On July 23, the GNYHA Board of Governors met in Washington, DC, to meet with legislators on important provisions of health care reform. The meeting marked the first time in GNYHA’s 105-year history that its Board met outside New York. After holding a morning meeting, where they were joined by Senator Charles “Chuck” Schumer (D-NY), who discussed his health reform priorities for New York, the Board members traveled to the Rayburn House Office Building on Capitol Hill to meet with members of the New York Congressional Delegation and a key White House official.  
     
In addition to meeting with Senator Schumer, senior members of Oversight and Government Reform Chairman Edolphus “Ed” Towns’ (NY-10th) staff, and John Sheiner, Legislative Counsel for Ways & Means Chairman Charles Rangel (NY-15th),  the GNYHA Board shared its concerns about pending health care legislation with New York Representatives Tim Bishop (NY-1st), Joe Crowley (NY-7th), Eliot Engel (NY-17th), Steve Israel (NY-2nd), Nita Lowey (NY-18th), Mike McMahon (NY-13th), Carolyn Maloney (NY-14th), and Anthony Weiner (NY-9th).  Energy & Commerce Health Subcommittee Chairman Frank Pallone (D-NJ) also stopped by to brief the Board on the latest negotiations between Energy and Commerce leadership, including full committee Chair Henry Waxman (D-CA) and the group of conservative Democrats known as the “Blue Dogs,” who are pushing to add more cost containment—including the creation of an independent Medicare advisory commission or “super MedPAC”—to the House health reform bill. Senator Kirsten Gillibrand (D-NY) also stopped by Rayburn and vowed to fight cuts to safety net providers and teaching hospitals in the Senate bill, including cuts from attempts to reduce  geographic variations in Medicare spending. She also noted that she’s been advocating to expand residency slots and to create incentive programs (loan forgiveness, etc.) to encourage physicians to practice in chronically underserved areas. Senator Gillibrand noted that expanding coverage to more Americans will be meaningless without ensuring access to physicians and hospitals to provide the care.

GNYHA’s Top Three As each member of Congress arrived to meet with the GNYHA Board, they shared insights and major concerns about the pending negotiations and likelihood of a House vote. In turn, the GNYHA Board focused its concerns on three main health reform issues: geographic variation, disproportionate share payments (DSH), and “super MedPAC.”

Geographic Variation The GNYHA Board emphasized that the Dartmouth research being used to support proposals to redistribute Medicare dollars to reduce the geographic variations in health care spending is flawed. Board members pointed out that the Dartmouth research doesn’t adjust for cost of living, which tends to be much higher in large, urban areas (which Dartmouth data suggest “overspend”) and does not adjust for socioeconomic factors. The Board also noted that while the Mayo Clinic, which is being cited as a model health care provider by the Obama Administration and others, is an excellent institution, it has a relatively homogenous patient population of mainly privately insured and Medicare patients. Only 4% of its patients are covered by Medicaid, making comparisons between Mayo and large, urban hospitals like those in New York City that treat large volumes of Medicaid beneficiaries and undocumented immigrants with no insurance coverage inappropriate. While all of the Members of Congress responded favorably to the Board’s points, Reps. Crowley and Israel in particular noted that while they didn’t mind including provisions to help rural hospitals, as the Blue Dogs demand, shifting money from urban hospitals to rural hospitals “robs Peter to make Paul whole,” as Crowley said.

DSH The Board also shared concerns about possible cuts to DSH payments, explaining that while expanding insurance coverage could reduce the number of uninsured patients coming to hospitals, it isn’t a foregone conclusion. In states with generous Medicaid programs,  like New York, an insurance expansion would likely result in more single adults being covered, but would do nothing to address the huge uninsured, undocumented immigrant population. Alan Aviles, President of the New York City Health and Hospitals Corporation (HHC), estimated that, in 2008, HHC treated 450,000 uninsured patients, 60-75% of whom were undocumented immigrants. Moreover, the GNYHA Board noted that expanded coverage could mean that low-income individuals who cannot afford coverage would now purchase low-cost, high-deductible policies—and if they can’t meet the cost-sharing requirements, hospitals will have to write off the cost of treatment, which would have previously been classified as charity care and covered by DSH as bad debt.

Super Med-PAC Lastly, the Board expressed grave concerns over reports that the Blue Dogs had negotiated a deal with the Obama Administration to create an independent Medicare advisory body, not unlike MedPAC, that would be responsible for cost containment and setting health care payment policy (effectively stripping this power from the Congress). 
     
The Board noted that MedPAC historically has been dominated by commissioners from rural areas and academia, often issuing policy recommendations that give short shrift to urban and teaching hospitals.  
The Board also stressed that it would be disastrous to give total policymaking authority to an independent, unaccountable entity. Citing his bad experiences with the Federal base-closing commission known as the BRAC, Rep. Pallone echoed GNYHA’s concerns, saying he strongly believed that an independent body with policymaking authority should be temporary, with authority over health care payment policy returning to Congress after a few short years. Many of the other Congressmen also expressed concern over losing their ability to make health care payment policy, but agreed with Pallone that the political will to appease the Blue Dogs would likely make “super MedPAC” inevitable.
     
In addition to the elected officials, the GNYHA Board met with two other influential health care policymakers:  former Senator Tom Daschle and Director of the White House Office for Health Reform Nancy-Ann DeParle. Director DeParle, who delivered the keynote address at the 2009 GNYHA Annual Meeting, said she believed the House would vote before recess, and that the White House was doing everything in its power to enforce the President’s bill deadlines, including meeting with the Blue Dogs and other groups on a daily basis. Compared to 1993, DeParle noted that we are already much closer to reform, or at least there is more agreement. However, she said that more must be done to control costs. DeParle concluded by saying that the President remains committed to passing health reform this year, that negotiations would not be any easier two months from now, and that the longer Congress waits to pass a reform bill, the longer the Administration will have to wait to begin implementation. Thanking Director DeParle for her time and efforts, GNYHA President Ken Raske promised to continue to provide input on the pending reform legislation.