March 16, 2010

Health Care

Dear Friends,

Health Care reform is as important an issue as I have dealt with in my life and it is of great interest to many people.

In my last communication I shared a detailed letter expressing some concerns and seeking input. Since that time, I have received many calls, emails and letters. Most calls merely express support or opposition to the proposal. Others have more detailed points to make. I value this input and I thank you. I am still weighing my vote.

I decided long ago that this is one of the few issues I will decide without regard for political impact — it is too important. I will cast my vote on the basis of what I think is in the best interest of our country, state and district; if there is a political price to pay for that vote, so be it.

So, as of this writing, here is the status of the issues I raised:

1. Pundit views to the contrary — I have NOT decided how to vote. I want to vote YES, but I am still not certain that this SPECIFIC bill deserves my support.
2. One reason for this hesitancy is that we still do NOT have a final draft of the reconciliation bill. No one can or should make a final decision before they read, consider and discuss the final product. We are so far beyond generalities and rhetoric that decisions made before the actual language of the bill is available are irresponsible.
3. Early Expansion States — This is our effort to make sure Massachusetts is not punished because we have already taken action to expand health care coverage. I have received clarifying information on some details.
   
   I am informed that the monies involved would not be CUT from current state receipts, but Massachusetts COULD nonetheless be treated unfairly in the future if we are not grandfathered somehow. In the House, we addressed the matter in a general manner and would have brought the state about $1.3 billion for the three years FY 2013–2015. The Senate specifically granted Massachusetts an exemption totaling $165 million for the three years FY 2014–2016. Every informed observer would accept the Senate protection even though it is less generous than the House's version. However, everyone also emphasizes how critically important it is that Massachusetts receive some protection from unfair treatment.
   
   The President seems to have backed away from his broad threat to strip all state-specific language because he realizes they are not all "give aways". At the moment, I expect this concern to be addressed, but won't know until the reconciliation bill is finalized.
4. Area Wage Index — This is an issue I did not include in the original letter, but it has been raised by so many commentators that I feel compelled to add it now. It is another immensely complex Medicare reimbursement issue. The House did not address it. The Senate did include corrective language that would allow Massachusetts to regain about $300 million. Here too I will need to see the text of the reconciliation measure to ensure that language remains intact.
5. DSH Cuts — These are the payments made to hospitals that provide services to a larger than average number of uninsured people, like Boston Medical Center and Cambridge Health Alliance.
   
   I am informed that Massachusetts will not be as adversely affected as I feared because we have expanded coverage to more people. Although the national cuts may be troubling to some, Massachusetts' early expansion will save us from much of this specific cut.
6. Value Index — This is the Senate proposal that could reward so-called "low cost areas" simply because they do not bear the burdens of a costly patient pool, medical education, a high cost-of-living region, significant research overhead, or other factors beyond merely the cost of direct service. Furthermore, this proposed index has never even been tested to determine its true impact.
   
   Although this proposal causes everyone in Massachusetts some degree of concern, no one has yet suggested I vote against the overall package simply due to this provision. A few commentators have suggested that it would be acceptable for Massachusetts to lose money and others to gain if it helped the nation — although I respect that view, I do not share it. Some observers have also pointed out that the Senate language has some possible protections.
7. Super IMAC — This is the proposal to strip Congress of oversight of Medicare and vest virtually all decision authority in the hands of the presidential appointees not subject to confirmation.
   
   Again, virtually every commentator has shared my concern but not suggested I vote against the overall proposal for this reason. One reason is that there is a ten year exemption for our major hospitals. I cannot say that I am as trusting yet — ten years is not that long.
8. Process — Some opponents of the underlying proposal are focusing on the process for passage. While I don't like the convoluted process we will be following, it will not deter me from a thorough analysis of the proposal. I would ask if anyone remembers the process that was used for Medicare, Civil Rights or any other important legislation. Furthermore, I can assure you that convoluted processes have been used many times by Republicans and Democrats. In fact, process is only a means to an end — the real issue is the product. If the product is good, I will vote yes — if it is bad, I will vote no. Following the process may be an interesting sidelight, but the important factors are decided in the substance of the bill.

Like others, I wait anxiously for the text of the reconciliation bill. When it is public, I will ask again for comment from informed observers.

I realize that many people are tired of this debate — so am I. But it is important and complicated. It took years to enact Medicare, Medicaid and Social Security — and I argue that it was worth the time and trouble.

I realize that some just want us to vote yes or no based on a few talking points. I will not succumb to that suggestion. Health care is a serious and complicated matter. I do not believe that the vast majority of people really want me to vote on the basis of rhetoric.

I also realize that some see this as a political tug-of-war between the right and the left or between Democrats and Republicans. I do not see it that way at all. I see it as the implementation of basic values:

First — Do you believe that every American should have health care coverage? I do.

Second — If you do not, the answer is easy, vote no. But then you should also think we should repeal Medicare and Medicaid.

Third — If you agree with me that the goal is to expand coverage, the next questions are whether THIS actual proposal gets us closer to that goal, does it do it in a fiscally responsible manner, and does it harm the programs we already have in place? The answers are never as clean and neat as the first two questions and this is what I am trying to decide now.

For those who have contacted me, I appreciate your input. For those who wish to do so, we are happy to hear from you.