Reconciliation Agreement Would Give House Democrats More Leverage in Health Reform

Written by Paul Campbell and Maura Farrell

The Washington Post has reported that Congressional Democrats have reached a tentative agreement on President Obama’s $3.5 trillion budget, including reconciliation instructions which would allow health reform legislation to pass the Senate with only 51 votes. The agreement would charge each of the Committees with jurisdiction over authorization of healthcare legislation to find $1 billion in savings. If the agreement moves forward and is passed by the full House and the Senate (as expected), these “instructions” would allow for the Senate to bypass normal Senate parliamentary rules requiring 60 votes for approval. The tentative conference agreement would also extend for two years the Medicare physician payment “fix”. The extension reduces a budget savings needed for a complete repeal of the current payment methodology, which applies a sustainable growth rate (SGR) limit.  

Reconciliation represents a win for House Speaker Pelosi, who shepherded the inclusion of the reconciliation provision in the House Budget. Pelosi’s hope was that reconciliation be included in the conference committee agreement, despite the fact that the Senate Budget Committee did not include the measure. The win also increases the House’s leverage in negotiations of health reform legislation. This process will be unlike the House Leadership’s experience with negotiations on a compromise for the American Recovery and Reinvestment Act (ARRA), when Majority Leader Reid needed to get the help of three Republican Senators to ensure passage of the stimulus bill in the Senate. 

Unlike the Senate, which will move two health reform bills concurrently, the House has agreed to develop a unified plan. Notably, both Speaker Pelosi and Ways and Means Chairman Charles Rangel are strong supporters of a public plan. 



Commonwealth Fund and Population Prepayments

Much of the work of the Commonwealth Fund and others seems to presume that payors are a necessary intermediary and should be the entities doling out population prepayment (aka capitation before it was a nasty word). However, it need not work out that way – particularly with House Dems’ concern that Medicare Advantage was profiteering.

It would be a small step for the new public plan likely to be created to make “population prepayments” directly to integrated health systems particularly because the covered lives under such a plan are likely to have the benefit of public reinsurance. Also, since that coverage will not be employer based it will be easier for those integrated systems to assume risk for that plan’s lives (no need for national networks).

Through such direct health system participation those systems would be incented to create the high performance integration these studies suggest is desirable. The Commonwealth Fund is about to release its new blue print . It will be interesting to see if such an evolution is being thought about.