Probable GOP nominee for president, former Mass. Gov. Mitt Romney, came under attack over the past couple of days for comments on discounting the “very poor” as this demographic benefits from the existence of a societal “safety net” for the delivery of essential services — presumably basic healthcare among them. Terming the gaffe as simply a “misspoken” choice of words, the GOP frontrunner initially found it difficult to run from those words and their implications from members of his own party and the Democrats.

Chief rival Newt Gingrich jumped on the metaphorical bandwagon early.

Gingrich said both Romney and Democratic President Barack Obama think poverty can be solved with a safety net.”What the poor need is a trampoline so they can spring up,” he said. “So I want to replace a safety net with a trampoline.” Romney spokeswoman Amanda Henneberg responded that Gingrich was joining Democrats in “distorting Mitt Romney’s comments.”

South Carolina Gov. Jim Demint, a prominent force of social conservatism within the party, was a little more sanguine.

“He needs to address it,” DeMint told Roll Call. “Because I know he does care about the poor. But I think he was trying to make a case that they’re taken care of. But, in fact, I would say I’m worried about the poor because many are trapped in dependency, they need a good job; they don’t need to be on social welfare programs. I think he needs to turn that around because — the middle class is key, and we have to focus on that. And, really, the problem with the middle class is not successful people, it’s politicians — but the key to making our country successful it to get everyone on that economic ladder.

Typical “bootstrap” rhetoric, to be sure, but a teachable point for Romney; because, as it applies to healthcare — let’s take Medicaid, for example — his disavowal of basic healthcare delivery to the poor (and elderly) runs in stark contrast to his pledge to “fix it” — meaning the “safety net”. What does Mitt Romney want to fix, exactly? Continued taxpayer subsidied care for the indigent without further acknowledgement, or does he want to weaken an already painfully inadequate payor of healthcare in chronically cash-strapped states — threatening any stake they have as the reform law takes hold? In his efforts in trying to explain away his current campaign gaffe, Romney has made his stance on healthcare reform much murkier in this young election season. | LINK

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Here’s a convenient talking point for the Obama campaign as it begins to coalesce its message surrounding healthcare reform spending under the ACA: enrollment in Medicare Advantage is up since the beginning of the current decade, while premiums have been on the decline. HHS Sec’y Sebelius attributes this to the core provisions within the ACA allowing stipulations of bonus payments based upon quality, changes to enrollment periods, new medical loss ratio requirements and penalties, and the power for CMS to reject plan bids.

According to Humana’s last quarterly report, it bought two Medicare Advantage contractors in the third quarter of last year and enrollment increased over the past 12 months. Wellpoint also acquired an Advantage contractor in 2011 and saw increased enrollment.

While it may be a little premature to trumpet reform to this sector of Medicare spending by the government as being a permanent fixture of ACA implementation, it does highlight the need to revisit the drama surrounding payments to providers in FFS plans. Will the doc-fix ever be truly fixed? Bipartisan Senate and House members tasked with establishing a permanent end to reimbursement cuts to physicians will have their work cut out for them starting today — apparently considering everything from repeal of the SGR in its current form for Medicare spending to the use of war funds to finance such a permanent patch. Should be interesting.

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We’re inching closer to the multi-day arguments set to happen before the SCOTUS regarding the constitutionality of the ACA, specifically, the individual mandate provision. A Kaiser Foundation tracking poll indicates that a third of all voters (respondents) think that the entire law will be revoked if the high court finds the plaintiffs’ assertions has cause. Perhaps what is more important is the fact that Americans remain divided over the issue of the existence of the law.

As the anniversary of the Affordable Care Act approaches on March 23, Americans remain as divided on the law as ever, with 37 percent in January saying they have a favorable view of it, and 44 percent having an unfavorable view. At the same time, the share of the public that favors expanding the law (31%) or keeping it in its current form (19%) remains larger than the share who would like to see the law repealed outright (22%) or repealed and replaced with a Republican-backed alternative (18%).

Mitt Romney, the probable GOP nominee for president, will have to exploit the differences between presiding over the initiation of the reform law’s progenitor in his home state of Mass. and Obama’s finished product — backed by the full faith and support of Big Insurance. | LINK to study PDF

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Embattled WI governor, Scott Walker (R), issued a statement yesterday opposing the implementation of a state exchange as provisioned by the ACA — opting to defer action on the measure until the case is heard by the SCOTUS in March. In doing so, he will be returning almost $40 M in federal funding earmarked for the healthcare exchange. Whether this is earnest on his part or merely a symbolic gesture to Wisconsin GOP faithful in the wake of a pending certified recall vote on his office remains to be seen. Walker has always been against the passage of the reform law, instead focusing on efforts to deny federal assistance in doing so (states which choose this path will have to demonstrate fiscal independence on healthcare exchange creation by 1/1/13 or will be mandated a program by the feds).

Is this entire episode a game of chicken by Walker in light of his sudden vulnerability? It is, if one listens to the rhetoric from the state’s Democrats on the issue. Advocacy groups are also weighing their own disapproval of the governor’s intentions. The SOCTUS will hear testimony on the constitutionality of the reform law (notably, the mandate for coverage) over a two day period by the end of March. By the end of Februrary numerous amicus briefs will be filed by both Obama admin (DOJ) and plaintiffs (states) in the case. In spite of all the rancor surrounding this issue, it will difficult to envision striking of the mandate provision, much less the entire reform law as two lower courts have offered split decisions on the matter — prompting the SCOTUS to act quickly on a decision on the entirety of the ACA well before the election. | PDF brief from UCB Labor Center in support of the ACA’s constitutionality

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The cornerstone of the ACA is the provision for a coverage mandate — whether that coverage includes complete subsidized services (Medicaid or another fed subsidized program) or via private insurer. In order that individual states comply with this most essential of the reform law’s benefits, HHS has announced that states have the option to create “essential benefits packages” as a method of increasing compliance within the ACA.

“Flexebility” is the key, according to Secretary Kathleen Sebelius.

The national health law lists 10 categories of health care that all insurance policies must cover: hospitalization, emergency care, out-patient services, maternity and newborn care, mental health and substance abuse services, prescription drugs, laboratory testing, preventive and wellness care, pediatric services (including dental and vision examinations), rehabilitative care and habilitative care such as services for children with developmental disabilities. But within those categories, the federal government is allowing each state to determine its own basket of essential benefits by choosing a “benchmark” package offered by any of a variety of insurers.

Sebelius: This move protects consumers by respecting states’ role in healthcare delivery under the ACA. Obama administration: This is the only way in which the mandate can be upheld while making essential services affordable in all fifty states. Consumers? Increased standardization among offerings of basic services by states under the ACA raises the possiblity of mandated coverage rather than making things too onerous for the feds in getting the legislation off the ground in just a couple of years. | LINK

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As 2011 fades into 2012 and the inevitable roll of “best of” lists begins to infiltrate the print, online, and broadcast media universe, healthcare policy is sure to be included. One of those bridging year-end/new year issues apprears to be headed in a more assured direction, as the House GOP and Senate Dems have agreed on a 2 month extension of the payroll tax cut — including the Medicare “doc-fix” provision. Here’s hoping GOP Speaker Boehner does the right thing and continues to push for a yearlong extension…

Of course, this saga is the first of many issues sure to keep the health policy flames ablaze in ’12. Concerns by states of rising Medicaid expenses as reform draws closer; more permanent solutions to incremental and programmatic Medicare reimbursements to be sought; continued legal challenges to the ACA (which the SCOTUS will be taking up in an unprecedented 3-day affair); and last — but certainly not least — the 2012 campaign itself. Will an Obama defeat mean the end of reform as we presently are getting to know it, or will a (narrow?) victory for the president bring greater sympathy for cause, establishing the type of legacy for his top domestic issue he so desperately desires after two terms in office? As always, stay tuned. Next year looks to be an exciting one.

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Honestly, these “clock-ticking countdowns” are getting a little irksome. The eleventh hour negotiations surrounding the legislative extensions of the payroll tax cuts for the middle class just hit another roadblock, outlets have reported. Cue the Senate showdown between the GOP and Dems. Closely tied into the GOP plan for the extension of the tax cut is the inclusion of the Keystone XL oil pipeline — a controversial project which President Obama had originally hoped to decide upon by 2013 its potential for environmental sustainability.

The Keystone pipeline pawn would force Obama to make a decision on its contruction by the end of this year.

With respect to healthcare, the inclusion of provisions to forestall cuts to Medicare payments for 2 years, preventing incremental threats to physician reimbursements (no permanent overhaul), would be the political gambit. It’s a political mixed bag for some healthcare entities. Hospitals would be better served by more long-term solutions to the so-called doc-fix problem. Providers would be spared more frequently intermittent threats to reimbursement. If passed, this payroll tax cut extension would eliminate the possibility of approximately 27 percent in cuts to Medicare payments.  | LINK

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He’s leaving his much embattled post, and he is not mincing words. Don Berwick will be stepping down as CMS head in lieu of what was sure to be a highly contentious Senate confirmation procedure next year. Calling much of what Medicare “does” as wasteful, the departing CMS chief sounded more like he was delivering a eulogy than offering up hopeful solutions to be implemented in his absence.

Dr. Donald M. Berwick, listed five reasons for what he described as the “extremely high level of waste.” They are overtreatment of patients, the failure to coordinate care, the administrative complexity of the health care system, burdensome rules and fraud. “Much is done that does not help patients at all,” Berwick said, “and many physicians know it.”

Berwick’s ascension came at a time in which President Obama was looking for a CMS chief who shared the same sense of analytical urgency in efforts to fix the nation’s ailing healthcare delivery system. Berwick sounded the clarion call for reform, but received very little cooperation from the GOP side of the ideological aisle, with those members of congress (and some Dems) essentially putting up a wall between him and any actionable improvements. Perhaps his own words project why he was essentially doomed from the start.

Berwick said he had not sought the job. Indeed, he said, “I did not even know if I was fit for it.” He took the post, he said, because he sensed that immense “tectonic shifts” were occurring in the health care delivery system.“I came with an agenda,” Berwick said. “I wanted to try to change the agency to be a force for improvement, covering one out of three Americans.”

Restating the obvious really does physicians he laments no good unless positive change, outside of obvious hyperbole, does occur. According to many pundits — including this one — his replacement offers more of the same, with true change occuring only if legislative control swings back to the Dems in 2012. | LINK

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As a follow-up to a DP post on the unusual strategy pharma company Pfizer is implementing in trying to protect market share for the formerly solely branded drug Lipitor, here’s another take on the issue. According to one analyst profiled, Pfizer faces an uphill battle in trying to convince the pharma marketplace that its branded agent is more clinically efficacious than generic atorvastatin.

Pfizer is doing a so-so job of convincing health plans and [pharma benefit managers] that Lipitor is somehow better than a generic. On a scale of 1 to 10, Pfizer received a 4. Nonetheless, 54.8 percent say they will offer the authorized generic, which is being sold by Watson Pharmaceuticals. Meanwhile, only 30.4 percent report they will receive added rebates or discounts from Pfizer.

Of course, the pharma company stands to lose a ton during its loss of exclusivity over the next 6 months, but it will remain tenacious — as many analysts do not believe future antitrust issues will occur. Perhaps even more interesting is the new ground being broken here: can healthcare consumers be weaned off of generics and stay loyal to branded medications — if insurers and key third parties allow them to gain incentives by continuing to utilize them? | LINK

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Medicare will now expand its breadth of covered preventive services to include obesity treatment and management. In what could be a sign of the increasing population of beneficiaries who were weaned in the Boomer mentality, treatment coverage for such a hot-button topic among politicians, lobbyists, healthcare advocates, and physicians themselves — will remain, indeed, controversial. According to CMS, obese Medicare beneficiaries (defined as those with a body mass index of 30 or higher) may see their primary care physician for one face-to-face visit every week for the first month. Then, Medicare will pay for one face-to-face visit every other week for the next five months. If the patient loses at least 3 kg (6.6 lbs.) over the first six months, Medicare will pay for an additional six months of once-a-month face-to-face visits with the doctor.

Insurance remains above the fray here. While the feds may explain away this coverage as putting a dent in future healthcare costs associated with the obese patient, the fact remains, that outside of a universally defined pragmatic treatment regimen (ie, dedicated drugs = dedicated reimbursements/payments) — provider acceptance of this latest move by CMS will continue to advance at a trickle. It’s hard to get on board with yet another taxpayer funded government initiative whose intentions really haven’t been proven to lower across-the-board healthcare costs, lower all-cause mortality, and assume that all physicians are competent weight-loss counselors. Also: about 30 percent of beneficiaries are projected to qualify for this latest Medicare preventive care benefit. | LINK

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