Congress Approves Budget Resolution

On Wednesday, April 29, the Senate voted 53 to 43 to approve the Conference Committee Report for Senate Concurrent Resolution 13. The day before the House voted 233 to 193 to approve the same budget resolution conference report. The measure received no Republican support. Seventeen Democrats in the House and three in the Senate voted against it. The compromise includes $3.4 trillion in budget authority and $3.5 trillion in outlays for 2010, and $17.783 trillion in budget authority and $18.031 trillion in outlays over 2010-2014. The compromise also includes reconciliation provisions that will limit debate.

Budget Resolution Explanation
The budget resolution provides the overall framework of anticipated costs, revenues, surplus or deficit for the federal government. The budget resolution sets spending limits for annual discretionary spending, places limits on the amount of spending the authorizing committees can approve and establishes revenue targets for the tax writing committees. The resolution represents the agreement between the House and the Senate concerning the overall size of the federal budget and the makeup of the budget by functional categories. Twenty functional categories make up the budget without regard to the agencies that may oversee the individual programs. Amounts in the functional categories result in allocations to committees with jurisdiction over the spending.

Separate Process for Appropriations
Appropriations is a separate process and restrictions on appropriations include limits in the authorizing legislation as well as constraints on discretionary spending caps and budget allocations from the concurrent budget resolution. The House and Senate Appropriations Committees subdivide the amounts allocated under the budget resolution to their subcommittees. The sub-allocations are to be made as soon as practicable following this after agreement on the concurrent resolution.

Budget Resolution Not Law
Budget resolutions do not have the force of law. Spending, revenue and public debt laws necessary to implement decisions agreed to in the budget resolution are enacted subsequently and separately. The budget includes direction both for discretionary spending (spending that is not mandated by existing law and is made available through annual appropriations) and mandatory spending (spending that is mandated in laws other than appropriations). Legislation must be consistent with the allocations and aggregate levels of spending and revenue. These are enforceable by points of order made during floor consideration of legislation.

Reconciliation
Reconciliation instructions in budget resolutions identify committees that must recommend changes to laws affecting revenues or direct spending (mandatory spending) programs within their jurisdiction. Reconciliation includes limitations on debate and on the types of amendments that may be considered.

Health Care Reform
The compromise budget resolution contains the principles of the President’s health care reform agenda as well as the health care reform reserve fund. The reconciliation process that would place limits on debate could be used if key committees (Senate Finance, Senate Committee on Health Education, Labor and Pensions, House Energy and Commerce, House Ways and Means, House Education and Labor) submit their recommendations to their respective chamber budget committees by October 15. The key elements of the President’s health reform include: (1) protect families' financial health including restraining the growth of health premiums and other health-related costs;(2) make health coverage affordable to businesses (in particular to small business and individuals who are self-employed), households, and governments, including by reducing wasteful and inefficient spending in the health care system with periodic reports on savings achieved through these efforts, and by moving forward with improvements to the health care delivery system, including Medicare;(3) aim for quality, affordable health care for all Americans;(4) provide portability of coverage and assurance of coverage with appropriate consumer protections;(5) guarantee choice of health plans and health care providers to Americans;(6) invest in prevention and wellness and address issues of health disparities;(7) improve patient safety and quality care, including the appropriate use of health information technology and health data, and promote transparency in cost and quality information to Americans; or (8) maintain long-term fiscal sustainability and pays for itself by reducing health care cost growth, improving productivity, or dedicating additional sources of revenue; by the amounts provided in such legislation for those purposes, provided that such legislation would not increase the deficit over the period of the total of fiscal years 2009 through 2019.

LIHEAP
The conference agreement includes the President’s request of $3.2 billion for LIHEAP in 2010. The agreement also includes a discretionary cap adjustment for an additional $1.9 billion if the President’s funding level of $3.2 billion is in an appropriations measure.

Community Development Block Grant
The conference agreement includes increased funding which could include full funding for CDBG.

Social Security
The Social Security Administration funding level in the conference agreement assumes the President’s full request for an adjustment for program integrity efforts including SSI redeterminations and SSI asset verification. It also reflects the President’s full request for more resources to address the backlog of disability claims and hearings.

To view the budget resolution visit http://thomas.loc.gov and search by bill number (SCR 13). The conference committee report is also available at the same site.


Spending in 2010 Concurrent Budget Resolution
In billions
Budget authority = BA
Outlays = OT

Mandatory Spending

Agriculture BA 17.559
OT 17.734

Commerce & Housing Credit BA 50.984
OT 75.553

Transportation BA 56.715
OT 2.233

Community & Regional BA 0.378
Development OT 2.399

Health BA 325.753
OT 324.079

Medicare BA 444.068
OT 444.228

Income Security BA 472.062
OT 470.879

Social Security BA 697.336
OT 695.343

Veterans Benefits BA 53.102
OT 52.994

Discretionary Spending

Agriculture BA 6.131
OT 6.217

Commerce & Housing Credit BA 13.391
OT 13.459

Transportation BA 31.436
OT 93.462

Community & Regional BA 17.930
Development OT 26.904

Health BA 58.556
OT 64.806

Medicare BA 5.600
OT 5.570

Income Security BA 64.778
OT 69.323

Social Security BA 6.072
OT 6.057

Veterans Benefits BA 53.396
OT 52.584

Leadership Council of Aging Organizations Sends Health Reform Recommendations

The Leadership Council of Aging Organizations(LCAO), of which NASUA is a member, has sent recommendations to Congress on key elements of upcoming health reform initiatives. While we are encouraged that the principles of Project 2020 are included under Chronic Care Supports & Services, because of the unfunded mandates throughout, NASUA abstained from supporting the recommendations as a whole. The recommendations focus on the following five areas:

Under-65 Population

Recommendations include offering a nationwide plan, setting premiums by community, keeping health care affordable, and elimination of the two year waiting period for SSI and Medicare

Medicare

Recommendations include addressing gaps in coverage, maintain choice of providers, expand access, improve prescription drug coverage, align payments to Medicare Advantage, and provide enhanced coverage for low-income beneficiaries

Medicaid

Recommendations include expanding eligibility to a simpler, more uniform system; incentivize states to cover more people; provide permanent additional federal funding; create an automatic trigger for FMAP increases; and reverse punitive DRA asset transfer provisions of the DRA

Chronic Care Supports & Services

Recommendations include expanding access to home based services; expand access and eligibility to Medicaid and non-Medicaid Home and Community based services to reach parity with institutional care, including Project 2020 principles; and improve the quality of life for nursing home residents

Systemic Reform

Recommendations include instituting care coordination, supporting a well trained workforce, improving caregiver support programs and employing Health information technology

The actual document can be viewed on the LCAO page of the NASUA website:

http://www.nasua.org/issues/federal_policy/LCAO_materials.html

Senate Finance Holds First Roundtable On Health Care Reform

Today the Senate Finance Committee held the first of three scheduled roundtable discussions on health reform. The first topic area considered was delivery system reform. The second roundtable will address coverage expansion and will be held on May 5. The third and final roundtable on financing will take place on May 14. Committee walk-throughs of tentative legislation will follow each roundtable with a mark-up expected in June.

After brief opening remarks from Senator Max Baucus and Senator Charles Grassley, the roundtable discussion began and was moderated by John Iglehart, founding editor of Health Affairs.

The major themes of the delivery system reform discussion were:

- Discussion of integrated systems like Geisinger Health System and tested care coordination models for adults with chronic conditions (such as the Advance Practice Nurse Transitional Care Model)

- Reforms of current payment system including bonus payments for primary care physicians, bundling of payments, revise process for setting relative values in Medicare, paying for outcomes

- Reform CMS to remove silos; should be a source of innovation and the best place in government to work; less prescriptive legislation with latitude to make decisions, subject to proper oversight; ability to implement successful pilots and demonstrations more quickly without having to seek additional authorization; public-private partnerships; leverage Medicare and Medicaid

- Health IT: electronic medical records, use data to educate providers about how they compare to their peers (e.g., hospital readmission data)

- Workforce: increase use of advance practice nurses, overcome barriers that prevent academic medical centers from valuing primary care as a specialty; possibly create commission to study workforce shortage and make recommendations to Congress

- Patient-centered model; medical home

-Individual choice, supported with information so that patients can make informed, evidence based choice; importance of comparative effectiveness research; provide incentives for patients to make healthy choices (Safeway example: financial incentives to lose weight, quite smoking)

- Importance of care coordination and availability of home and community based services (Washington state was the example cited and discussed by Senator Cantwell and Mark McClellan as a model that could save billions if implemented nationwide)

- Prevention of fraud and abuse: scrutinize providers and suppliers before enrollment; establish payment methodologies that are reasonable and reflect the marketplace; require compliance plans; vigilant monitoring (better data systems); respond quickly to detected fraud

The participants in today’s roundtable are listed below. Their written statements may be access at http://finance.senate.gov/sitepages/hearing042109.htm:

Allan M. Korn, M.D., Senior Vice President, Chief Medical Officer, Office of Clinical Affairs, Blue Cross Blue Shield Association, Washington, DC

Glenn M. Hackbarth, J.D., Chairman, Medicare Payment Advisory Commission, Washington, DC

Peter V. Lee, J.D., Executive Director, National Health Policy, Pacific Business Group on Health, San Francisco, CA

Mark B. McClellan, M.D., Director, Engelberg Center for Health Care Reform, Brookings Institute, Washington, DC

Lewis Morris, J.D., Chief Counsel to the Inspector General, Office of Counsel to the Inspector General, Washington, DC

Mary D. Naylor, Ph.D., FAAN, RN, Marian S. Ware Professor in Gerontology, University of Pennsylvania School of Nursing, Philadelphia, PA

Debra Ness, President, National Partnership for Women and Families, Washington, DC

Frank G. Opelka, M.D., FACS, Vice Chancellor for Clinical Affairs, Professor of Surgery, Office of the Chancellor, Louisiana State University, Health Science Center, New Orleans, LA

Glenn Steele Jr., M.D., PhD, President, Geisinger Health System, Danville, PA

John Tooker, M.D., MBA, FACP, Executive Vice President/Chief Executive Officer, American College of Physicians, Philadelphia, PA

Richard J. Umbdenstock, FACHE, President and CEO, American Hospital Association, Washington, DC

Ron Williams, Chairman and CEO, Aetna Inc., Hartford, CT

Paul J. Diaz, J.D., President and CEO, Kindred Healthcare Inc., Louisville, KY

Health Care Reform Newsmakers Series

The Kaiser Family Foundation, Families USA and the National Federation of Independent Business are sponsoring a series of “reporters only” briefings regarding health care reform. Wednesday, April 15, Nancy-Ann DeParle, Director of the White House Office of Health Care Reform was the featured guest. Ms. DeParle was administrator of the Health Care Financing Administration - what is now the Centers for Medicare and Medicaid Services - during the Clinton administration. She also worked at the Office of Management and Budget and in the private sector.

In introductory remarks, Ms. DeParle noted that unlike the health care reform efforts of the ‘90s, this time more groups are at the table and no one wants the status quo. Every group wants to lower costs for businesses and for families. Reporters quizzed Ms. DeParle on a number of aspects of reform. Some of the questions and answers are summarized below.

1. Does the administration support taxing health benefits? Ms. DeParle responded that the president wants to build on the current employer based plans.

2. What options are being considered to lower Medicare costs? Ms. DeParle replied that options for lowering costs to Medicare include more equitable payments to Medicare Advantage Plans, bundling payments to hospitals to create incentives to reduce readmissions, promoting comparative effectiveness so that physicians and patients are able to make better decisions that will reduce costs in the long run, encouraging health information technology to improve care, lower costs and reduce errors, and emphasizing wellness and prevention to reduce utilization.

3. How do you respond to questions that have been raised about the public plan option? Ms. DeParle related that confusion exists about what a public plan is. She mentioned that often the concern is not whether a public plan should be available but the details of how a public plan will work. Some concerns have been raised about payment rates and options available. She noted that examples already exist including the state health plans that administer health coverage for state employees and use private health plans.

4. Will the administration support continuation of fee for service plans? Ms. DeParle reminded the audience that the president wants to strengthen fee for service and change incentives such as the bundling of payments to hospitals to avoid readmissions. She said that the emphasis on health information technology (HIT) assumes a robust private fee for services system. She noted that HIT is not a silver bullet but thinks that HIT will provide overall improvements to care and will lower administrative costs.

5. How does the concept of a medical home fit into the reform plan? Ms. DeParle noted that the idea is to create a less fragmented health care experience for patients with a medical clinician coordinating care so that patients are referred to the right specialists and are prescribed the right medications.

6. How will we pay for the reform? Ms. DeParle said that some “game changers” are included in the plan such as HIT and emphasis on wellness and prevention that will generate savings.

7. What strains do you foresee for the health care system if the 45 million uninsured suddenly have health care coverage? Ms. DeParle reminded the reporters that when Medicare began in July of 1966 millions of older adults were added to the health care system without overwhelming it. She also noted that different parts of the country have different capacities and that we need to make additional investments in the health care workforce.

In closing, Ms. DeParle reiterated that health care reform is one of the most important issues we are facing as a nation. It is clear that we all want better health care outcomes and stability in costs.