Congress Readies for Fall Action on Health Care Reform
Overhauling America's health care system has become a leading priority of Congress this year to realize President Obama's pledge to cover millions of uninsured people while addressing rising health care costs. Since before Obama's inauguration, APA members and Department of Government Relations (DGR) staff have been working to ensure that this effort includes meaningful mental health care reform. Building on the advances of 2008 Medicare and commercial insurance parity laws, APA is fighting for timely access to appropriate psychiatric care for all Americans without payment and medical management discrimination.
In Congress, five committees hold jurisdiction over health reform legislation. Three are in the House of Representatives: Energy and Commerce, Ways and Means, and Education and Labor. They have developed a“ Tri-Committee” bill introduced in July as America's Affordable Health Choices Act. Throughout July, each committee conducted a line-by-line review and amendment process called “marking up” the legislation. Three amended versions of the bill passed out of committee and will be combined into one final version of the Tri-Committee bill for a vote on the House floor this month.
The two Senate committees are the Health, Education, Labor, and Pensions (HELP) and Finance. The committees plan to mark up separate bills and merge them into one prior to consideration by the full Senate. On July 15 HELP approved its bill, the Affordable Health Choices Act, after a 13-day markup, one of the longest in the committee's history; more than 400 amendments were considered. The committee is now waiting for Finance to finish work on its bill. Sen. Max Baucus (D-Mont.), chair of the Finance Committee, set a tentative deadline of September 15 for having a bill ready for markup.
The Congressional Balancing Act
Achieving comprehensive health reform means finding a balance between competing ideological views in Congress. Even within the Democratic Party, members must work to find a compromise agreeable to both poles of the party. These competing interests can cause lockdown at any point, as seen in the House Energy and Commerce Committee; markup was stalled for weeks as conservative Blue Dog Democrats on the committee worked with Chair Henry Waxman (D-Calif.) to adjust provisions of the bill, only to be sidelined by the committee's more liberal Democrats.
The Senate Finance Committee is balancing competing interests in trying to produce a bipartisan proposal. A core group of six committee members—three Democrats and three Republicans—emerged as the lead negotiators for achieving compromise legislation. However, since Finance remains the only committee not to mark up legislation, some Democrats are pressuring Baucus to move forward in a partisan manner if the group fails to produce a bill by September 15. Challenges may also exist in reconciling the two Senate bills.
In health reform, the “balancing act” is particularly difficult when the principles of the debate are diametrically opposed by liberal and conservative members of Congress. Some of these principles include the presence of a public-plan option, increased regulation of the insurance market, and mandates, including mandated coverage and benefit mandates.
House Bill Highlights
Here's a summary of the House bill, America's Affordable Health Choices Act (HR 3200):
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Establishes a National Health Insurance Exchange so that individuals can be pooled together. The smallest employers would be allowed to participate in the exchange first; later larger employers would be eligible to join.
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Requires a basic benefit package for all qualified health benefit plans in the exchange. Mental health and substance-use disorder treatment is included in the basic benefit package, and the coverage requirement would be extended to all health insurance plans within five years.
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Includes a public option in the exchange. The original bill stated that Medicare-participating physicians would be enrolled as participating providers in the public option unless they opt out; the bill as amended by Energy and Commerce adds language that physicians can opt in or out of the public option without penalty.
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Mandates that employers must offer health insurance and that individuals must obtain a qualified health plan or face tax penalties.
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Rebases the Medicare sustainable growth rate (SGR) at 2009 levels, permanently avoiding the disastrous physician payment cut that would have been upward of 20 percent in 2010.
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Establishes two new spending targets: (1) primary and preventive care including evaluation and management services that can grow at 2 percent of GDP and (2) all other medical services, allowed to grow at 1 percent of GDP. The bill adds a five-year rolling target, with any debt accumulation falling away the sixth year.
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Includes bold steps to eliminate gaps in coverage:
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Preserves advances in the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 for the coverage of treatment for mental health and substance abuse disorders.
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Blocks insurance discrimination based on health status and preexisting conditions.
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Extends the Medicare physician fee schedule mental health add-on as enacted in 2008.
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Phases out the Part D “donut hole” for Medicare prescription drug coverage and allows midyear changes if enrollees are adversely impacted by formulary changes.
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Addresses racial and ethnic disparities in health care through cultural competency provisions.
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Extends Medicaid eligibility to 133 percent of the federal poverty level, with federally f unded affordability credits for low-income Americans to purchase health insurance.
Senate HELP Bill Highlights
Here's a summary of the HELP bill, the Affordable Health Choices Act:
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Extends mental health parity to all plans in the Gateway (which would be similar to the “Exchange” in the House bill), as advocated by APA, but exempts small businesses.
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Requires the essential health care benefit design in the Gateway to include mental health and substance use disorder services.
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Prohibits discrimination based on a preexisting condition or medical status.
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Keeps dependents on parents' policies until age 26.
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Provides $50 million in community-based mental and behavioral health grants.
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Includes the CLASS Act—a voluntary program to help disabled Americans purchase community living assistance services.
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Includes means for future expansion of the National Health Service Corps.
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Includes mental and behavioral education and training grants for child and adolescent psychiatry, among others.
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Encourages employer-sponsored wellness programs to reward employees for positive health behaviors.
Senate Finance Committee Update
As this issue went to press, the Senate Finance Committee had not released a bill and has been tight-lipped on details. Baucus is embroiled in a working group of Democrat and Republican Finance members in an effort to craft a bipartisan bill. It is expected that they will unveil their bill and proceed to markup late this month. Then the HELP and Finance bills must be combined for a floor vote.
Stay Tuned...
The heat has been turned up by the masses while Congress was back home for recess, and there are still several moving targets; even the president's priority “public option” is reportedly at risk. When Congress reconvenes this month, work is expected to progress quickly to finalize the bills in the House and Senate for floor votes, and if passed, to combine the two versions into a workable compromise for the president's signature.
APA leadership and Department of Government Relations staff continue to monitor health reform legislation and advance congressional proposals that benefit APA members and their patients. By joining forces with like-minded groups, including the AMA, the Mental Health Liaison Group, and an ad-hoc coalition of medical specialty political action committees, APA expands its impact on health care decisions in Congress.
More information on the House and Senate proposals and APA's letters to Congress about them are posted at<www.psych.org/dgr>.▪
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Published online: 4 September 2009
Published in print: September 4, 2009
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