prosecutions occurred. Physician-owned hospitals are often smaller and more specialized than community hospitals. including emergency departments. When those physicians refer their patients for services from which the physician reaps the additional financial benefits — a practice known as self-referral — there is reason to be concerned about the physician’s motives. this practice often results in an “increased use of services and higher payments from third party payers. Community hospitals find it difficult to compete with their more cash-rich physicianowned counterparts. 71 . This concern is heightened by the fact that the patient often is unaware of a physician’s financial interest in providing services at a hospital in which he or she has an ownership interest. and many types of medical equipment and supplies. payment. if any. One example is physician ownership of hospitals. home health care. and referrals to imaging facilities or medical laboratories were not deterred. Community hospitals. 28 In 1989. on the other hand. the trend of increasing physician ownership of hospitals jeopardizes the continued viability of community hospitals. There is concern that physician ownership of hospitals leads to cherry-picking the patients who are healthiest and most able to pay. however. hospital. This cherry-picking only exacerbates the cost shifting to those Americans with insurance. Increased transparency to both patients and payers in the form of disclosure of physicians’ financial interests is first step. 25 Self-referral creates conflicting incentives for physicians. which “broadly prohibits the purposeful offer. Physicians deserve fair pay for providing services.

and more than 60 percent claim to have searched for information to help make health care decisions. Medicare. which undermines the value of any comparison by patients and beneficiaries. pneumonia care. Rising health care costs have fueled an interest in greater public availability of price and quality information. that this information is too detailed and not meaningful. recent legislation has required public reporting of hospital retail charges. for example. Cost and Quality Transparency. An August 2006 Executive Order directed Federal health programs ! including the Federal Employees Health Benefit Program. the price and quality information is not linked. Information is also available for risk-adjusted mortality rates and patient satisfaction. and surgical care improvement. 90 percent of health care consumers want to partner with their physician in making health care decisions. In addition. such as wrist fracture pinning. Most experts agree. Medicare currently posts hospital quality measures online at the Hospital Compare website. 34 Pursuant to this order. Decisions about health care are often involuntary — made under emergency 72 . 2007. colonoscopy. 33 Public programs have also embraced greater transparency. The Centers for Medicare and Medicaid Services (CMS) has also started making available comparative price information for common outpatient procedures. 35 Trying to estimate a hospital stay based on charge data is “like shopping for a car by adding up the prices suppliers charge for all the nuts and bolts that go into one. because it contains unit prices rather than episodes of care. The demand for more transparent price and quality information has been driven primarily by employers and health plans. 32 Additionally. and pharmacies to publish their prices. the information is based on an average. And health care price and quality information can be used by private health plans and public programs to reward quality and efficiency. physicians. Public reporting and transparency can aid patients in making more informed decisions about their treatment options. No serious effort at reform can ignore the potential gaming that financial conflicts may create. Such information could also spur providers to make improvements by benchmarking their performance against their peers. Hospital-specific process measures include those related to heart failure and heart attack care.The issue of self-referral must be reviewed in light of how health care is and will be delivered. found that 84 percent of Americans want hospitals. programs operated by the Indian Health Service. A recent survey. and building on existing programs. While public availability of Medicare price information is novel and has been hailed as a first step. and hernia repair. 31 But consumers believe they have much to gain from greater transparency. too. and TRICARE ! to make quality and pricing information available to beneficiaries and enrollees by January 1.” 36 The value and usefulness of cost and quality information may be limited by practical factors. and it is not current or hospital-specific. however. At the state level.

also described in recent congressional testimony by the Commonwealth Fund. Some of these lessons. the Baucus plan would leverage Medicare’s ability to play a leading role. For example. these patients incur most health care costs. stakeholders must agree on a common set of performance measures. payers. variation in quality. combined with real-life examples from the private sector. ! ! To promote greater transparency in ways that would be meaningful and reliable to consumers and providers. Moreover.conditions or emotional distress. To access the Medicare data. Yet.37 Medicare’s recent experience with making cost and quality information available online. Price and quality information should be provided together. particularly when care is sought under emergency conditions. Transparency alone is not likely to transform health care. particularly if combined with information on the quality or outcomes of the care. Even for non-urgent elective procedures like LASIK vision-correction surgery. the current price information available for outpatient procedures should be paired with information on quality measures and expanded to other sites of care. provide valuable lessons for making information meaningful. and providers — not patients — are in a better position to demand greater quality and efficiency. all contribute to imperfect market conditions. Patients also may not have the opportunity to choose among hospitals if a referring physician is not on staff at the preferred hospital. Information on the price of a specific health care service provides little value. purchasers. 38 include: ! Information currently available is inadequate. and physicians lack comparative information on the quality of the care they provide or the care provided by physicians to whom they refer their patients. Although progress has been made even in the past two years. Medicare can and should release more information about the price and quality of covered services. The Department of Health and Human Services has started down this path by initiating Charter Value Exchanges in select communities. so that it can be combined with similar data from other payers (such as health plans that serve employers and Medicaid) to build more robust profiles of clinicians’ care that are based on a broad spectrum of their patients. with significant regulation of its use. and inconsistent bundling of services that makes apples-to-apples price comparisons difficult. Knowing the total cost of caring for a condition is more meaningful. These initiatives allow stakeholders in a community to combine their data with Medicare data with the goal of releasing a single set of cost and quality measures for the entire community. Shopping for the best physician or hospital is impractical for very sick patients and patients with chronic conditions. misleading advertising. And providing price information without a clear use could lead to collusion instead of competition. cost and quality information is rarely available to patients. Medicare should also make its data more widely available. 73 .

74 . Better educating workers about the full cost of their health care coverage could encourage them to seek or demand lower premiums. health system toward greater efficiency and increased engagement in health care decision making among consumers. C. along with the taxes withheld from such wages during the calendar year. as done through the Charter Value Exchanges.39 While the prospect of data sharing generates concern among clinicians. Plans would also be encouraged to incorporate this information into pay-forperformance systems. Pennsylvania. This data must be used in ways that build consistency around cost and quality measures. reporting is acceptable and less burdensome for the provider community. Currently. or visits primarily to avoid liability rather than to benefit patients may contribute to unnecessary health care spending.With appropriate privacy protections. MEDICAL MALPRACTICE REFORM Medical malpractice insurance premiums have risen steadily over recent decades. Medicare data can be used to generate more meaningful. But no such requirement exists for the amount an employer pays for health insurance coverage. Some employers voluntarily report the value of the health benefits they provide. This plan also would require health plans offered through the Health Insurance Exchange to provide uniform cost and quality metrics. The Independent Health Coverage Council would work with health plans and purchasers to develop consistent definitions and principles. information about the full cost of employer-provided health care should be transparent to employees. must be given to each employee by January 31 of the succeeding year.40 Some states have seen even more dramatic increases. 43 physicians and other health care providers contend that the current legal environment leads to the practice of defensive medicine. accurate and consistent information across the health system so that. at times increasing an average of 15 percent a year. experienced increases ranging from 26 to 73 percent in 2003. for example.42 and malpractice costs account for less than two percent of health costs. Taken together. Medicare data can be instrumental in promoting greater cost and quality transparency within the health system. As a further step in greater transparency of health care costs. Ordering more tests. procedures. these tools can help drive the U.S. employers must inform employees of the amount of wages paid by the employer. The information. The push for increased transparency highlights the need for greater adoption of health information technology (IT) and evidence-based medicine. however. which in turn could help contain growth in spending. provided on the Form W-2. 41 While the Government Accountability Office has found that access to medical care is not “widely affected” by large premium increases. This plan proposes to invest in health IT and comparative clinical effectiveness research. ultimately. either in an annual statement to their employees or in box 14 of the Form W-2. This plan would require employer health costs to be fully disclosed to all employees.

5 percent. changes made as part of reforming the health care system would affect medical malpractice. Also. The University of Michigan Health System (UMHS) implemented this system in 2002 with astounding results. The Fair and Reliable Medical Justice Act.4 to 0. 46 Alternatives to civil litigation need to be utilized so that administrative costs associated with litigation. introduced in the 109th Congress and again in the current Congress. to pay compensation to any patient injured or harmed as a result of care. The current litigation system does not do a good job of compensating victims of malpractice or of reducing the occurrence of medical malpractice. UMHS had reduced its 75 . The early disclosure model offers health care providers tort liability immunity after an offer. and only two file a lawsuit. and (3) the health court model. 48 This legislation would provide grants to states to create alternatives to current tort litigation in an effort to increase access to recovery for patients with low-dollar value claims and improve satisfaction with claims resolution for patients and provides. in good faith. Of every one hundred Americans injured in an accident. For example. Additionally. improvements in preventive care and care coordination would reduce the likelihood of risky procedures that are a source of malpractice claims. States would have flexibility in developing alternatives to civil litigation. 47 can be reduced.” 44 But helping patients and providers to cooperate rather than participate in time-consuming and expensive legal battles may help to shift America’s health care system away from the costly practice of defensive medicine and toward the best quality care and adherence to standards of care. damages awarded for care necessary as a result of malpractice would be reduced because the cost of care would decrease across the board. CBO estimates that a 25 to 30 percent reduction in malpractice costs “would lower health care costs by only about 0. which account for 60 percent of malpractice premiums.” 45 Yet. while working to limit malpractice insurance premiums.A serious effort at comprehensive health care reform. and the likely effect on health insurance premiums would be comparably small. The compensation would have to include any economic loss to the patient. noneconomic damages (as determined by the state) and reasonable attorney fees. In fact. Malpractice reform could address money and time spent on litigation. (2) the administrative determination of compensation model. and only 30 percent of claims filed result in payments to victims of medical malpractice. while simultaneously allowing credible claims to be compensated fairly and quickly. the large number of malpractice claims filed still overwhelms the legal system. includes ideas for ensuring safe and effective medical care. Reducing malpractice premiums alone would not have a substantial effect on overall health spending. should address medical malpractice. with three specific models outlined in the bill: (1) the early disclosure and compensation model. then. “research typically shows Americans rarely take their disputes to court. as well as improve patient and provider satisfaction with the resolution of complaints or grievances. Three years after the program was established. only ten make a liability claim.

provide incentives to disclose medical errors. Like the legislation. the systems developed by the Department of Defense and the Veterans Health Administration that successfully track such data could serve as models. The second approach. such as early disclosure. The court would be presided over by judges with expertise in health care with the ability to hire outside experts. Data collection is essential to preventing errors by enabling providers to better understand how errors occur. states would also receive assistance to collect data about medical errors. the Baucus plan would call on states to take the opportunity to develop alternatives for resolving conflicts and compensating patients who are the victims of medical errors. Alternatives to litigation. the administrative determination of compensation model.” 50 Unfortunately. the collection of medical error data will increase. rather than participate in a time-consuming and expensive legal battle. under the current system. D. In fact. while continuing to protect the provider and improve patient safety. insurers agree to provide coverage for the range of Medicare benefits that their enrollees need. data collection remains limited because of the lack of incentives. By increasing communication about medical errors. In return. The Fair and Reliable Medical Justice Act serves as a foundation for an important element of this health reform plan. Based on these classes. An appeals process would also be established to review decisions made by the board. The program allowing private insurers to serve Medicare beneficiaries is called Medicare Advantage (MA). a specialized health court would be established. The judges’ decisions regarding compensation would be binding but subject to an appeals process. by more than half. as well as the time it took to resolve the suits. which would help keep patients better informed and create an opportunity for providers to learn from each other. In addition to receiving Federal assistance to establish an alternative model. calls for the establishment of an administrative board to designate classes of avoidable injuries. PRIVATE INSURANCE PLANS IN MEDICARE Medicare beneficiaries can obtain benefits through the traditional fee-for-service program or by enrolling in private insurance plans that are approved to offer Medicare benefits. 49 That is one of the goals of the early disclosure model. “Accurate information also provides a baseline measurement for further assessment of the effectiveness of the changes made. the board would determine the level of compensation awarded to the patient. and doing so in a non-adversarial setting. This plan would help achieve that important objective. Private insurance plans are paid a monthly amount by the government for each beneficiary whom they enroll. Patients and providers should have the chance to cooperate. leading to improved patient safety. 76 . Under the third alternative. Fostering communication about medical errors and awarding appropriate compensation in a non-adversarial setting are the hallmarks of this approach.annual litigation costs by $2 million and reduced the number of lawsuits.

and lower copayments. MIPPA has already directed MedPAC to compare Medicare and private insurance costs and develop alternative ways of setting MA payments. 54. Even so. One is to set MA payments on par with traditional Medicare in every county in the country. Medicare costs can be low in some areas of the country and extraordinarily high in others. dental coverage. Enacted in July 2008. reducing MA payments in high-use areas and increasing payments in low-use areas. MIPPA took modest steps to reduce overpayments to private plans beginning in 2010. Comptroller General estimate the administrative costs of private plans serving Medicare beneficiaries are in the range of 11 to 13 percent. MA payments should be reformed to achieve neutrality with traditional Medicare at the national level. Moreover. 52 The health insurance industry defends these payments by pointing to extra benefits that lowincome MA enrollees receive relative to traditional Medicare. But delivering these extra benefits through Medicare Advantage is not as efficient as delivering them directly through traditional Medicare. all Medicare Advantage payments are based on the same rates — whether or not the plan uses advanced methods of coordinating and delivering care. Simply setting MA payments equal to traditional Medicare could maintain overpayments in some areas and create severe underpayments in other areas relative to insurers’ costs. 56 . CBO and the U. However. Not all Medicare Advantage plans are designed to integrate or coordinate care across the spectrum of providers. and not all use electronic medical records to better manage care. 53 Private insurers’ higher overhead and added administrative costs — including profits — mean that fewer benefits are passed along to beneficiaries. and the insurance industry contends that private plans better coordinate care and improve quality oversight in the Medicare program. 55 . There is no solid evidence that supports this assertion. Congress must act to level the playing field between traditional Medicare and Medicare Advantage payments and the Baucus plan would do so.S. 77 . There are a number of ways to complete this. 57 The majority of Medicare beneficiaries have multiple chronic conditions that could be treated more effectively through interdisciplinary care teams.51 Current estimates indicate that these excess payments will total $62 billion over the next five years. MedPAC reports that MA plans are less efficient at delivering Medicare Part A and B benefits than the traditional fee-for-service program. MedPAC has called for Medicare Advantage payments to be set equal to traditional Medicare. and $169 billion over the next ten years.The Medicare Payment Advisory Commission (MedPAC) estimates that Medicare Advantage (MA) insurers are currently paid 13 percent more than the amount Medicare would pay if the same beneficiaries remained in the traditional fee-for-service program. compared to estimates of 2 to 5 percent for the traditional Medicare program. 58 One option is to base MA payments on a blend of local and national Medicare costs. But the benchmarks against which MA plans are paid should have more to do with plans’ own costs. The Baucus plan would seek to better understand how insurers’ costs differ by region of the country in designing new policies to eliminate the remaining excess spending in the Medicare Advantage program. like eyeglasses.

costeffective care to beneficiaries with the highest risk of complications and spending. At a minimum. insurers’ payments could be based on a blend of their own costs per enrollee with Medicare’s costs per beneficiary at the local or national level. Congress should consider paying Medicare Advantage plans for delivering coordinated. In addition to determining and adopting mechanisms to reduce overpayments. and they negotiate with drug manufacturers for discounted prices. in order to gauge the performance of the prescription drug program. Care for these individuals is most often provided by informal caregivers ! family or friends ! who provide care with little or no compensation.60 78 . LONG-TERM CARE SERVICES AND SUPPORTS Long-term care differs from other types of health care in that the goal is not to cure an illness. Finally. If MA plans do not meet these criteria. Insurers would continue to negotiate prices on behalf of the other beneficiaries who enroll in their plans. their payments would be reduced over a defined period of time. which was switched from Medicaid to the Medicare drug benefit in 2006. E. relative to Medicaid and other sectors. working-age adults with inherited or acquired conditions ! many of whom are able to work ! and the elderly with chronic illnesses. but to provide patients with the highest level of functioning possible and improve quality of life. Congress should repeal the “premium support” demonstration included in the MMA of 2003 because it unfairly ties Part B premiums to how much insurers’ costs differ from traditional Medicare. More than 50 million informal caregivers currently tend to the needs of individuals and family members of all ages. Insurers in the program contract with pharmacies to dispense drugs. Recent studies suggest that the price breaks negotiated by Medicare prescription drug plans are not as high as those legislated through the Medicaid drug rebate program. paying MA plans for such care could increase the quality of care provided to beneficiaries in MA plans and could possibly lower Medicare spending by reducing complications from chronic illnesses. 59 This means Medicare pays more than Medicaid for the prescriptions of the dual-eligible population. Congress must seek ways to eliminate excess spending that results from differences in the ways MA plans and traditional Medicare code diagnoses in patients’ medical records. Competitive bidding is another option that could be considered or tested for MA plans.Alternatively. The need for long-term care affects individuals of all ages: children born with disabling conditions. One option is to pay MA plans more if they meet medical home criteria defined by NCQA and specific performance measures. As with proposals involving traditional fee-for-service Medicare. Congress should consider extending the Medicaid price discounts to the drugs consumed by the dual-eligible population in the Medicare program in order to maintain the previous price breaks. Current law allows insurers to use their own formularies to negotiate prices with manufacturers and to manage the quality of the drug benefit. Private insurance plans also deliver Medicare’s prescription drug benefit and are paid by the government for each beneficiary they enroll. Congress should also be apprised of Medicare’s price breaks in the aggregate.

Medicaid alone accounts for as much as 49 percent of long-term care spending ! most of which was provided in an institutional setting. 65 States and the Federal government are the largest payers of these services. and does not encourage the delivery of high-quality care. 61 and about 1. Without financial assistance from Medicaid or private insurance.1 million children living in the community have long-term care needs.000 Medicaid beneficiaries for HCBS waiver services. about 9. by 2005 there was a waiting list of more than 207. and covered services for Medicare and Medicaid programs often lead to uncoordinated care and a fractured delivery system for individuals needing long-term care and assistance. 68 Home or community-based care is more cost-effective. 64 The current system for delivering long-term care is expensive. but beneficiaries must have a significant level of disability to qualify. HCBS options are generally provided through Medicaid waivers. 67 Divergent characteristics. 69 and most patients would prefer care in these settings to institutional care. eligibility requirements. And Medicare benefits are not coordinated with Medicaid ! even though the Federal government bears much of the cost for these programs. The cost for nursing home care is extremely expensive. 62. Congress has considered innovative.71 In recent years. national spending on long-term care was estimated to be nearly $207 billon. program goals.000 per year on average. alternative approaches to institutional care. Home and Community Based Services (HCBS) have become a popular way to support individuals who want to remain in their own homes and communities. five percent of the adult population. Congress has taken some steps to reform the long-term care system.4 million adults. inefficient. These options include providing states with new tools and incentives to make them more available to more beneficiaries and exploring options to better coordinate care for dualeligible individuals under Medicare and Medicaid. 72 Despite this progress.Today. conflicting incentives may increase costs and diminish the quality of care. 74 And even those who qualify often have difficulty accessing care. 66 Medicare covers a limited amount of post-acute care in skilled nursing facilities and in the home for certain beneficiaries. the program maintains a strong bias toward institutional care due to payment and access rules. 70. The plan would also encourage states to explore new options that improve access to longterm care services and supports to prevent the progression of disability and to help 79 . most people simply cannot afford extended nursing home care. Likewise. The Deficit Reduction Act of 2005 provided new flexibility for states to offer home and community-based long-term care services in Medicaid. 73 but reform has remained elusive due to a lack of consensus on both policy and financing. In 2005. receive long-term care services in the community or in institutions.63 An estimated 69 percent of people turning 65 years old will need some form of long-term care assistance before they die.75 The Baucus plan would consider options to further expand access to HCBS in Medicaid. about $70.

such as the Green House model. Because almost 25 percent of deaths occur in long-term care settings. 78 Congress should explore ways to restructure the current tax incentives to encourage more efficient spending on health and to target our tax dollars more effectively and fairly. F. This plan would pilot new models of institutional care. Achieving ultimate success will require both public and private solutions. In 2007. exploring inefficiencies and conflicting incentives within Medicare and Medicaid could improve the quality of care and decrease costs. Others may include investment in aging and disability resource centers (ADRCs) and programs that limit secondary disabilities by promoting nutrition. exercise and fall prevention. Family caregivers cannot be expected to fill all the gaps in our current system. One concept that has been put forward to address these shortages is providing educational and training opportunities to adults who are participating in the Temporary Assistance for Needy Families (TANF) program. this plan incorporates several options to reform the delivery system to provide better care coordination and chronic disease management. By intervening earlier with targeted assistance. states can help prevent or delay costly institutionalizations and provide a more patientcentered benefit. an employee’s share of the 80 . ways to provide the best quality care at the end of life should be considered.individuals remain in their own homes. who represent a pool of more than 900. however. Institutional or residential care is appropriate in some cases. fundamental reform of the long-term care system will be necessary. Current tax law favors individuals who receive health insurance through their employer. we should also explore policies that make quality long-term care insurance products more affordable and accessible. 77 In the long run. it should be a choice for individuals and families. the total value in foregone revenue for health tax benefits was more than $300 billion.000 individuals who could provide an important resource in meeting our nation’s workforce needs. With this help. families and caregivers in navigating the complex and fractured long-term care services and supports system. 76 that has shown promise for both improving the quality of life and care in these settings. The plan would provide assistance to individuals. Providing support for family caregivers should also be an important part of any reform plan. Long-term care reform should include options to recruit. In addition. In addition. train. individuals in need of care and their families would be better able to make the most appropriate care choice. In addition. TAX INCENTIVES FOR HEALTH COVERAGE Tax breaks for health insurance premiums and other health expenses are among the largest tax expenditures in the Federal budget. The employer’s contribution to health care and premiums is excluded from an individual’s income for both income and payroll tax purposes. and retain a robust workforce that can ensure high-quality care. While we consider options to improve the care in our public programs.

Second. more valuable to taxpayers who are subject to higher marginal rates. up to $2. An employee’s pre-tax contributions for health insurance or medical expenses through a Flexible Spending Account (FSA) are excluded from income and therefore not subject to tax. Some have proposed eliminating the current tax exclusion for employer-based health insurance premiums and converting the benefit to a tax deduction or tax credit. they give larger subsidies to higher-income workers. The unlimited tax benefit for the exclusion encourages workers to purchase more expensive coverage to avoid co-payments and deductibles. because it lowers the cost of buying insurance through an employer. For individuals who qualify to contribute to a Health Savings Account (HSA) by enrolling in a high-deductible health plan. they argue that the incentives are inequitable because the amount of tax benefit received differs based on how health coverage is received: those covered through their employers are rewarded with the largest tax breaks. This is less favorable treatment than employerprovided health insurance. for the most part.84 This approach goes too far because it could cause widespread disruption in employer-based 81 . other incentives to purchase health care and health coverage are available through the tax code.5 percent of their adjusted gross income and they itemize their deductions. those who purchase health insurance through the individual market. employees who have different health insurance options from which to choose may spend health care dollars unnecessarily to simply buy the most expensive plan they can afford. 83. Most economists argue there are problems with the current set of tax incentives for heath care. or none at all.800 for families are deductible in tax year 2008. 79. Self-employed individuals can deduct the cost of health insurance premiums for themselves. 82 First. their spouse. As such. In addition to the employee exclusion. This lower cost sharing can lead to higher use of services that are considered non-urgent and discretionary. while those who must obtain coverage on the individual market receive a much smaller tax break. instead of looking at the amount of coverage that they actually need. but they must pay self-employment tax on these amounts. There is no limit on the amount of premiums that can be excluded from wages. The tax exclusion fosters employment-based health coverage. instead of to the lower-income Americans who need more help buying insurance.900 of those contributions for individuals and $5. 80 . And finally. many economists argue that the unlimited employee tax exclusion leads to increased health spending. Current incentives are also regressive because they are. Additionally. This means workers are not taxed on the value of their health premiums.premium cost can be excluded if it is made through what is called a cafeteria benefit plan. even though the premiums are part of the worker’s total compensation package. There are no limits on the amount of wages an employee can contribute on a pre-tax basis to an FSA. and those who have out-of-pocket medical expenses. may deduct their spending to the extent that it exceeds 7. 81 . and their dependents for income tax purposes.

Current tax policies for health coverage must promote efficient uses of care and distribute subsidies fairly. June Gibbs Brown. We must also balance any tax reforms in this area with the desire of Americans to maintain employer-based health coverage. for example. 9 Centers for Medicare and Medicaid Services. http://www. New tax incentives for small businesses and low-income individuals were discussed earlier in this plan. “New Analysis: Congressional Health Care Proposals Would Cover All Uninsured. “2007 Improper Medicare FFS Payments. 3. “Health Care Fraud Abuse Control Program Annual Report for FY 2006”. If they purchase health plans with greater benefits. More targeted reforms of the exclusion might make the incentive more equitable and reduce spending in the health care system.lewin.pdf. Reform should not endanger coverage for the more than half of all Americans who now have health insurance through an employer. Employees could be allowed to exclude.health benefits. Health Spending by Up to $61 Billion.gov/CERT/CR/itemdetail. 85 Tax incentives can be an effective way of subsidizing the cost of health insurance.S.S. 1 Centers for Medicare and Medicaid Services.cms. Orszag. The Commonwealth Fund.asp. (2007). April 22. 82 . One option for reform is to cap the amount of health care premiums that can be excluded from employee wages for income and payroll tax purposes.hhs. 5 4 3 2 John Sheils and Randall Haught. as an alternative.” CMS.” GAO. the difference between a more generous plan and the cap could be subject to Federal and state income taxes. House of Representatives.asp?filterType=none&filterByDID=99&sortByDID=1&sortOrder=descending&itemID=CMS1205324&intNumPerPage=10. Senate. Peter R.and medium-cost areas were reduced to the level in low-cost areas. Eugene Steuerle and Randall R Bovbjerg. The CBO estimate is based on an estimate of spending variation in Medicare and the costs that could be saved — without any negative effect on health outcomes — if high. that potential savings in Medicare is $129 billion. (1992) http://archive. (2007). 6 Government Accountability Office. no. the exclusion could be available on a sliding scale based on income: people with low wages could be allowed to exclude 100 percent of the premiums offered through their employers.pdf. (2003). C. “Health Insurance: Vulnerable Payers Lose Billions to Fraud and Abuse. In 2007. with the percent allowed phasing down or out with income. and Reduce Total U. HHS & DOJ.” (Testimony before the Committee on the Budget. July 16. “Cost and Coverage Analysis of Ten Proposals to Expand Health Insurance Coverage.hhs.S. “National Health Expenditure Data.gao. 7 8 The Department of Health and Human Services and Department of Justice.” Health Affairs 27. (Testimony before the Senate Appropriations Committee. “Health And Budget Reform As Handmaidens. U.” The Commonwealth Fund. 1994). (2008): 633-644. U.” The Lewin Group. This could be done by limiting or capping the tax exclusion based on the value of health benefits or. 2008).gov/t2pbat6/146547.gov/NationalHealthExpendData/02_NationalHealthAccountsHistorical. Alternatively. http://oig.gov/publications/docs/hcfac/hcfacreport2006. (2007).cms. based on a person’s income — or both.” CMS.hhs. http://www. up to a specific dollar amount in health benefits from their wages each year.com/content/publications/CoveringAmerica. “Increasing the Value of Federal Spending on Health Care. http://www.pdf.

gov/oei/reports/oei-09-04-00420. (1998). et al. Medicare Payment Advisory Commission..2002.” HHS-OIG.phrma. “Aligning Incentives: The Case for Delivery System Reform. (2006). U.” (2007). Julie Donohue et al. no. Eric Campbell.S. http://www.7: 673-681. 2007.pdf. 17: 1742. September 16.org/files/PhRMA%20Code. 19 20 18 American Medical Association. 13 12 11 10 ExpectMore. 18: 18851890. “Health Care Fraud and Abuse Control. http://www.” New England Journal of Medicine 357.” New England Journal of Medicine 356.cahi.org/cahi_contents/resources/pdf/CAHIPollResults042806. 83 .” (2004). Office of the Inspector General. no. “Memorandum: Results from Nationwide Poll on Price Transparency. “Report to the Congress: Reforming the Delivery System. http://www. Eric Campbell.” http://www. 32 The Council for Affordable Health Insurance. “Draft Background Paper on Hospital Cost and Price Transparency: Usable.” (2008): 153. “Report to the Congress: Physician-Owned Specialty Hospitals.” (2005): 11.” AMA.” (2004). 15 16 17 14 Ibid. Medicare Payment Advisory Commission. HHS-OIG.” (Testimony before the Senate Committee on Finance. 26 27 25 24 23 22 21 Ibid.hhs. Report on Medicare Compliance. S. National Quality Forum. “Medicare Home Oxygen Equipment: Cost and Servicing. 2008). “The Prevalence of Physician Self-Referral Arrangements After Stark II: Evidence From Advancing Diagnostic Imaging. “OCIG Official Unveils FivePoint Strategy to Help the Next Administration Combat Fraud”.” Health Affairs 26. “Report to the Congress: Reforming the Delivery System.. 3 (2007): 415.pdf: 3. The Physician Payments Sunshine Act of 2007. Jean Mitchell.2029.Department of Health and Human Services.” (2006). no. Orthotics. David Blumenthal. no. Ibid.gov. 30 31 Ibid.” New England Journal of Medicine 351. “A National Survey of Physician-Industry Relationships.gov/omb/expectmore/detail/10000292. Department of Health and Human Services. Prosthetics. 28 29 Ibid. Medicare Payment Advisory Commission. Senate. and Supplies. (2008): 1-3.” (2008): 154-155. “Doctors and Drug Companies. September 6. “Gifts to Physicians from Industry.html#performanceMeasures. “Report to the Congress: Physician-Owned Specialty Hospitals. “A Decade of Direct-to-Consumer Advertising of Prescription Drugs. Office of the Inspector General.” (2005): 12. Pharmaceutical Research and Manufacturers of America.qualityforum. “PhRMA Code on Interactions with Health Care Professionals.whitehouse. introduced by Senators Chuck Grassley and Herb Kohl. Medicare Payment Advisory Commission.pdf. Department of Health and Human Services. http://oig. Audience-Specific Information on Hospital Costs and Prices.org/pdf/projects/transparency/txpricetranspforcommentJun12.pdf. “Final Report to Congress: Evaluation of Medicare’s Competitive Bidding Demonstration for Durable Medical Equipment.

Glenn M. 109th Congress.. Hackbarth. “Making Patient Safety the Centerpiece of Medical Liability Reform. April 11. 43 44 45 42 Congressional Budget Office. http://www. “Limiting Tort Liability for Medical Malpractice. http://findarticles. http://www. (2006). “Designing a Premium Support System for Medicare.S. introduced by Senator Mike Enzi and Senator Max Baucus.html. 2007. 19.w4.qualityforum. http://healthcaredisclosure. 354. 54 Congressional Budget Office. David M. 2006).” CBO. Thomas Burke.” NQF.” (Testimony before the Subcommittee on Health of the House Committee on Energy and Commerce. 10.S. no. U. Executive Order 13410.” Health Affairs (2004): 4-25 (published online 21 January 2004. (2006): 2024-2033. 36 37 35 34 Ibid.1481. Senate. (accessed November 4. March 15. The Fair and Reliable Medical Justice Act.. Lawsuits. (2007). This estimate is for plan year 2008 and does not take into account the effect of MIPPA of 2008.” (2007). Hillary Clinton and Barack Obama. “An Examination of Medicare Advantage. 2007). “Report to the Congress: Medicare Payment Policy. “Implications of Rising Premiums on Access to Health Care.pdf. and Compensation Payments in Medical Malpractice Litigation. 51 52 53 Medicare Payment Advisory Commission.com/p/articles/mi_m0FSL/is_/ai_n27000693.33 Consumer-Purchaser Disclosure Project. (2006): 1-56. 50 49 48 47 46 Joanne Stow.pdf.” University of California Press.” Health Affairs (2004): 4-25 (published online 21 January 2004. 40 41 39 38 Congressional Budget Office. (2004): 3. May 24.w4. introduced by Senators Grassley and Baucus. S. “Using Medical-Error Reporting to Drive Patient Safety Efforts.20) S. introduced by Senator Max Baucus and Senator Michael Enzi. (2004): 6. (Testimony before the Subcommittee on Health of the House Committee on Ways and Means.” (2008). House of Representatives. “Claims.S.” CBO. House of Representatives.whitehouse. Ibid.” New England Journal of Medicine.gov/news/releases/2006/08/20060822-2. S. “Building Health Care Value By Providing Consumers With Better Information To Make Good Decisions. “Transparency in Health Care: the Time Has Come.” The New England Journal of Medicine. “The Medical Malpractice ‘Crisis’: Recent Trends and the Impact of State Tort Reforms. Thorpe.1377/hlthaff. 2006). and Legal Rights: The Battle Over Litigation in American Society. Studdert et al. U.” CBO. 84 . 110th Congress. and act that would establish a framework for the release and use of Medicare data. 1507. Sara Collins.” GAO. U.org/docs/files/DisclosureFactSheetsConsumerTools10-10-07. Kenneth E. July 18.” AORN Journal. (2004): 4.1337. Kenneth E. Thorpe. Tu. Ha T. The Fair and Reliable Medical Justice Act . 2008). National Quality Forum. (2009): preface.org/pdf/projects/transparency/txpricetranspforcommentJun12. 10. “The Medical Malpractice ‘Crisis’: Recent Trends and the Impact of State Tort Reforms. no. “Limiting Tort Liability for Medical Malpractice. “Promoting Quality and Efficient Health Care in Federal Government Administered or Sponsored Health Care Programs. “Lawyers. Ibid. Errors.” (Testimony before the Senate Committee on Finance. AudienceSpecific Information on Hospital Costs and Prices. “Background Paper on Hospital Cost and Price Transparency: Usable.1377/hlthaff.” (2006). 13. 21 (2006): 2208. 354.20) Government Accountability Office.

Centers for Medicare and Medicaid Services, “National Health Expenditure Data, Tables 11 and 12,” CMS, (2008) http://www.cms.hhs.gov/NationalHealthExpendData/downloads/tables.pdf.
56

55

Merrill Mathews, “Medicare’s Hidden Administrative Costs: A Comparison of Medicare and the Private Sector,” Council for Affordable Health Insurance, (2006): 1-16.

Government Accountability Office, “Medicare Advantage Organizations: Actual Expenses and Profits Compared to Projections for 2005,” GAO, (2008): 1-14. Robert A. Berenson, “From Politics To Policy: A New Payment Approach In Medicare Advantage,” Health Affairs, (2008): 156, (published online 4 March, 2008; 10.1377/hlthaff.27.2.w156). Richard G. Frank and Joseph P. Newhouse, “Mending the Medicare Prescription Drug Benefit: Improving Consumer Choices and Restructuring Purchasing,” The Brookings Institute, (2008), http://www.brookings.edu/papers/2007/04useconomics_frank.aspx. The Department of Health and Human Services, “Informal Caregiving: Compassion in Action,” HHS, (1998), http://aspe.hhs.gov/daltcp/Reports/carebro2.pdf.
61 60 59 58

57

S. Rogers and H. Komisar, “Who Needs Long-Term Care? Fact Sheet, Long-Term Care Financing Project,” Georgetown University Press, (2003). Most but not all individuals were over 65 years of age, 6.3 million; the remaining 3.7 million were younger

Achintya N. Dey, Jeannine. S. Schiller, and Diane A. Tai, “Summary Health Statistics for Children: National Health Interview Survey, 2002,” National Center for Health Statistics, Vital and Health Statistics, 10, no. 221, (2004).
63 64

62

Forum on Child and Family Statistics, http://www.childstats.gov/.

Peter Kemper, Harriet L. Komisar, and Lisa Alecxih, “Long Term Care Over An Uncertain Future: What Can Current Retirees Expect?” Inquiry, 42, (2005-06): 335-350. Georgetown University Long-Term Care Financing Project, “National Spending for Long-Term Care,” Georgetown University, (2007). Ibid.

65

66 67

David Grabowski, “Medicare and Medicaid: Conflicting Incentives for Long-Term Care,” Milbank Quarterly, 85, no. 4, (2007). MetLife, “The MetLife Market Survey of Nursing Home and Home Care Costs,” MetLife, (2006), http://www.metlife.com/WPSAssets/1875695828115945575V1F2006NHHCMarketSurvey.pdf. In 2006, annual costs for 24 hour care in a nursing home ranged from about $67,000 for a semi-private room to about $75,000 for a private room, or from $183 a day to $206 a day for a private room. Carol O’Shaughnessy, Julie Stone, Thomas Gabe, Laura B. Shrestha “Long-Term Care: Consumers, Providers, Payers, and Programs,” CRS Report for Congress, (2007). Enid Kassner, “Medicaid and Long-Term Services and Supports for Older People: Fact Sheet,” AARP Public Policy Institute, (2005). Nancy A. Miller, Charlene Harrington, Elizabeth Goldstein, “Access to Community-Based Long-term Care: Medicaid’s Role,” Journal of Aging and Health, 14, no. 1, (2002): 138-59.
72 73 71 70 69 68

Public Law 109-171

S.1758, The Community Living Assistance Services and Supports Act or CLASS Act, introduced by Senator Edward Kennedy, July 2007; S.3779, the Community Choice Act of 2007, introduced by Senator Tom Harkin, March 2007; S.3227, The Empowered at Home Act of 2008, introduced by Senator John Kerry and Senator Charles Grassley, July 2008.
74

Cynthia Shirk, “Rebalancing Long-Term Care: The Role of the Medicaid HCBS Waiver Program,” George Washington University National Health Policy Forum, (2006). Individuals must meet a level of functional need that qualifies them for a nursing home.

85

75

Ibid.

76 The Green House Model creates a small community for a group of elders and staff. They differ from traditional skilled nursing homes and assisted living facilities, by altering size, interior design, staffing patterns, and methods of delivering skilled professional services. Its primary purpose is to serve as a place where elders can receive assistance and support with activities of daily living and clinical care, without the assistance and care becoming the focus of their existence. Developed by Dr. William Thomas and rooted in the tradition of the Eden Alternative, it is a model for cultural change within nursing facilities, http://www.ncbcapitalimpact.org/default.aspx?id=148. 77

Pedro L. Gozalo and Susan C. Miller, “Hospice Enrollment and Evaluation of its Causal Effect on Hospitalization of Dying Nursing Home Patients,” Health Services Research, 42, (2007): 2.

78

Edward D. Kleinbard, “Tax Expenditures for Health Care,” (Testimony before the Senate Committee on Finance, U.S. Senate, July 31, 2008). For a comprehensive list of current health tax benefits for health expenses, see Appendix A of this testimony.

Many economists in the public and private sector have analyzed and commented on problems with current tax health incentives. A few examples are: Jonathan Gruber, “Subsidies to Employee Health Insurance Premiums and the Health Insurance Market,” National Bureau of Economics Research, (2007), http://papers.nber.org/papers/w9567.pdf. Kate Baicker, “Making Health Insurance More Affordable Through Health Insurance Finance Reform,” Business Economics, 42, no. 3, (2007), https://commerce.metapress.com/content/f67110210634770k/resourcesecured/?target=fulltext.pdf&sid=05mdup55rn1nd055gl0gfx55&sh=www.springerlink.com.
81 80

79

Jason Furman, “Health Reform Through Tax Reform: A Primer,” Health Affairs, 27, no. 3, (2008): 622632. Edward D. Kleinbard, “Tax Expenditures for Health Care,” (Testimony before the Senate Committee on Finance, U.S. Senate, July 31, 2008). S.334, The Healthy Americans Act, introduced by Senator Wyden, January 18, 2007.

82

83 84

Budget of the United States Government, Fiscal Year 2009, submitted by President George W. Bush to the U.S. Congress on February 4, 2008.
85

Certain data collection issues would need to be addressed in order to implement an income cap.

86

CONCLUSION
The case for health reform is undeniable. Improving the U.S. health system is one of the most important challenges we face as a nation, and the inability to achieve comprehensive health reform will undermine any efforts to secure economic recovery. Health reform is an essential part of restoring America’s overall economy and maintaining our competitiveness at home and around the world. Health care reform is also necessary to protect the finances of our working families. Nearly 46 million Americans lack health coverage and another 25 million are underinsured. Rising health care costs and mounting medical bills have become a pocketbook issue for too many families, becoming one of the biggest factors in personal bankruptcy filings. Each of the key challenges facing our health care system ! lack of access to care, the cost of care, and the need for better-quality care ! must be addressed in concert. Covering millions of uninsured through a broken health system will be fiscally unsustainable. Attempting to address the inefficiencies plaguing our system and the perverse incentives in the delivery system without covering the uninsured will fail to alleviate the burden of uncompensated care and cost shifting. The time for incremental improvements has passed; health care reform must be comprehensive in scope. This Call to Action provides a starting point for the upcoming health care reform debate. It is a vision and not a legislative proposal. It is comprehensive but not an exhaustive exploration of every health care issue that can or should be considered. As a first step toward consideration of health care reform, Congressional leaders and the public must understand that reform will likely require an initial investment. In the short term, health care reform will cost more than can be achieved in savings from all the quality improvement initiatives and financing changes. But these changes will improve the quality of the health care that Americans receive and reduce the cost of that health care, ultimately putting our system on a more sustainable path. More importantly, the costs of inaction, both in human and financial terms, are greater than any initial outlays. The next crucial step is a constructive dialog on policy priorities among policymakers, stakeholders, health policy thought leaders and the public. Consensus will be difficult to achieve, but common ground from which to build can and must be found.

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Education.APPENDIX LIST OF ABBREVIATIONS AAMC – American Association of Medical Colleges ABIM – American Board of Internal Medicine ACE – Acute Care Episode ACO – Accountable Care Organizations AFDC – Aid to Families with Dependent Children AHRQ – Agency for Health Care Research and Quality AMA – American Medical Association ARDC – Aging and Disability Resource Center BBA – Balanced Budget Act of 1997 CBO – Congressional Budget Office CDC – Centers for Disease Control and Prevention CHIP – State Children’s Health Insurance Program CMS – Centers for Medicare and Medicaid Services COPD – Chronic Obstructive Pulmonary Disease EHR – Electronic Health Record FEHBP – Federal Employees Health Benefit Program FMAP – Federal Medical Assistance Percentage FPL – Federal Poverty Level FQHC – Federally Qualified Health Center FSA – Flexible Spending Account GAO – Government Accountability Office GDP – Gross Domestic Product GME – Graduate Medical Education HCBS – Home and Community Based Services HCFAC – Health Care Fraud and Abuse Control HELP – Senate Committee on Health. and Pensions HHS – Department of Health and Human Services HIT – Health Information Technology HQID – Hospital Quality Incentive Demonstration HRSA – Health Resources and Services Administration 88 . Labor.

HSA – Health Savings Account IHS – Indian Health Services IME – Indirect Medical Education IOM – Institute of Medicine IRS – Internal Revenue Service MA – Medicare Advantage MedPAC – Medicare Payment Advisory Commission MIPPA – Medicare Improvements for Patients and Providers Act of 2008 MRI – Magnetic Resonance Imaging NCQA – National Committee for Quality Assurance NHCS – National Health Care Survey NHIS – National Health Interview Survey NIH – National Institutes of Health NQF – National Quality Forum OASIS – Outcome and Assessment Information Set OIG – Office of the Inspector General OMB – Office of Management and Budget PGP – Physician Group Practice PhRMA – Pharmaceutical Research and Manufacturers of America PHSA – Public Health Service Act PQRI – Physician Quality Reporting Initiative RHC – Rural Health Center RUC – Relative Value Update Committee SGR – Sustainable Growth Rate SSDI – Social Security Disability Insurance SSI – Social Security Income TANF – Temporary Assistance for Needy Families UMHS – University of Michigan Health System VBP – Value Based Purchasing 89 .

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