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Dialysis Discussion => Dialysis: News Articles => Topic started by: okarol on October 03, 2008, 04:01:54 PM
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How the next president could affect dialysis
By: Keith Chartier
Posted on: 09/30/2008
Renal Business Today
On Jan. 20, 2009, The 44th President of the United States will inherit a country at a crossroads. The confluence of the Iraq War, sluggish unemployment and the housing crisis is expected to continue into next year, and nearly 46 million people still don’t have health insurance. But in the meantime, the 24-hour news cycle would have you believe that the future of the free world hinges on the seven houses Sen. John McCain, R-Ariz., thinks he might own or whether Sen. Barack Obama, D-Ill., has eclipsed Paris Hilton as the biggest celebrity in the world.
Patients and clinics alike are at the mercy of government decisions. And with the next president certain to push for major healthcare reform, it’s vital to push through the tall grass of partisan rhetoric to understand how the next four years could alter the healthcare landscape.
The 2008 Election and Dialysis
Dialysis has largely been a nonpartisan issue over the years garnering support from both sides of the aisle. For example, the Kidney Care Quality and Education Act of 2007 (KCQEA), which helped influence recent Medicare reform, enjoyed Democrat and Republican support after it was introduced in Congress. Specifically, the bill drew 107 Democrat and 56 Republican co-sponsors in the House. In the Senate, 10 Republicans and 18 Democrats supported the bill.
If past elections are any indication, the End-Stage Renal Disease Program is not a hot-button issue in presidential politics, so it’s difficult to gauge if either candidate even has a specific position on the ESRD Program. It also may be too early to tell how the next president might affect renal care specifically, said John Jonas, head legislative counsel for the lobbyist group Kidney Care Partners. “You’d really have to see who they appoint as administrator of [Centers for Medicare & Medicaid Services] and see who is secretary of [Health and Human Services] and see how interested those people are in preventive care, and how interested they are in managing chronic care,” Jonas added. “Those issues are very important in what happens to dialysis.”
One can surmise that Obama holds, at the very least, tacit support for ESRD reform as he was one of the Senate co-sponsors of the KCQEA last year. The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) could be another barometer in gauging McCain’s and Obama’s stance on Medicare and dialysis. MIPPA delayed scheduled physician fee cuts, phased out payments to private Medicare Advantage plans and revised how Medicare will reimburse dialysis treatments. McCain was the only senator not present July 9 when MIPPA passed the Senate by a vote of 69-30. Obama voted in favor of the legislation. However, neither senator was present when the Senate overrode President Bush’s veto to pass the bill into law on July 15.
Neither candidate has been particularly expedient in their recent Senate attendance. As of late August, McCain has missed 63.8 percent of all Senate votes since January 2007—the most of any senator, according to a Washington Post database. Obama isn’t too far behind, though, as he has missed 45.5 percent, putting him at third for most Senate votes missed. Sen. Tim Johnson, D-S.D., came in at second, missing 48.7 percent of all votes. Johnson, however, suffered a brain hemorrhage in Dec. 2006, and had to spend several months recovering.
“Nothing I have heard from either candidate leads me to believe one would be better than the other on renal issues,” Rob Foreman, president of Washington, D.C.-based Kidney Care Council, said. “The question more likely will be: How would the renal delivery system be affected by whatever form of healthcare reform each candidate would propose as president? My sense is that Senator Obama would be more aggressive in changing the existing structure—especially on entitlements—and that could impact dialysis. This is something we need to watch very carefully as any kind of healthcare reform will likely include a review of all providers and how they deliver care.”
Private insurance could be a major area dialysis providers keep an eye on as healthcare reform inches closer. Currently, private insurance, which typically reimburses more than Medicare, pays for the first 30 months of dialysis, then Medicare covers the costs.
“Either plan, if they increase private coverage, are probably good things both directly for dialysis because there is an insurance component to it, but also because generally you want to have better preventive care,” Jonas said. “If private payers had these patients longer rather than putting them onto the government program after 30 months, we think a lot of them would spend more time and effort in disease management and quality programs.”
The Congressional Question
The president isn’t the only variable in the Medicare reform equation. Congress has plenty of influence as well, and the speed at which reform occurs will depend on which party controls the legislative branch. “As we have seen in the past, however, rarely if ever has Congress succeeded in comprehensive reform of the healthcare system,” Foreman said. “Nevertheless, that certainly won’t stop them from trying and the momentum for getting something done in the next two years will certainly continue to escalate.”
In addition to the presidential election, many congressional seats are up for grabs, and many polls have the Democrats expanding the hold on the Senate and House. This could have a major impact on the next president’s ability to reform healthcare. “Generally, Democrats have been more inclined to enhance and spend money on the Medicare program a little more,” Jonas said.
If Obama is elected, a sympathetic Democratic Congress could aid his style of reform. However, a Democratic-controlled Congress would be a massive impediment to any McCain Administration legislation. “I think with McCain, it’s more of the same, which is the painful, grudging, incremental steps forward,” Jonas said. “I think with a Democratic president and a Democratic Congress, you can have potentially more sweeping reform. There isn’t a guarantee that reform is perfect with everything you want, but there certainly is potential.”
Insuring the Uninsured
The U.S. Census Bureau recently reported that there were 45.7 million uninsured Americans in 2007. Therefore, a major tenet in both presidential candidates’ healthcare reform is getting insurance coverage for all Americans.
The non-partisan Tax Policy Center, which is a joint-venture between the Brookings Institute and the Urban Center, said in mid-August that McCain’s healthcare plan (see McCain sidebar further down) would cut the number of uninsured by only 1 million in 2009 and approximately 5 million by 2013. The Center said those numbers would start to rise, though, as the tax credit McCain has proposed “would fail to keep pace with premiums.”
On the other hand, Obama’s healthcare plan (see Obama sidebar further down) would reduce the number of uninsured Americans by 18 million in 2009 and 34 million by 2018, according to the Tax Policy Center. Despite this reduction, the Center estimated there would still be 33 million uninsured Americans in 2018, under the Obama plan.
Each candidate’s tax plans could also play a role in how effective healthcare reform is and how it might affect specialties like dialysis. The Tax Policy Center estimated that Obama would cut taxes by $2.9 trillion between 2009 and 2018, by reducing taxes for low to moderate family incomes while raising taxes for high-income earners.
McCain, on the other hand, would cut taxes by about $4.2 trillion, by reducing taxes on middle- and high-income earners. Obama, however, would raise government revenues approximately $600 billion over 10 years, while McCain would lose $600 billion, according to the Tax Policy Center.
Americans uninsured for all or any part of 2008 received approximately $86 billion in care during the time they lacked coverage, according to a study published online Aug. 26 in Health Affairs. Of that cost, the uninsured paid $30 billion out of pocket and received around $56 billion in uncompensated care, which is covered through public and private subsidies. The study estimated, however, that the government bears the brunt of uncompensated care spending nearly $43 billion. The study estimated it would cost a total of $208.6 billion to cover all of the uninsured.
So with less money coming in under both candidates’ plans and more money needed to pay for coverage, the government, which pays for a majority of uncompensated care, could look to existing programs to shift the burden of cost. And the $20 billion ESRD Program is always a potential target, despite the reforms of 2008.
Immediate Concerns for Dialysis
In 2008, the renal community saw the passage of MIPPA, under which dialysis services were granted an annual update in addition to a bundled payment of services that includes once separately billable drugs, such as the anemia drug Epogen. In addition, the bill included a number of provisions centered on education and prevention.
Many renal associations hailed the new law as a victory for an industry that has been searching for reform for years. Despite the changes, Medicare, which pays for the majority of ESRD bills, could become a legislative target as Congress will have to tackle, yet again, the physician fee reimbursement cut, which was essentially delayed 18 months by MIPPA.
That means any changes made to dialysis payment in 2008 could be revisited anytime Congress opens up Medicare, said Foreman. “Accordingly, we cannot rest on our laurels but will need to carefully follow the development of next year’s Medicare bill to ensure that no changes are made to the ESRD reform provisions,” he added. “Congress will be looking for money to pay for the physician fix. I fully expect the ESRD updates will be an easy target for some on the Hill to set their sights on. We need to preserve and protect those provisions from any tinkering by the new Congress.”
That scenario could be further exacerbated if the next president tackles healthcare reform head-on. Obama and McCain offer divergent healthcare plans that do have one common, dominant theme: controlling costs. These changes could not only affect how each patient’s dialysis treatments are paid for, but could also have an impact on how employers pay for their employees’ health services.
“Now that we have an update, occasionally, when they’re looking for money they cut updates, freeze updates or do other kinds of things,” Jonas said. “That’s always a possibility that there’s some kind of further cuts either from Medicare that impact us indirectly or are specifically targeted at dialysis. We’re going into a very tight budget environment. We can’t assume dialysis is exempt from cuts.” RBT
Next Page: Obama's Healthcare Plan
Obama’s Plan
Families USA, a nonprofit, nonpartisan, government watchdog group, said in an August report that McCain and Obama “both promote increased access to information on the cost and quality of care, evidence-based medicine, health information technology and electronic prescribing, and medical malpractice reform. In addition, both proposals stress the importance of disease prevention and management.”
Obama’s healthcare plan, which the campaign said would cost between $50 billion and $65 billion, is centered on a mix of employer mandates, public and private insurance and insurance market regulation. In his plan, Obama wants to establish a new public service insurance program for Americans who don’t qualify for Medicaid and SCHIP (Obama also calls to expand the eligibility for these programs). It would also cover people who don’t have access to insurance through their employers as well as small business owners who want to offer the insurance to employees.
According to Obama’s plan, no American would be turned away from this public program because of illness or pre-existing conditions. In addition, the program would offer similar benefits to the Federal Employees Health Benefits Program, which many members of Congress use.
In addition, Obama’s plan calls for the creation of a National Health Insurance Exchange for Americans who want private insurance. “The Exchange will act as a watchdog and help reform the private insurance market by creating rules and standards for participating insurance plans to ensure fairness and to make individual coverage more affordable and accessible,” Obama wrote in his 15-page plan.
“Pay or play” is a feature of the Obama plan that could affect business, especially small business operators. Under the Obama plan, employers that don’t provide “meaningful” insurance coverage for their employees will be required to contribute a percentage of payroll that would be used to fund the new national plan.
Obama doesn’t specifically call for a mandate that requires all adults to obtain health insurance, but his plan does require that all children have coverage. In addition, children can continue under their parent’s plan until the age of 25.
In terms of information technology, Obama has proposed to invest $50 billion over five years in electronic health records. As for drugs, his plan would allow the reimportation of drugs, increased use of generics and would repeal the ban on the government directly negotiating prices with drug companies.
Next Page: McCain's Healthcare plan
McCain’s Plan
In contrast to Obama’s plan, McCain opposes any mandated coverage, and his plan looks to rely on market forces and the shift to individually purchased plans to reform U.S. healthcare. To initiate reform, McCain plans to start by changing how the federal government taxes health insurance. Employees today do not pay taxes on the health insurance premiums their employers pay for. Under the McCain plan, that tax exclusion would end and the added revenue—estimated at $3.6 trillion over 10 years—would be used to pay for refundable tax credits for those who want to purchase private insurance. Individuals would be eligible for $2,500 and families would be eligible for a $5,000 tax credit.
According to McCain, those without insurance could use the tax credit to help purchase individual health insurance. In addition, Americans with employer-based coverage could use the credit to pay the new taxes placed on their employers. Employees could also use the credit to opt out of their employer plan and purchase an individual plan. The thought is that Americans would seek lower-cost, less-comprehensive insurance plans that would create more competition among insurers. Any extra money left over could be placed into health savings accounts, as well.
McCain is also looking to deregulate the insurance market by allowing companies to sell policies across state lines. People could conceivably shop around the nation to find cheaper policies. McCain would also focus on bundling medical payments instead of the traditional fee-for-service method of payment.
Critics of McCain’s plan say employers, especially smaller businesses, would stop offering health insurance causing some workers to lose insurance coverage. In addition, more people could move from more comprehensive employer-based packages to individual insurance with less coverage.
He would also call for provider transparency in terms of medical outcomes, quality of care, costs and prices. McCain said he would work with states to create a federally supported Guaranteed Access Plan for people who are denied coverage because of pre-existing conditions. Premiums in this plan would be limited and those below a certain income level would be given financial assistance.
And like Obama, McCain is pushing for generic drug development, disease prevention, improving chronic disease care and reforming medical malpractice. McCain said he would promote competition among providers by only paying them for quality. In addition, his plan would promote the use of “alternative providers,” such as nurse practitioners, as well as “alternative treatment settings,” such as walk-in clinics in retail outlets.
http://www.renalbusiness.com/articles/next-president-and-dialysis.html#
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a long, but useful article. thanks for posting Karol.
This is a key point of concern for me:
"In contrast to Obama’s plan, McCain opposes any mandated coverage, and his plan looks to rely on market forces and the shift to individually purchased plans to reform U.S. healthcare."
When I read market forces, I think of the CEO friends of Wall Street and the people that own Da Vita.
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I think for people on dialysis, it is the prospect of McCain abolishing states' rights when it comes to health insurance that is really problematic.
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