Health Insurance News

Will Kennedy’s Death Revitalize Health Care Push?
by Liz Halloran - NPR

Exactly one year before Massachusetts Sen. Edward Kennedy’s death from cancer Tuesday, the longtime senator and scion of one the nation’s most famous families took a labored walk to the podium at the Democratic National Convention and declared guaranteed health care for every American the “cause of my life.”

Indeed, Kennedy’s influential work on expanding health care spanned his nearly half-century in Washington: from the 1960s and the establishment of Medicare during the Johnson administration, to the current effort by President Obama to advance a historic overhaul of the nation’s health care system.

Many on Capitol Hill are now wondering how or whether the current acrimonious debate over Obama’s health care initiative could be affected by Kennedy’s passing at age 77.

Will his death mute the heated — and often distorted — rhetoric that has surrounded public discussions on health care and help proponents move a bill forward? Or has Kennedy’s public absence from the Hill over the past few months as he battled brain cancer — and the contentious debate that overhaul proposals have inspired nationwide — mean that his influence will quickly pass?

New Momentum For Health Care Overhaul?

Labor groups, including the Service Employees International Union, the nation’s largest, were among organizations that were quick to seize upon the senator’s death to urge Congress to pass overhaul legislation in his honor.

“Let us continue his cause,” SEIU President Andy Stern said in a morning statement. “Let us take action this year to pass health care reform. And let us continue to build Kennedy’s vision of America.”

Even those on the other side of the debate predicted that there would be a desire to honor the senator, and an afterglow left by his legacy that could give momentum to overhaul advocates.

“It will provide a burst of adrenaline to proponents of what Kennedy stood for,” says Michael Franc, vice president for government relations at the conservative Heritage Foundation. “There will be an emotional plea to make this about Sen. Kennedy — to name the bill after him, to inject the notion of sympathy that this could be done for him.”

“They’ll hope it can transcend the negative vibes of the past months,” Franc said.

But both he and Randel Johnson, a senior vice president of labor, immigration and employee benefits at the U.S. Chamber of Commerce, predict that any benefit to advocates of a health care overhaul will be temporary.

“I don’t think it’s ultimately going to have any long-term effect,” says Johnson, who said he has the “highest admiration for Sen. Kennedy, although we were on opposite sides of the labor issue.”

“He’s been out of the public debate, and the health care issue is so huge across the country that it has eclipsed one personality,” he says. “That doesn’t mean that they won’t use Sen. Kennedy’s passing to add fire to passing the bill.”

Will there be a truce in the rhetoric over health care? “No,” says Johnson.

His Voice Will Reverberate

But longtime Democratic strategist Kiki McLean, now a partner at the public relations firm of Porter Novelli, argues that, in death, Kennedy’s legacy and his passionate voice on health care may get a wider hearing, as news outlets replay his speeches, focus on his biography and talk about his commitment to revamping health care.

“In some ways, we will hear more of his powerful voice this week than we’ve had the benefit of hearing through his illness,” says McLean, who manages Porter Novelli’s Washington office.

“The coverage of this week and modern technology will give his legacy even greater influence,” she said. “He’s going to remind us all — people at town hall meetings, on the Senate floor — where this debate began, and where the real need is.”

A Legacy Of People

What will likely prove more influential, some predict, will be the enormous network of staffers, former staffers, supporters and policymakers that were part of Kennedy’s close-knit circle.

“When you think of the influence of Sen. Kennedy on health care, some of that was about the senator himself: his personality, his ability to give a good speech,” Franc says. “But a lot of the effectiveness he brought to the Senate floor was the function of the incredibly talented staff he brought to the scene.

“They will continue to be involved in shaping this, and his influence will continue in his network — and it’s far and wide,” he said.

Until recently, Kennedy himself had been very involved in conversations during the development and markup of the bill that came out of his Senate health committee. He was staying in contact “impressively often,” according to a Senate aide familiar with deliberations.

One person who may keenly miss the advice of the late senator is Senate Majority Leader Harry Reid, who was close to Kennedy, said the aide, who declined to speak on the record because of the sensitivity of the situation. Reid, no doubt, will feel Kennedy’s absence as a bill moves to the Senate floor.

Effect On Current Debate

Johnson, of the Chamber of Commerce, is among those who predict that rather than attach Kennedy’s name to whatever health bill that may emerge from Congress, his colleagues may choose to name after Kennedy a smaller piece of legislation close to the late senator’s heart.

“I think they’ll look more closely at a smaller bill that will mark his passing, something like the Healthy Families Act,” Johnson says.

First introduced in 2005 and sponsored by Kennedy, the bill would require that businesses employing 15 or more workers provide their employees the opportunity to earn up to seven paid sick days a year. The bill was reintroduced in May.

That, indeed, would become part of his legacy — and, says McLean, “legacy has influence. That’s why it’s a legacy.”

Whether Kennedy’s legacy will continue to influence the current national debate over health care will become clearer next month, when Congress returns from what has proven to be a tumultuous, and sad, summer recess.

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Waxman Takes on Drug Makers Over Medicare
By DUFF WILSON - The New York Times

As the health care debate focuses on whether cost cuts are looming in Medicare coverage, Representative Henry A. Waxman is on a crusade to save Medicare billions of dollars — in a way that he says would end up helping the elderly.

That is because the money would come from the drug industry, which is why Mr. Waxman may have a fight on his hands.

Drug makers contend they have already worked out a 10-year, $80 billion cost-savings deal with the White House and crucial Senate gatekeepers on the trillion-dollar health care overhaul. The industry says that trying to add Mr. Waxman’s provision could scuttle that agreement.

“You not only break the deal, but you break the bank for us,” said Billy Tauzin, chief executive of the drug industry’s trade group, the Pharmaceutical Research and Manufacturers of America, known as PhRMA.

At issue is a multibillion-dollar “windfall” that Mr. Waxman contends the drug industry received when drug benefits were added to Medicare coverage in 2006. Mr. Waxman, Democrat of California, is chairman of the House Energy and Commerce Committee and is central to the House’s legislative efforts on health care.

When drug coverage was added to Medicare, under the so-called Part D program, about 6.4 million low-income elderly or disabled people were shifted into the program from the government’s Medicaid program for the poor. Such people, entitled to Medicare and Medicaid, are known as dual eligibles in health policy-speak.

Before that shift, because Medicaid administrators have the legal authority to negotiate prices with drug makers, those 6.4 million dual eligibles had their drugs paid for by the government at deeply discounted prices.

But under the Part D program, by law, Medicare is not allowed to negotiate drug prices. And so, when the dual eligibles were added to Medicare’s drug rolls, the government suddenly started paying higher prices for their drugs — 30 percent higher, on average, according to an analysis by Mr. Waxman’s committee.

As a result, Mr. Waxman contends, the drug industry got a $3.7 billion windfall in the first two years of the Medicare drug program, and he says pharmaceutical makers continue to reap more from Medicaid-eligible patients in the program than the companies would get if their drugs were provided through Medicaid.

“We want it back,” Mr. Waxman said in an recent interview. “We want to make sure the windfall for the drug companies does not continue, and we want to recover the money that has been a windfall.”

Dual eligibles now total some eight million people — or about one-fourth of Medicare drug beneficiaries. Mr. Waxman wants the drug makers to pay rebates on medicines sold to the dual eligibles, to put the prices more in line with what Medicaid pays for the same drugs.

The drug industry, says it has not received a windfall, and that Mr. Waxman’s analysis oversimplifies the issue.

It says that the government and patients in the Medicare Part D drug program can save more money in other ways that the industry has already worked out in the $80 billion agreement with the White House. That deal, which PhRMA says specifically precludes rebates for the dual eligibles, reportedly has the backing of Max Baucus, the Montana Democrat who is chairman of the Senate Finance Committee, which is a leader in the Senate’s health care effort.

Some details of the deal, including what political assurances the industry received for its offer, have not been made public by the White House, or Mr. Baucus. But PhRMA has agreed to support health care reform with a $150 million television advertising campaign — as long as the deal is what the industry says it agreed to.

Ron Pollack, executive director of Families USA, a nonpartisan group in Washington that works for affordable health care, said Mr. Waxman faced “an uphill climb” on the issue. Even if the House legislation includes the rebates Mr. Waxman seeks, Mr. Pollack predicted, the Senate will not go along.

But Mr. Waxman vowed to fight for the rebate plan in a conference committee with the Senate.

In 2003, when the Part D drug program was being planned as part of a Congressional overhaul of Medicare, Republicans insisted that the program be administered by private insurers and that the government be precluded from negotiating prices.

Stephen Schondelmeyer, a professor of pharmaceutical economics at the University of Minnesota who had conducted research for the government and industry, said that in 2003 many in Congress argued that private insurers would be more than capable of negotiating discounts with drug makers.

“That didn’t pan out,” Dr. Schondelmeyer said. The dozens of insurers involved, competing among themselves, simply do not have the government’s negotiating clout. While Medicaid is able to obtain rebates of up to 35 percent from drug makers, the Medicare drug rebates have been less than 15 percent, he said.

Dr. Schondelmeyer said it would be easy for the government to impose rebates on the dual eligible part of Medicare. But groups that promote free enterprise oppose that idea.

“This is best described not as a rebate but as a price control,” said Michael F. Cannon, director of health policy studies at the Cato Institute, a research group.

The nonpartisan Congressional Budget Office has studied the dual eligibles. A report it issued in mid-July showed that the federal government could save a net $30 billion over 10 years if drug prices were set at Medicaid levels for dual eligibles.

It was partly to head off such talk that PhRMA made an offer to the White House. As part of its $80 billion savings plan, it would give all people in the Medicare drug program a 50 percent discount if they entered an annual no man’s land in the coverage known as the doughnut hole.

The doughnut hole is a coverage gap that occurs after the person’s drug costs for the year reach $2,700; the coverage does not resume until the person’s costs exceed $6,154 for the year.

While in the hole, Medicare beneficiaries must pay for their own drugs or buy supplemental insurance. The PhRMA deal would give people drugs at half price during the doughnut hole period. PhRMA estimates this part of its proposal would save Medicare patients $34 billion over 10 years.

According to Ken Johnson, a PhRMA vice president, the industry placed a condition on its offer: the White House and Mr. Baucus would not support Mr. Waxman’s proposal for rebates.

“Over the long run,” Mr. Johnson said, “we felt seniors would be better served by reducing out-of-pocket costs in the doughnut hole, as opposed to a rebate in the so-called dual eligibles.”

He said that a study paid for by PhRMA had concluded that imposing rebates to benefit the low-income dual eligibles would make drug coverage 25 percent to 50 percent more expensive for the rest of the Medicare population.

But Mr. Waxman is not convinced by PhRMA’s arguments — or its agreement with the White House and Mr. Baucus.

“We don’t have any deal with them, and the whole enterprise of doing health insurance for all Americans isn’t to make the drug companies happy, or wealthier,” Mr. Waxman said. “They’re going to make a lot of money when we insure all Americans. There’s no argument for them to get a windfall.”

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Ted Kennedy, Senate’s Liberal Lion, Dies
Ron Elving and Brian Naylor - NPR

Sen. Edward M. Kennedy of Massachusetts — the scion of an American political dynasty who became an iconic liberal legislator — died Tuesday night of complications related to a cancerous brain tumor. The 77-year-old Democratic lawmaker was surrounded by family members at his home in the Kennedy compound in Hyannis Port on Cape Cod.

He will be buried in Arlington National Cemetery, though the date has not yet been announced.

Kennedy’s malignant brain tumor was diagnosed in May 2008, after a seizure struck him while at home on the Cape. He underwent a lengthy surgery in June 2008. Aided by cancer treatments, he returned to his work in the Senate late in 2008, pushing for an overhaul of the nation’s health care system and promoting legislation giving the FDA regulatory powers over tobacco products.

We’ve lost the irreplaceable center of our family and joyous light in our lives, but the inspiration of his faith, optimism, and perseverance will live on in our hearts forever,” said a statement released by the Kennedy family early Wednesday. “We thank everyone who gave him care and support over this last year, and everyone who stood with him for so many years in his tireless march for progress toward justice, fairness and opportunity for all.”

President Obama said that he and his wife were “heartbroken” by the news of Kennedy’s death. “I valued his wise counsel in the Senate, where, regardless of the swirl of events, he always had time for a new colleague,” the president said in a statement issued on Martha’s Vineyard, where the Obama family is vacationing. “I cherished his confidence and momentous support in my race for the presidency. And even as he waged a valiant struggle with a mortal illness, I’ve profited as president from his encouragement and wisdom.”

Obama said “an important chapter in our history has come to an end,” noting that Kennedy had played an important role in “virtually every major piece of legislation” for decades.

Kennedy had hoped to be at the center of this year’s debate over a landmark bill remaking the American health care system. Even after suffering a seizure on Inauguration Day, he again returned to work. He took part in early legislative skirmishes on behalf of the new president — whose nomination for the White House he had given a boost with an early endorsement. But as his illness advanced, Kennedy was unable to take the gavel when the Senate committee he chaired took up the bill in June.

Universally known as Teddy, Kennedy had served in the Senate since 1962, making him the third-longest-serving senator in history.

Staunch Liberal

In nearly a half-century in office, Kennedy was known as a champion of liberal causes and a defender of the Senate’s traditions. While he served briefly as the Senate’s majority whip (the second-most-powerful position) in his first full term, Kennedy lost that job to Sen. Robert C. Byrd of West Virginia in 1971. He did not return to the formal leadership thereafter.

Instead, Kennedy made his mark with legislative work, earning a reputation as a formidable negotiator as well as a fierce floor fighter. His committee assignments included Labor and Human Resources, Judiciary, and Armed Services. He was chairman of the Judiciary Committee in the 1970s and later shifted to the gavel he held this year on the Health, Education, Labor and Pensions Committee.

Over the years, he saw the agenda of the Senate change from the civil rights debates of 1964 to the war in Vietnam to Watergate to the struggles against Democratic President Jimmy Carter and Republican President Ronald Reagan. As a member and later chairman of the Senate Judiciary Committee, he participated in the confirmation proceedings for every member of the current Supreme Court except Justice Sonia Sotomayor, from Justice John Paul Stevens in 1975 to Justice Samuel Alito in 2006. (He left the committee at the end of 2008 and did not participate in the hearings on Sotomayor’s nomination.)

Kennedy had been seen as an inevitable presidential candidate almost from the time he was old enough to run, following in the footsteps of his brother, President John F. Kennedy, who was assassinated in 1963, and their brother, Sen. Robert F. Kennedy, who was assassinated while running for president in 1968.

But an early grab for the brass ring, expected in 1972, was scuttled after Kennedy drove off a bridge at Chappaquiddick Island, Mass., in July 1969. The young woman who was with him, an aide named Mary Jo Kopechne, drowned. Though charged with leaving the scene of the accident, his two-month sentence was suspended and he was not punished further. But Kennedy never entirely escaped the incident’s shadow.

When he did run for president in 1980, it was as an intraparty challenger to Carter, the incumbent. Kennedy saw Carter as squandering an opportunity for progressives to guide the nation, but Democratic primary voters gave the nomination to Carter. Although Kennedy initially positioned himself for another try in 1988, he took himself out of the running early.

A Political Dynasty

Attraction to the pinnacles of power had made the Kennedy family the best-known political dynasty of its era.

Its patriarch, Joseph P. Kennedy, was a Wall Street financier and political power broker who served as the first chairman of the Securities and Exchange Commission and then as ambassador to Great Britain. The eldest of his sons bore his name and was killed in World War II. Teddy was the fourth son — and last of nine children. He was born to the elder Kennedy and his wife, Rose, in 1932, the year Franklin D. Roosevelt won his first term as president.

The youngest Kennedy graduated from Milton Academy in 1950 but was dismissed from Harvard the following year for having another student take a Spanish exam in his stead. He enlisted in the Army during the Korean War and was sent to Europe.

In 1953, he was readmitted to Harvard, graduating in 1956. He received his law degree from the University of Virginia in 1959 and, after working as coordinator of Western states for his brother’s presidential campaign in 1960, became an assistant district attorney in Suffolk County, Mass.

That job was just a holding pattern. Bay State Democrats could scarcely wait to move the president’s telegenic and well-spoken brother into statewide office — specifically, the Senate seat the president had vacated. But the younger Kennedy first had to turn 30 to meet the constitutional age requirement, and the party had a family friend, Benjamin A. Smith, hold the seat as an appointee for two years. In November 1962, Kennedy was elected to finish out the two remaining years in his brother’s term.

A Key Figure In The Senate

Kennedy’s early years in the Senate were marked by ambition and strong commitment to his brothers’ causes and the Great Society programs of President Lyndon Johnson.

He was an advocate for labor unions and a higher minimum wage. He was involved in the civil rights and voting rights debates at mid-decade, and he pressed for an expanded role for the government in health care. He supported the creation of Medicare in 1965 and of a national system of neighborhood health care centers as part of the Economic Opportunity Act of 1966.

In the 1970s, Kennedy continued to press a national approach to health care and health insurance, negotiating with Presidents Richard M. Nixon, Gerald Ford and Jimmy Carter but never reaching the agreement he wanted on systemic change.

Although he came up short as a presidential candidate in 1980, Kennedy redirected his energies and became a legend in the Senate. He immersed himself more than ever in health care and labor issues. Among the legislation he helped to pass were the Family and Medical Leave Act, the WIC nutrition program, job training programs and AmeriCorps.

As chairman of the Judiciary Committee, Kennedy defended abortion rights and helped lead the effort that denied confirmation to President Reagan’s Supreme Court nominee Robert Bork in 1987. Schools were also a Kennedy focus, and in 2001 he worked with newly elected Republican President George W. Bush to pass the “No Child Left Behind” education program, helping win substantial increases in federal education spending.

But the two soon parted ways. Kennedy was an early and outspoken opponent of the war in Iraq, voting against the 2002 resolution authorizing the invasion and calling it George Bush’s Vietnam. He also opposed Bush’s tax cuts — as well as Bush’s Supreme Court nominees, Alito and John Roberts.

Yet as partisan as he could be, Kennedy also was known for the partnerships and friendships he forged with Senate Republicans. Utah’s Orrin Hatch, Sam Brownback of Kansas and Mike Enzi of Wyoming all worked closely with Kennedy on the Health, Education, Labor and Pensions Committee.

Kennedy was also known to work easily with the GOP’s 2008 presidential nominee, Sen. John McCain of Arizona. The immigration bill that Kennedy and McCain co-sponsored in 2007 had the support of President Bush, but it could not overcome objections from Senate Republicans.

Speaking on the floor of the Senate, Kennedy evoked some of the battles he had voted on in that chamber in earlier decades.

“It was in this chamber a number of years ago that we knocked down the great walls of discrimination on the basis of race, that we knocked down the walls of discrimination on the basis of religion,” he said. “Here in this Senate, we were part of the march for progress, and today we are called on again.”

Leader Among Democrats

While Kennedy made just one run for the presidency, he was an influential voice in national party politics for decades. In 2004, he campaigned extensively for fellow Massachusetts Democrat Sen. John Kerry’s bid for the party’s nomination and helped steer the Democratic National Convention to Boston.

In 2008, Kennedy made a timely and somewhat surprising endorsement of one of his Senate colleagues, Barack Obama, over another, Hillary Clinton. Having Kennedy in his corner helped candidate Obama cement his hold on the party’s liberal bloc and paved the way to his nomination.

Kennedy had three children with his first wife, Joan; the couple divorced in 1982. He also had two stepchildren with his second wife, Victoria Reggie, a Washington attorney he married in 1992. His son Patrick J. Kennedy represents the 1st Congressional District of Rhode Island.

Kennedy was passionate about his beliefs, a tireless worker for his causes, and he loved fighting the good fight.

In 1980, having failed in his challenge to Carter, Kennedy addressed the Democratic National Convention. He was talking about his campaign, but his words are an apt summation of his life:

“For me, a few hours ago, this campaign came to an end. For all those whose cares have been our concern, the work goes on, the cause endures, the hope still lives, and the dream shall never die.”

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Swine Flu Could Infect Half of U.S.
Presidential Panel’s Estimate Is First To Gauge Possible Impact of Pandemic
By Rob Stein - Washington Post Staff Writer

Swine flu could infect half the U.S. population this fall and winter, hospitalizing up to 1.8 million people and causing as many as 90,000 deaths — more than double the number that occur in an average flu season, according to an estimate from a presidential panel released Monday.

The virus could cause symptoms in 60 million to 120 million people, more than half of whom might seek medical attention, the President’s Council of Advisors on Science and Technology estimated in an 86-page report to the White House assessing the government’s response to the first influenza pandemic in 41 years.

Although most of the cases probably would be mild, up to 300,000 people could require intensive care, which could tie up all those beds in some parts of the country at the peak of the outbreak, the council said.

“This is going to be fairly serious,” said Harold E. Varmus of Memorial Sloan-Kettering Cancer Center in New York, co-chair of the 21-member council. “It’s going to stress every aspect of our health system.”

The estimates mark the first time experts have released specific calculations about the possible U.S. impact of the pandemic. The “plausible scenario” is based on previous pandemics and how the swine flu behaved in the United States this spring and during the Southern Hemisphere’s winter over the past few months, said Marc Lipsitch of the Harvard School of Public Health, who helped prepare the estimate.

“They are not a prediction, but they are a possibility,” he said in a telephone interview, noting that the estimates are based on various assumptions, including that the virus will not mutate into a more dangerous form or infect more older people.

“If it turned out to affect a lot more adults, the severity would be a lot worse,” Lipsitch said.

While the seasonal flu is associated with 30,000 to 40,000 deaths and 200,000 hospitalizations each year, the lack of immunity to the swine flu virus probably will lead to many more people becoming infected, sick — and possibly to 30,000 to 90,000 deaths, the council said. And while most deaths during a typical flu season occur in the elderly, swine flu is more likely to kill children and young adults, the panel said.

Lipsitch stressed that the outbreak could turn out to be milder, too. The primary purpose of the estimates was to help guide planning to protect the public. For example, it was estimated that the outbreak could peak in mid-October, so the panel urged expediting the availability of a vaccine.

In addition, the panel recommended clarifying how antiviral drugs should be used to fight the pandemic, speeding a decision about whether to approve intravenous antivirals in case they are needed, designating someone at the White House to coordinate the nation’s response to the virus, and improving the system for tracking the spread of the new virus.

Swine flu virus, or H1N1, emerged last spring in Mexico and quickly spread to the United States and around the world. Although far less dangerous than initially feared, the virus has sickened children and young adults more frequently than the typical seasonal flu.

“This isn’t the flu that we’re used to,” said Health and Human Services Secretary Kathleen Sebelius. “The 2009 H1N1 virus will cause a more serious threat this fall. We won’t know until we’re in the middle of the flu season how serious the threat is, but because it’s a new strain, it’s likely to infect more people than usual.”

The pandemic has caused significant disruptions and economic damage in parts of the Southern Hemisphere, and has contributed to the deaths of more than 1,799 people in at least 168 countries, including at least 522 in the United States. A second wave of infection is expected to begin within weeks in the Northern Hemisphere as schools reopen and cooler weather returns.

Overall, the panel praised the federal government’s response, which has included signing contracts to spend nearly $2 billion to buy at least 159 million doses of vaccine from five companies that are rushing to produce it. But the first batch is not expected to be available until mid-October, when the outbreak could peak.

“This potential mismatch in timing could significantly diminish the usefulness of vaccination for mitigating the epidemic and could place many at risk for serious disease,” the report states.

The report recommends that a portion of the vaccine be made available by mid-September for those at highest risk by asking the manufacturers to start filling vials with vaccine even though the studies to determine dosages and whether a booster will be necessary have not been completed.

Administration officials said they are already taking action on the panel’s recommendations. All five companies “have been asked to put their initially available vaccine in vials as soon as they are ready,” for example. “This will move forward, even while awaiting results of clinical studies to confirm expected dosing, to ensure the earliest possible availability of initial doses of vaccine.”

“This report is being read very carefully,” said John O. Brennan, White House deputy national security adviser for counterterrorism.

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Dems mull healthcare bill without GOP 
By Jared Allen - The Hill
 
A leading House Democrat on Monday said Democrats are prepared to pass healthcare reform without Republican support, echoing comments made over the weekend by a leading Senate Democrat.

“I think that at some point everyone’s going to see that the Republicans simply are not going to agree to any kind of healthcare reform that the insurance industry isn’t supporting and that, reluctantly, we’re going to have to do it without them,” said Rep. Jan Schakowsky (D-Ill.).

“If we have to, we will,” said Schakowsky, a chief deputy whip and the chairwoman of the Congressional Progressive Caucus’s healthcare task force.

On Sunday, Sen. Charles Schumer (D-N.Y.) said Senate Democrats are formulating a game plan that includes passing healthcare on the backs of Democrats alone.

“At some point after we get back, if we don’t have a bipartisan bill, we’ll never be able to meet the goal of having a bill signed into law by the end of the year, so yes, we are considering alternatives,” Schumer said on NBC’s “Meet the Press.”

Liberal groups around the country have been frustrated with efforts by some Senate Democrats to craft a bipartisan bill through negotiations among six members of the Senate Finance Committee. They’ve worried those discussions will needlessly water down a bill, and that the party that holds the White House and large majorities in the House and Senate should be able to pass healthcare on the strength of their own members.

The large House majority means Democrats could lose dozens of votes in the chamber and still pass a bill without Republicans’ support, but the situation is much more complicated in the Senate. Democrats hold a filibuster-proof 60 votes in that chamber, but health issues have kept two Democrats away from the House for much of the year, and some centrist Democratic senators may not support a healthcare bill that includes a public insurance option.

Even in the House, it may be difficult to pull together the Democratic votes necessary to move a bill that includes a public health insurance option, something that Schakowsky said is the goal of House Democrats.

“I believe what the Speaker has said — that we will pass a bill, that it will have a public health insurance option in it — and I think that we will be able to abide by the timetable that was originally set out, which would be that by October the House will have passed a bill and hopefully the Senate will as well,” Schakowsky said.

Senate Democratic leaders are contemplating breaking up healthcare reform into smaller pieces in part to get bipartisan support for less controversial provisions and potentially build momentum for the heavier lifting. Doing so also could allow them to invoke special budget rules that would require only 51 votes to move more controversial provisions, such as the public health insurance option. 

Schakowsky’s comments came on a conference call organized by the Democratic National Committee that was designed to hit back against Republican National Committee Chairman Michael Steele’s Monday op-ed in The Washington Post, in which Steele wrote that seniors in particular would be hurt by the Democrats’ healthcare reform plans.

Schakowsky called Steele’s op-ed “just simply riddled with lies, and we need to call him out on that.”

In announcing a “Seniors’ Health Care Bill of Rights,” Steele charged that the reform Democrats are backing would threaten Medicare and force seniors to accept worse and rationed healthcare. Steele also re-introduced the idea that a Democratic healthcare system would coldly dictate the type of end-of-life care seniors would receive.

“The Republicans are doing nothing but saying ‘no’ and spreading lies,” Schakowsky said. “Fear is their friend.”

The Democrats’ angry reaction to Steele’s op-ed further eroded hopes for a bipartisan healthcare bill, which began to fray at the beginning of the August recess when bipartisan talks among members of the Senate Finance Committee stalled.

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This Could Be the Next Big Issue in Health Reform
No, this is not about “death panels.”
 
The town hall meetings.  The media coverage of the town hall meetings.  Media polls about how the American people feel about the town hall meetings.  And even the media myth busting and fact checking about the most extreme claims made at the town hall meetings and the Administration’s daily efforts to set the record straight.  All these things have focused attention on a few hot button issues that activists on the right and the left who attend town meetings care about most.  They have diverted attention from the core elements of health reform legislation, and from the core concerns of the American people about their health care costs, which generated the health reform debate in the first place.  When the congressional recess ends, policymakers will hopefully refocus on those concerns.

Possibly the biggest issue—the biggest real issue, that is—standing in the way of movement forward on health reform has been how to finance a plan.  That’s not particularly surprising.  It’s always been expected that generating tax revenues and savings in Medicare and Medicaid to offset the new costs associated with expanding insurance coverage would be difficult and controversial.

There’s been a lot less talk, however, about what people will get for that financing.  What level of subsidies will be available to make coverage more affordable for people?   What kind of coverage will people receive and will it meet the public’s expectations?  These issues are, of course, linked.  If reform is to be deficit neutral at least for the first 10 years (as the President and Congressional leaders have vowed), then the costs associated with reform and the revenues to fund it are a bit like a see-saw.  Revenues or savings and costs have to be in balance.  But, so long as costs and offsets are equal, balance can be achieved at any level—a cost of $800 billion over 10 years, $1 trillion, or $1.5 trillion or more.

They are linked politically, too.  The greater support there is for the positive things that reform will do for people, the easier it will be to gain political support for the revenues and savings needed.  A smaller package—that is, one that costs less—is, from one perspective, more politically palatable.  It increases government spending by a lower amount, and therefore requires lower savings and revenues to avoid raising the deficit.  But, it will ultimately only be judged a success if the benefits provided are perceived as worth the cost of providing them.

If reform legislation advances in Congress, the media and the American people will start to look beyond the cost and financing issues and focus on the coverage and subsidies in the proposals. Will they be viewed as a good deal for the roughly $1 trillion spent over the next ten years and as a fair deal by people who will now be required to have health insurance coverage?  This could be the next big issue in the reform debate, if and when a final bill emerges, and much will depend on whether the American people feel it delivers a reasonable level of relief for the expenditures required.

Here are five things to watch out for as this discussion plays out:

1.  How high up the income scale will subsidies go?

Health insurance is expensive, and therefore out of reach for many Americans.  Who will be eligible for subsidies in the new insurance exchanges?  Everyone with annual income up to 400% of the poverty level?  300% of poverty?  Even less than that if pressure builds to lower the cost of the legislation?  At the point where subsidies stop, people without access to employer coverage will be responsible for the entire health insurance premium, and this could represent a substantial portion of their income.  For example, if subsidies reach people with annual income up to 400% of the poverty level ($88,200 for a family of four), a family at 401% of poverty would pay 11% of income for a $10,000 insurance policy.  But, if subsidies only go up to 300% of poverty ($66,150), a family at 301% of poverty would pay 15% of income for that same policy.  Also, since subsidies generally phase out as the maximum eligibility threshold is approached, taking subsidies higher up the income scale will mean more help for people below the threshold.

2.  Is there an individual requirement to obtain coverage and how severe are the penalties for not complying?

The level of premiums (net of subsidies) that people face under reform will be viewed very differently if everybody is required to buy insurance and penalized if they don’t.  The lower the subsidies available—and, therefore, the more people will have to pay—the more pressure there will be to moderate the penalties for not complying with the individual requirement and/or creating exemptions for people who face premiums that represent a substantial portion of their incomes.  Mandatory insurance also changes the politics of the public’s reaction.  People will be very focused on the cost of coverage to them and the benefits they get, because they will not be able to opt out if they think it’s a bad deal.

3.  What coverage will people get?

This involves a tough balancing act.  With an individual requirement to purchase coverage, some level of minimum insurance needs to be defined.  There will be pressure to keep the minimum low to hold premiums down and avoid forcing many people who are insured today to increase their coverage and the premiums they pay.  At the same time, there is a risk that too parsimonious a package—which does little for people who are underinsured today—will cause people to look at it and decide reform isn’t worth it.  For low and modest income people, in particular, the level of cost sharing they face is key to making health care more accessible.  Even if subsidies make their premiums affordable, will the deductible and coinsurance be affordable too?  An important element is whether the insurance policy has an out-of-pocket maximum that would prevent families from going into severe debt even with insurance.

4.  How much will insurers be allowed to vary premiums by age?

In a voluntary insurance system like we have today, age rating is necessary to avoid having younger (and, therefore, generally healthier) people flee the market.  But in a universal system that  is no longer necessary, and proposals coming out of Congressional committees are looking to limit how much premiums can vary by age.  How age rating is handled is partly a question of values—should younger people subsidize the cost for older people or not?  However, it also interacts with subsidies.  Particularly if the subsidy threshold is low, large variations in premiums due to age could result in older people just above the threshold paying a very substantial percentage of income for insurance.  For example, if premiums were allowed to vary by age by a factor of two to one, the premium for a family of four with a 64 year old head of household could perhaps be $15,000 per year.  At 301% of the poverty level, that would represent 23% of income.  But if premiums were allowed to vary for age by a factor of five to one, the premium for that family could jump to $22,000, or 33% of the family’s income.  Both two to one and five to one ratios are being discussed.

5.  What will be available for the lowest income Americans?

The answers to these questions could affect all Americans, including related changes to the insurance market that would make coverage more accessible and stable for people with health conditions. However, it’s also important to remember that 65% of the uninsured have incomes below 200% of the poverty level ($44,100 for a family of four).  What will reform mean for them?  Will Medicaid—which is now limited by categorical requirements that generally exclude childless adults and income guidelines that vary state to state—be expanded to cover all people and up to what percent of the poverty level—100%, 133%, 150%?

There are tradeoffs in all of this.  Expanding subsidies and making coverage more comprehensive costs money, and deficit hawks are hesitant to sign on to a bill that increases government spending by too much, even if it leaves the deficit unchanged over 10 years.  That’s the discussion we’ve been watching play out with the Blue Dog Democrats in the House and the negotiations with moderate Democrats and Republicans in the Senate Finance Committee.  However, there are risks on the other side as well.  People may start to look more closely at the benefits and subsidies that a bill costing $1 trillion or less over 10 years can buy.  Regardless of how Congress and the Administration ultimately navigate this territory, it will be important to look not only at the financing of reform, but also at what people will get for the money.  Once there is a bill in the House and in the Senate that can be scrutinized more closely, the benefits delivered for the money spent and whether or not it meets the public’s high expectations for help with their health care costs could be the next big issue in health reform.

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Concern, Doubts From the Left on Obama’s Health-Care Plan
By Dan Balz - The Washington Post

Through most of the summer, opposition to President Obama and his health-care initiative has come almost entirely from the right. In the past week, however, the president has been trying to tamp down a noisy uprising on the left.

The immediate cause for the rebellion is growing concern among Obama’s progressive allies that he is prepared to deal away the public insurance option to win passage of a health-care bill. Obama insists that he still prefers the public option as part of any legislative package, but some friends on the left now clearly doubt his resolve.

That has given way to broader criticisms: Is Obama tough enough to defeat the interests arrayed against health-care legislation? Has he lost the passion that was such an asset during the campaign? Have his rhetorical skills been muted as he descends into the dry, arcane details of health care? Is he too enamored of bipartisan consensus, given what is seen as Republican implacability? Has he given up the moral high ground in the health-care battle?

From liberal commentators to progressive bloggers to grass-roots activists who went door to door during the campaign, there has been a chorus of concerns raised about Obama — on health-care strategy, on the deals he and his team have struck with the health-care industry, on the stepped-up troop commitment in Afghanistan, on detainees and torture policy.

How serious is the discontent on the left? Jane Hamsher, founder of the progressive blog http://firedoglake.com and a harsh critic of the White House strategy on health care, said Obama and his team have negotiated themselves into an untenable corner and should not expect the left to bail them out.

“I think it was always coming, and I think they were foolish not to see it coming,” she said of the disenchantment expressed by some on the left. “He campaigned on a public plan, and people are really attached to it.”

The deals the White House has made with drug companies and other health-industry stakeholders, she added, “have neutered their ability to pass any kind of meaningful health care reform. . . . There is no natural constituency for that bill. Blue Dogs don’t want it. Republicans don’t want it. Progressives don’t want it.”

Obama seems to regard the flare-up on the left as less serious. He coined the phrase of the week in describing the state of play in health-care politics when he said that in August, Washington often gets “wee-weed up” over some change in the landscape. He urged everyone to calm down.

David Plouffe, Obama’s 2008 campaign manager, a year ago dismissed Democratic nervousness about Obama’s candidacy and pointed criticism of the campaign’s strategy as “hand-wringing and bed-wetting.” Now he says the current uproar reminds him of those trying moments when Obama’s allies were running for cover.

“In many respects, this is not different from the political campaign we went through,” he said. “There are going to be twists and turns and moments you think are going to be decisive. I’m not sure this is a seminal moment. But people have strong views and have a right to air those views.”

A close look at public polling offers some perspective on the current clamor from the left. Obama is still highly popular among liberals, but there has been some falloff, although precisely how much and for what reason are not clear.

The latest Washington Post-ABC News poll showed that Obama’s overall approval rating among liberals has gone from 94 percent at the 100-day mark of his presidency in April to 83 percent today. Fifteen percent now disapprove, up from 1 percent in April.

An NBC News-Wall Street Journal poll also showed the president’s approval among liberals dropping. It went from 89 percent in April to 81 percent last week, with disapproval hitting double digits for the first time (at 13 percent).

The Pew Research Center measured changes among liberal Democrats and found that Obama’s approval slid from 95 percent positive in July to 86 percent in August. The falloff among liberal Democrats was one of the biggest recorded for any group examined in the poll.

One note of caution is that these polls were completed before the turbulence over the public option hit full force.

Bill McInturff, a Republican pollster who teams with Democrat Peter Hart to conduct polls for NBC News and the Wall Street Journal, said that over the past month there seemed to be as much or more movement away from Obama among white Democrats who say they are not liberal or moderate (the equivalent of Blue Dog Democrats) as among liberals.

He also emphasized that the changes measurable in public opinion surveys among these groups are subtle and very much at the margins. “Here’s the point you can make as a pollster,” he said. “We can measure from late July to mid-August. To the extent there was slippage, it was from the right side of his party, not his left. But now that the president is in the crossfire on dealing with the public plan, that could be changing.”

Andrew Kohut, who directs the Pew Research Center, said it is difficult to know whether the changes in support simply reflect that liberal Democrats are catching up with other Americans in their perceptions of Obama or whether the uproar over the public plan marks a genuine change in attitudes.

Kohut said Obama is still doing better with his base than Bill Clinton was doing at a comparable point in his presidency and is doing about as well as George W. Bush did in holding support among his party’s base. “There are a few clouds that weren’t there a month or two ago, but there’s not a real storm brewing with the base for Obama,” he said.

White House officials said Obama’s public advocacy last week, including a conference call with grass-roots supporters during which an estimated 280,000 people dialed in, has helped to calm nerves on the left. It’s likely to take more than that, however, to stir the passions of those who long for a return to the atmospherics of the campaign.

Plouffe said he thinks Democrats have a historic opportunity to make improvements in the economy, health care and energy that will benefit the country and pay dividends to their party for years to come — if they don’t lose their nerve. “That could be our legacy and will be our legacy,” he argued. “We need to stay focused on that.”

The test will come in the fall, when Democrats are presented with a concrete set of proposals and the bells ring for a vote. That will be when it becomes clear if there is a real rupture between Obama and his progressive allies.

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Can Health Reform Pass? Experts Weigh In
By KHN Staff

Will President Barack Obama and congressional Democrats have to greatly scale back their health care overhaul proposals to get legislation passed this year?

Here’s what some experts are saying.

Henry J. Aaron, health care economist at the Brookings Institution:

Congress and Obama should attempt to pass what is necessary for setting the foundation for a process of evolution to change the health care financing and delivery system. That may come in part through legislation, but in addition large-scale institutional changes. . . . The challenge of finding acceptable ways of paying for near-universal coverage is formidable and may prove insurmountable. For reasons that President Obama has forcefully stated, health care system reform is vital. But the full reform agenda may be beyond immediate political reach. It is therefore essential to identify elements of the full plan that would set the stage for later reforms and that can be financed at a politically digestible price – and find a way to ensure their passage.

Ross K. Baker, professor of politics at Rutgers:

I absolutely think they’ll have to have a fallback position. They’ll have to accept something considerably less comprehensive, less federal government-centered and simply use it as a place holder – whatever it is, as inadequate as it may appear to be to the core of the Democratic Party. It would be a presumed placeholder for something to come along later. That’s been the history of social legislation in the United States. FDR wanted to have national health insurance as part of Social Security. The battle over getting Social Security was so fierce he later dropped it. (Harry) Truman tried to get Medicare and failed. (John F.) Kennedy tried it and failed. And it wasn’t until (Lyndon) Johnson was in office in 1965 that Congress finally passed it. In this country, social policy changes incrementally. It’s almost never done in a single stroke.

Karen Davis, president of the Commonwealth Fund:

All the elements of what Obama talked about are there now in the House and pretty much in the Senate (Health, Education, Labor and Pensions) bill: an individual mandate, insurance exchanges, income-related premiums, shared financial responsibility with employers contributing, Medicaid expansion. When I hear scaled-back, is the idea to drop that framework and just do some Medicaid expansion and tax credits for private insurance? I don’t see that yet. What I understood the Senate (negotiators) to say was that they’re scaling back to $800 billion or $900 billion (over 10 years), keeping the basic structure, but limiting the actuarial value of benefits or how far up the income scale they go with premium subsidies, helping low-income working class families, but not making it truly affordable for the median income family. That kind of scaling back may be inevitable.

Charles “Chip” Kahn III, president of the Federation of American Hospitals:

I don’t think anybody expected this kind of visceral reaction (at health care town hall meetings)…. I think the members from those swing districts are going to take this real seriously. I think the Republicans could think this means they could be successful in holding this thing off. If nothing else, I think it’s energized their base.

Peter Lee, executive director of health policy at the Pacific Business Group on Health:

For Obama and the Democrats, they have to be able to announce major reform. It may be a lot less than many would have wanted …but any reform is substantial reform, so we’re likely to see something they can trumpet as significant reform.

Marilyn Moon, vice president and director of the health program at the nonprofit American Institutes for Research in Washington:
“I’m not sure anyone knows where they should be or where they will end up being. They seemed awfully quick to dump some things that I think are based on the misinformation out there. I hate to see us making policy on the basis of essentially the lunatic fringe. I’ve heard some (lawmakers) have dumped the provision in Medicare aimed at extending end of life information. To let that go reinforces bad behavior on the part of policymakers and pundits. Then there’s the question of the (proposal for a government-run public health plan). I don’t see how you can possibly make a co-op work. If you give up on the public plan, that pretty much is giving up on something to counter the private sector. What　they’ll need then are really good, tough regulations. Will that then be a target of the right?

David Nexon, senior executive vice president at the Advanced Medical Technology Association and former aide to Sen. Edward Kennedy, D-Mass.:

I would be astonished if (the Democrats) weren’t able to pass a big health care bill.…This is the best shot to get most people covered in a generation.”

Len Nichols, an economist at the New America Foundation:

I don’t think people have given up on the big thing. The committee chairs, the leadership, the White House and the stakeholders understand profoundly that our (health care) system is unsustainable and they have to start restructuring incentives (now) because it will take a decade. If we fail and wait a decade, it will be that much harder.

John Rother, executive vice president, policy and strategy, AARP:

This is a dynamic environment, and the public plan is the most obvious of the potential changes…There’s so much in this bill that’s interactive. When you go through it, the core provisions pretty much have to stay put….You can’t pull one piece without having the rest of the structure collapse, at least on the basic issues of finance, shared responsibility, that kind of thing. I do think they have the price tag about as low as it can go and still have insurance be affordable.

Larry J. Sabato, director of the University of Virginia Center for Politics:

I think it’s already probable. I don’t see how they get anything even close to what Obama originally proposed. Most people think he’ll end up with half of what he wants: Some requirement for insurance affordability, maybe that co-op proposal. But no one understands what that proposal is. . . . The Democrats are not going to do to Obama what they did to (Bill) Clinton (in rejecting his national health care plan), because they saw the (politically damaging) results of that. Doing nothing is worse than doing everything. . . . The logical solution is to do something in between to give Obama and the Democrats something to crow about.

Neil Trautwein, vice president of the National Retail Federation:

I think getting wiser heads to kind of scale back expectations and to really focus on the end goal of enacting reform (is needed). We still miss the deal makers we had in the older times and when I started my career in Washington, but hopefully they can conger up a little of that deal-making of the past.

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House Democrats Examine Health Insurers’ Pay, Profit
By Lorraine Woellert and Brian Faler - Bloomberg.com

Aug. 19 (Bloomberg) — House Democrats asked the nation’s biggest health insurers to provide details on executive pay, spending on entertainment, and other financial records, a move that an industry spokesman denounced as an intimidation tactic.

House Energy and Commerce Committee Chairman Henry Waxman and Representative Bart Stupak, chairman of the panel’s oversight committee, sent a letter to 52 insurance companies, including Hartford, Connecticut-based Aetna Inc., Louisville, Kentucky-based Humana Inc. and Philadelphia-based Cigna Corp.

In a separate letter, Representatives John Dingell and Sander Levin, both Michigan Democrats, today asked Blue Cross Blue Shield of Michigan to explain a series of rate increases the company announced last week.

Waxman, of California, and Stupak, of Michigan, along with Dingell and Levin, are among a team of House Democrats trying to beat back criticism of legislation to revamp the nation’s medical-care system. House Speaker Nancy Pelosi, a California Democrat, has complained about the insurance industry’s “immoral” profits.

A spokesman for the Washington-based industry group, America’s Health Insurance Plans, criticized the Waxman letter.

‘Fishing Expedition’

“This is a fishing expedition that is designed to silence the health-insurance industry,” said Robert Zirkelbach. “It’s an effort to change the debate to focus on health insurers rather than focus on the solutions to the health care concerns that the American people have raised.”

Zirkelbach declined to say whether the group believes the companies ought to comply with the lawmakers’ request.

“We are reviewing the letter from Chairman Waxman and will respond as appropriate,” Chris Curran, a spokesman for Cigna, said in an e-mailed statement. He said some of the information is already available in public documents. Humana spokesman Tom Noland said the company plans to cooperate “fully” with the committee. An Aetna spokesperson didn’t immediately respond to a request for comment.

The energy and commerce panel is investigating “executive compensation and other business practices in the health insurance industry,” Waxman and Stupak wrote in the Aug. 17 letter. The lawmakers asked the insurers to provide most of the pay information by Sept. 4, and the other data by Sept. 14.

Targeting High Earners

The letter asks the companies to name all employees who were paid more than $500,000 in a single year between 2003 and 2008 and to itemize their pay, including bonuses, stock options, perquisites and deferred compensation.

The letter asked the companies to explain how they determined what to pay executives and provide documentation used by their boards’ compensation committees. It also seeks information about corporate events held off company grounds since Jan. 1, 2007, including how much was spent on transportation, entertainment, gifts and food.

The lawmakers asked the companies how much they earn through programs such as Medicare Advantage, which allows private insurers to deliver federally funded benefits. They called on the companies to provide data on profits from the individual insurance market and insurance provided through employers.

‘Tough Decisions’

Dingell and Levin questioned Blue Cross Blue Shield of Michigan’s need for a rate increase. The lawmakers asked the Detroit-based company to explain why it didn’t use a $2.4 billion surplus to offset the rate rise.

“These rate increases have the potential to force more and more families to make tough decisions that no one should be forced to make — whether they pay the mortgage or utility bill or pay health insurance premiums,” the Michigan lawmakers wrote. They also asked company president and chief executive officer Daniel Loepp to provide pay data for employees who earned more than $500,000 a year.

Blue Cross Blue Shield of Michigan Vice President Andrew Hetzel said the company accepts everyone for coverage regardless of medical condition and limits its profits. Last year, the company paid $133 million more for care for its individual members than it collected in premiums, Hetzel said.

“Even with the rate increase, Blue Cross will continue to lose money to its individual products,” he said in a written statement.

The Obama administration has proposed financing its overhaul of the nation’s health-care system in part by cutting federal subsidies to insurers participating in the Medicare Advantage program by $175 billion over the next 10 years.

Some plans under consideration in Congress would offer Americans the option of purchasing health insurance from a government-run program. Republicans say this proposal would harm private insurers and hurt consumers.

To contact the reporter on this story: Lorraine Woellert in Washington at lwoellert@bloomberg.net, or Brian Faler in Washington at bfaler@bloomberg.net.

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Tackling the Mystery of How Much It Costs
By GINA KOLATA - The New York Times

You go to a restaurant, peruse the menu, take your waiter’s suggestions, and order a meal. But there is something odd: the menu has no prices and you have no idea what you will be required to pay until a few weeks later when the bill arrives in the mail.

That, it turns out, is analogous to what goes on in health care, where fees are hidden at the time of service. Making matters even worse, patients often are seeking care when they are frightened and vulnerable, in no position to ask about prices or haggle.

For the most part, doctor fees are a mystery. If people see a doctor who is part of their insurance network, they are responsible only for deductibles and co-payments, and the price the health insurer pays is often a secret. And if people see a doctor outside their network, they usually have no idea what the charge will be — even though they are responsible for most of it — until the bill comes.

“This is a huge part of why expenditures are so high and why they are rising,” said Dr. Alan Garber, a health economist at Stanford University. “How can you get a market to work if no one has any idea of what the prices are?”

But the health care legislation under discussion does not directly address the out-of-network fee issue. And that is intentional, says Dr. Mark McClellan of the Brookings Institution. Dr. McClellan, a former head of Medicare who works closely with policy makers, says the goal of the House and Senate bills is to encourage people to stay in their networks. He added that the result should be networks that provide better care “so that people don’t have so much need to go outside of them.”

Linda Douglass, communications director for the White House Office of Health Care Reform, explained the legislation in an e-mail message: “Under health insurance reform, insurance plans will be required to give consumers much more information about what is covered and what is not. They will be expected to warn consumers that if they go out of network, they can be hit with some very high costs.”

Legislation proposed by the House Committee on Energy and Commerce also says that health insurers must pay a full out-of-network bill in one circumstance — if an insurance network is “inadequate,” as determined by a state insurance commissioner, and a patient goes outside that network for care unavailable within the network.

Some prominent health economists and policy experts, however, say there should be limits on how much doctors can charge for out-of-network care.

Mark A. Hall, a professor of law and public health at Wake Forest University, for example, advocates restricting out-of-network fees to a fixed amount, perhaps 150 percent of the amount Medicare would pay.

That is how the system works in Germany, says Uwe Reinhardt, a health economist at Princeton University. Professor Reinhardt advocates a national law that caps the maximum doctors can charge when they are out of a patient’s network.

America’s Health Insurance Plans, which represents health insurers, is also trying to draw attention to out-of-network doctors’ fees. Last Tuesday, the group released results of its own survey to show how high such fees can go. It included, for example, a patient in Colorado who was charged $26,000 for gall bladder surgery, compared with Medicare’s fee of $681, and a patient in California who was billed $15,870 for cataract surgery for which Medicare pays $638.

One company, Ventana, in San Francisco hopes to help people estimate ahead of time what prices have been negotiated within insurance networks and how much they would pay to go out of network.

“Providers have no interest in disclosing what their actual price is,” said Ventana’s founder, Dr. Giovanni Colella, a San Francisco doctor and businessman.

Dr. Colella added that the issue of varying prices was not just a problem for patients but also for insurers who negotiate with doctors and hospitals.

“There is the retail price and the negotiated price, and the negotiated price stays secret,” Dr. Colella said. And the negotiated price — the amount doctors agree to accept from insurers — can vary enormously, for the same procedure in the same geographical area. For example, the negotiated price for a colonoscopy in San Francisco ranges from $700 to $7,000, Dr. Colella said.

Even well-insured and sophisticated health economists, like Dr. Garber, an adviser to Dr. Colella’s company, can be hit by unexpected fees. When his wife had a baby, an anesthesiologist spent a few minutes administering an epidural anesthetic. Dr. Garber assumed the doctor was part of his insurance plan — the hospital participated in the plan and the doctor had not said he did not. But then the bill came for a few thousand dollars, and it was up to Dr. Garber and his wife to pay it.

It would not have helped for the doctor to disclose his fee, though, Dr. Garber said.

“With my wife in pain, I don’t think I could have said, ‘Hold off, I’m going to call around to find another anesthesiologist,’ ” he said. “I would have had to find an anesthesiologist who was available, in-network, and with privileges in the same hospital.”

“Hospitals should warn that some of the hospital-based physicians do not participate in the networks with them,” Dr. Garber said, and let patients line up with a doctor who does participate.

Mr. Hall says his research shows that when people go to doctors and hospitals that are not part of their insurance network, they can expect charges that are double, triple, even quadruple the negotiated price within networks. And that, he said, is “price gouging, exploiting market power to charge prices virtually unrelated to actual cost or market value,” and is a factor in what drives people into medical bankruptcy.

The American Medical Association said the fundamental problem was that health insurers often paid doctors too little and made it too burdensome to get payments at all, driving doctors outside insurance networks.

But if patients want to pay more to see a doctor outside their network, that should be their choice, said Dr. Robert M. Wah, a spokesman for the medical association.

“We’re in America, where people pay for things they value,” Dr. Wah explained.

Jonathan Gruber, a health economist at M.I.T., says, however, that it makes more sense to encourage people to stay in networks.

If health care overhaul accomplishes its goals of encouraging medical care that is not excessive and is based on the best evidence of what works, prices and quality can be kept under control for patients in insurance networks, Dr. Gruber said.

Some may want to pay anyway for an out-of-network doctor, and that is fine, he said. “If you want to go outside your network, God bless you,” he said. “It’s the American way.”

But the only way to fix the system, Dr. Gruber said, is to make the networks better so that people will stay in them and then, most patients, knowing what it will cost them to leave their networks, will decide not to.

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