A Billion More Reasons to be Disappointed in this Congress

It was good news when Congress recently agreed on a budget for the first time in forever.  It was the product of compromise, and everyone expected to give at least a little. 

But when the details came out last week, it turned out that some had to give more than others.  And the ones who probably gave up the most were the people who have saved the greatest number of lives over the past century – the public health and prevention community.

Last week, the House introduced the FY2014 Omnibus Labor, Health, Human Services, and Education bill – one of twelve appropriations bills that will implement the FY2014 budget.  As the bill summary noted, the legislation includes $156.8 billion in discretionary federal spending for all these important areas combined. That is a big number, and comes to around $500 per person.  By comparison, Defense– which is often considered to be the other “big” area of discretionary spending – will get around $1500 per person.

But the disappointing number wasn’t the bottom line, which is $100 million below the FY2013 level.

It was that – to get to the bottom line – Congress has proposed to cut $1 billion from already-promised public health and prevention funding.

When the Affordable Care Act was passed in 2010, it had a price tag of around $1 trillion over ten years.  This wasn’t all new spending.  We were going to spend at least that much on health care programs whether the law passed or not.  What ACA did was to re-structure that spending.

Historically, public health and prevention have gotten about 3 percent of our health dollars.  And if ACA had continued to provide that share, then $30 billion would have been dedicated to public health and prevention.

But when the dust settled in 2010, the new Prevention Fund (which was once targeted for as much as $80 billion) was promised only $15 billion, or an average of $1.5 billion per year for ten years.  And even this more modest amount was described by Senator Tom Coburn (a physician) as “a slush fund” within two weeks of its passage. 

Congress has hacked away at this fund ever since.  Two years ago, it slashed $5 billion from it.  As I wrote at the time, this represented 6 percent of total public health spending in 2010, and would cost us over 13,000 lives.

This was beyond disappointing for anyone who cares as much about the health of the population as he or she does about health care.

But it did not stop Congress was disappointing us again this year.  Or from using some of the same hypocritical reasons for cutting prevention programs today as it has in the past.

The bill summary claims that the legislation “seeks to focus tax dollars on programs that are critical to the health and well-being of Americans, including disease prevention and research programs.”  But it appropriates a total of only $160 million of the bill’s $156.8 billion to the Prevention Block Grant.

That represents just one dollar for prevention block grants for every one thousand dollars of omnibus bill spending.

And just two sentences later, it announces that it will reduce “the Prevention and Public Health ‘slush’ Fund by $1 billion.”

The reason it gives for slashing the “slush fund” is “to prevent the Secretary of HHS from raiding these funds for Obamacare exchanges.”  That actually happened in 2013, as Sarah Kliff explained in a terrific Washington Post blog on the shrinking fund last April.

But Congress raided these same prevention funds in 2012 to pay for the so-called “Doc Fix” (i.e., to prevent a sudden 30 percent decrease in Medicare payments to physicians that was caused by an error in a reimbursement formula in place since 2002 that Congress has failed at least a dozen times to fix permanently).

Members of Congress, like everyone, expect to have water that is drinkable, food that is edible, air that is breathable, homes that are safe to live in, and outdoor spaces to relax and exercise in.  If they take care of themselves, they hope to avoid cancers, heart disease, and other chronic conditions.

They understand the connection between these things and public health and prevention funds.  They just choose to ignore it.

If you have been disappointed by this Congress in the past, you probably have your reasons. And if you care about prevention and public health, now you have a billion more.

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/

In the Fiscal Cliff Deal, A New Push for Long Term Care in 2013

When the House of Representatives voted by a comfortable margin a few hours ago to approve the American Taxpayer Relief Act (ATRA) and step away from the "fiscal cliff" for another two months, it agreed to two Senate provisions affecting elders and others with long term care needs.

The first was the "doc fix," which prevented a nearly 30% cut in Medicare payments to physicians.  This was important.  If it hadn't happened, doctors would have fled the Medicare program.

The second was tucked away into Section 643 of the Act.  It establishes a new 15-member Commission on Long Term Care, replacing the CLASS Act provisions of the Affordable Care Act that are now finally, formally repealed by ATRA.

The Commission could turn out to be a very big deal if it does it job well, because it could lead the way in changing our system of providing and financing long-term care in America.

The Commission is charged with writing a bill over the next six months "to establish a plan for the establishment, implementation, and financing of a comprehensive, coordinated, and high-quality" long term care system for elders, people with cognitive impairments, people needing help performing activities of daily living, and all "individuals desiring to plan for future long term care needs."

The Commission will focus on three things:

• the interaction and coordination of new services with Medicare, Medicaid, and private long term care insurance;
• improvements to Medicare, Medicaid, and private long term care insurance needed to ensure availability of long term supports and services; and
• long term care service workforce needs.

If the Commission completes its work on time, it could mean the introduction of new long term care legislation as early as the fall of 2013.

What could this legislation mean for us?

It could be the first step on our nation's long and necessary path to bring long term care costs under control, and make long term care services available to individuals without first impoverishing and exhausting them or their families.

It could also help states bring Medicaid costs under control, and the federal government better manage Medicare costs, too.  Long term care costs are the real culprits in rising Medicaid costs for state budgets and state taxpayers.

Let's keep our eyes open, and hope for two things.  First, that this new Commission does a better job fixing our nation's long term care problem than our broken Congress has done with the Fiscal Cliff.  And second, that if it does bring some recommendations forward, Congress listens.

This column is an Our Health Policy Matters extra.  Read on below for this week's regular column.  Follow Paul Gionfriddo on Twitter @pgionfriddo.  

Ending the Medicare Debate

If you care about Medicare, then who lost last week’s Presidential debate?  Perhaps we all did.

That’s because both candidates favored some cuts in the Medicare program.  And cuts translate into a real impact on real people.

But no cuts could mean something even worse - unsustainable levels of spending in the Medicare program.

The question is what’s the lesser evil – a cut in payments to providers or a cut in benefits to individuals?  That’s the choice President Obama and Governor Romney gave us.

President Obama favored cuts in payments to providers.  Governor Romney favored cuts in benefits to individuals.  The difference in their positions became clear as Romney pressed his point about the $716 billion in “cuts” that Obama supported in the Affordable Care Act.

The “cuts” Obama favored actually fell into two categories that are built into the law – provider rate reductions and cuts to private insurers offering Medicare Advantage plans. 

The provider rate reductions arguably hit doctors the hardest, because ACA presumed that the so-called “doc fix” won’t happen anymore beginning next year.  The “doc fix” has had bipartisan support every year since 2002, because it corrects a provision in the Medicare reimbursement formula that would immediately reduce reimbursement by around 30%. 

The other provider cuts are realized by limiting the increase in future Medicare reimbursements to 5% per year – less than the 5.7% health care costs are expected to grow.

Romney was emphatic during the debate that as President he would restore not just these provider dollars, but the private insurers’ administrative dollars, too.

But Obama pointed out that these savings were used in part to finance the closing of the Medicare donut hole and new Medicare prevention benefits.

More significantly, they also change the trajectory of Medicare spending significantly over time.  According to the 2012 annual report of the Medicare Trust Fund trustees, even with the savings the overall cost of Medicare will grow from just under 4% of GDP today to just over 6% in around thirty years, and then grow a little higher through 2085 (those are the green lines in the chart). 

So Obama just cuts away at the increase.

Romney’s position is more extreme.  Because without the savings, the cost of Medicare will grow to 7% of GDP by 2040, and then skyrocket to over 10% (those are the red lines in the chart) by the time babies born today hit retirement age.

If we had to borrow to cover that, it could bankrupt America.

Romney obviously doesn't want to bankrupt America.  But he did say that he favored leaving Medicare alone for people age 60 and above. (Note: The Ryan plan says 55, but Romney said “60” in the debate.)

For everyone else, Romney wants to reduce the projected cost of Medicare by changing it to a voucher program. 

He would give a health insurance voucher to everyone when they turn 65, and let them use it to purchase either “traditional” Medicare or private insurance through a federal Medicare exchange. 

The value of the voucher will be tied to the second-cheapest plan available, and won’t keep up with health care inflation.  The Medicare recipient will have to pay the difference out of pocket, negotiate with a doctor to accept less, or ration their own care.

Romney made a good argument for at least doing the “doc fix” again by arguing that many doctors won’t be able to absorb a huge rate cut, and will drop out of Medicare if the rate reductions are put into place.  But Obama made an equally valid point that the vouchers could be even worse for recipients. 

If the arguments are left standing there, as they were in the debate, then something has got to give, and everyone's going to lose.

So why not give voters a different choice – one that could end the debate with everyone a winner?  Because there is another option that could save Medicare for our grandchildren without resorting either to borrowing or to huge provider cuts or to Medicare vouchers. 

We have all enjoyed a 2% payroll tax “holiday” for the last couple of years to help stimulate the economy.  When this holiday comes to an end, all we need to do is to dedicate 1.33% back to the Medicare Trust Fund.

If we did this, then Medicare would be solvent for the next seventy-five years.

That's a choice about taxes we all should be offered.  Maybe we’d vote no, but at least we’d be voting with our eyes open.

If you have questions about this column or wish to receive an email notifying you when new Our Health Policy Matters columns are published, contact gionfriddopaul@gmail.com.

The 13,386 Lives Congress Sacrificed Last Week

“I will keep them from harm and injustice.”

“I will prevent disease whenever I can, for prevention is preferable to cure.”

-Classic and modern versions of the Hippocratic Oath, from MedicineNet.Com

Senator Tom Coburn of Oklahoma is a physician.  He’s familiar with the Hippocratic Oath, and has used it to explain his opposition to health care reform.

Last November, Senator Coburn famously termed a $15 billion appropriation for public health and prevention a “slush fund.”  That’s because it was paying for community tobacco control programs, immunization activities, and addiction disorder prevention and treatment services around the country. 

For information on sources, see note below

“Prevention is about focusing on an individual patient,” he commented, apparently forgetting everything he learned about epidemiology at the University of Oklahoma’s College of Medicine and at least some of the words of the Hippocratic Oath.

Public health is the basis of health promotion and disease prevention. 

It focuses on the well-being of entire populations and communities.  It gets only 3% of our total health funding according to CMS data.  It has been responsible for at least half of the increase in life expectancy in America in the last century.

Now it is going to get even less funding, because Senator Coburn’s view has prevailed. 

Last week, his Congressional colleagues – in approving what was described as the last significant piece of legislation like to pass this year – agreed to cut $5 billion from the public health fund.  (Senator Coburn voted against the final bill, but not because it cut public health funding.)

We now know how many lives that $5 billion cut to public health will cost. 

This is because of an article written by Glen Mays and Sharla Smith and published last July in Health Affairs.  In that article, the authors showed that increasing spending on public health reduces infant deaths and deaths from cancers, heart disease, diabetes, and other chronic illnesses. 

They found that a 10% difference in public health funding is associated with a 6.9% difference in infant deaths, a 3.2% difference in heart disease deaths, a 1.4% difference in diabetes-related deaths, and a 1.1% difference in cancer deaths.

The CMS tally of U.S. spending on public health in 2010 was $78 billion.  A $5 billion dollar cut represents 6% of that total.

So that 6% cut this year will be associated with the following:

• 1,077 additional infant deaths;
• 7,831 additional deaths from heart disease;
• 617 additional deaths attributed directly to diabetes;
• 3,861 additional deaths from cancer.

Let’s be clear.  Mays and Smith were careful to point out that we can’t say that lower public health spending causes more deaths – but the association is real.  The amount of disease and death go up as public health spending goes down.

There are two levels of irony in the vote.

The first is that, before this happened, Mays and Smith cited the public health fund as evidence of Congress’s increasing awareness of the value of public health.  So much for awareness.

The second is that Congress decided to use the $5 billion to pay physicians to see Medicare patients who suffer from conditions like heart disease, cancer, and diabetes.

Physicians needed that so-called “doc fix.” Congress caused the problem way back in 1997 when it adopted a Medicare reimbursement formula with a flaw. 

Ever since the flaw became apparent a decade ago, Congress has plugged the reimbursement hole it created one year at a time, kicking the solution another year down the road.  After ten years of kicking, the hole is so large that doctors’ reimbursements would have been cut by 27% without the plug.

Kaiser Health News has an excellent summary of the doc fix dilemma on its web site for those who want to read more about it.  Because Congress won’t fix it for good, doctors are forced to waste their time and money lobbying for a fix every year.

Physicians are undoubtedly relieved that they came out okay again this year, but I seriously doubt that most of them would have wanted the money to be taken from public health.  After all, they’ve all sworn the same Oath as Senator Coburn.

But here’s the important question.  When Congress is able to afford $40 billion in oil and gas tax subsidies over the next ten years for hugely profitable companies, how come, when our health and well-being is concerned, it has to be either/or – and at the expense of thousands of lives?

Note on Source Data for Lives Lost Calculations:  Sources for numbers of deaths attributable to cancer, diabetes, heart disease, and infant mortality were websites of national chronic disease advocacy organizations and U.S. Government (CDC).  Death calculations were made by OHPM using the one-year death total for the most recent year available (usually 2010) and applying a 6% change factor.  The implicit assumptions is that if the 6% cut were to become annualized, so too would the annual number of increased deaths.

If you have any questions about this column, or would like to receive an email notifying you when new Our Health Policy Matters columns are published, please email gionfriddopaul@gmail.com.