Nothing much happened last week other than behind-the-scenes discussions about the remaining controversies surrounding HR 3590, Sen. Reid’s health reform bill (he used a House vehicle to create his 2,000-page proposal, which is why it has an HR designation). The controversies of significance are:

• The public option. Sen. Lieberman (I-Ct.) won’t vote for any bill if any version of the public option is in there; Sen. Snowe (R-Maine) wants to see a trigger approach if it exists in the bill; Sens. Ben Nelson (D-Neb.), Mary Landrieu (D-La.) and Blanche Lincoln (D-Ark.) are somewhat queasy about this issue, as well. The only Republican who might agree to any version of the public option appears to Sen. Snowe.
  
  
• Funding reform. The Senate’s (I think smarter) concept of taxing “Cadillac” insurance plans remains very controversial with the House Democrats. Because labor doesn’t like it! Most senators seem comfortable with their approach, but organized labor is getting to some of them to continue to raise the threshold for what defines a taxable Cadillac. Reid has already compromised up to anything that exceeds $8,000 a year for an individual or $23,000 a year for a family. Except for the very pricey insurance that automakers and others have been saddled with, almost nobody else in the professional or employment world would be buying coverage this expensive. What is amazing is that CBO still thinks a lot of money can be raised by taxing excess coverage over these thresholds. It may be that the Senate will do a little of this kind of taxing, and the House will succeed in getting a little of their version of how to pay for reform in taxing high-income earners directly.
  
  
• Abortion. This controversy should not be part of a health reform bill, but it is. I think this is going to be relatively easily resolved in the end.
  
  
• Premium differential between young and older beneficiaries. AARP and the House bill limit the differential between young and older Medicare beneficiaries to a ratio of 1:2. This means younger people would be charged no less than half the average of what someone age 60 – 65 would have to pay. The essence here is that this kind of a differential causes the younger patient to subsidize the older beneficiary by paying a higher premium. The actual differential in costs is closer to 1:4 or 1:5, and the Senate is concerned that younger people will opt out of coverage if the differential is 1:2.
  
  
• Penalties for opting out of the individual mandate: A $750 tax penalty for not buying insurance is not a great incentive to comply when coverage will likely cost $4,000-5,000 for an individual. Insurers want the penalty higher in exchange for the reforms they face in the bill. I’m sure ER physicians do too -- as will we.
  
  
• Independent Medicare Advisory Commission: Having 5 people decide how to implement cost controls could be scary, depending on whom these people are! And Congress isn’t likely to want to relinquish their power to such a body either…

AMA endorsed the House Bill, but is taking a more discerning view on HR 3590 (Reid’s bill), by identifying provisions they like and those they don’t. This is the approach ACC is taking also. But Florida Medical Association and several other state societies have departed from AMA to fully oppose both the House and the Senate bills on various bases. They won’t be at the table to discuss amendments -- the profession needs to stay involved I feel.

The ACC unfortunately has to fight the Medicare Rule issue as our first priority at this point, but we will be weighing in on HR 3590. The quality of care provisions are much improved over the previous bills -- there are opportunities for ACC in this legislation to seriously consider if we could only get beyond the current Medicare dysfunctionality.

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