AAP Federal Health Care Reform Update #2

Just yesterday, we had an update from the AAP about how healthcare reform items are taking shape in Washington.  Now, we have a new one, a little more fresh.  The most important part is the "ACADEMY PERSPECTIVE" I think.


July 31, 2009

To:       AAP Chapter Presidents
AAP Chapter Vice Presidents
AAP Chapter Executive Directors

Fr:       AAP Department of Federal Affairs

Re:       Federal Health Care Reform Update


After another weekend of meetings with the conservative Blue Dog Democrats, at the outset of this week the House Energy and Commerce Committee seemed to be in deadlock over issues regarding the cost of health care reform, the public plan option and employer mandates. Even though the Energy and Commerce Committee was tentatively scheduled to continue debate earlier this week, the Blue Dogs succeeded in postponing the Committee's action, confirming Majority Leader Hoyer’s statement at the end of last week that it was unlikely that the House of Representatives would vote on legislation before the August recess.

Despite the delay, the House did take a step forward Wednesday afternoon when House leaders announced they had come to an agreement with the Blue Dogs. Chairman Waxman’s deal with four of the Energy and Commerce Committee Blue Dogs cuts more than $100 billion from the bill, prevents a new public option from using Medicare rates to reimburse providers and exempts small businesses with payrolls of less than $500,000 from a new employer mandate, among other changes. Following the announcement, progressive Democrats in the House expressed their concern and disappointment over the House leadership’s willingness to surrender several key provisions in the legislation, particularly the weakening of the public option. Moreover, the Blue Dogs received an assurance that the full of House of Representatives would not vote on health care reform before the August recess, insisting that they needed to review the full legislation and discuss it with constituents during the district work period.

We expect the Energy and Commerce to pass their legislation later today.

The Energy and Commerce Committee assembled Thursday morning to debate amendments to the America’s Affordable Health Choices Act (HR 3200). During the morning session, they considered seven amendments. Two of the amendments agreed to will strengthen the current legislation by improving the health and well-being of children.

These two amendments include:

· An amendment introduced by Jerry McNerney (D-CA) and Tim Murphy (R-PA) to improve access to health care for children by preventing enrollment waiting periods for children who lose insurance due to parents’ job loss; preventing waivers to enroll children who are uninsured due a reduction or elimination of parent’s work hours; and expediting enrollment for children in families whose health costs exceed 10% of income.

· An amendment introduced by Tammy Baldwin (D-WI) to improve Medicaid coverage for children and young adults through the expansion of therapeutic foster care.

The Committee also rejected two amendments that could have threatened children currently enrolled in CHIP and Medicaid and limited children’s ability to access quality health care:

· An amendment offered by Rep. Nathan Deal (R-GA) to expand the citizenship documentation requirement established under the Deficit Reduction Act to apply to all newly enrolled Medicaid beneficiaries. The amendment was defeated by a vote of 28-29.

· An amendment proposed by Reps. Joe Barton (R-TX) and Nathan Deal (R-GA) to provide families and children eligible for Medicaid and CHIP with premium assistance to purchase private insurance. The amendment was defeated by a vote of  21-33.

Recognizing the concerns of many child advocates and pediatricians over the potential elimination of the CHIP program, Energy and Commerce Committee Vice-Chair Diana DeGette (D-CO) , plans to introduce an amendment which would require the HHS Secretary to submit a report to Congress by December 31, 2011, comparing the coverage that would be offered in an Exchange plan (new plans that would be available under the insurance Exchange structure established in the legislation) to the coverage offered by an average CHIP plan. The Secretary would examine the benefit package, cost-sharing, and the adequacy of provider networks to ensure that the coverage offered under the Exchange is at least comparable to the coverage offered by an average CHIP plan. The current legislation would transfer children currently enrolled in CHIP into the Exchange when the CHIP program expires in 2013; under this amendment, no child would be enrolled in an Exchange plan unless the Secretary certifies that the Exchange plans will provide comparable coverage.

Due to ongoing negotiations in the Senate Finance Committee, Senator Durbin (D-IL), Majority Whip, stated last week that the Senate would postpone any vote on health care reform until after the August recess. Finance Committee Chairman Max Baucus (D-MT) continues to meet with three Republicans (Finance Committee Ranking Member Charles Grassley and Senators Olympia Snowe, and Mike Enzi) and two Democrats (Senators Kent Conrad and Jeff Bingaman) to craft a bipartisan bill. Senator Enzi, meanwhile, emphasized that no deal was imminent, and legislative language had not been crafted for many provisions. While many Senators, including Democrats, are frustrated with the process in the Finance Committee, the six Senators in negotiations have assured their colleagues that they have made significant progress, but also that they want to make sure they come out of negotiations with a strong, cost effective and bipartisan compromise. Despite pressure from their colleagues, Chairman Baucus stated late Thursday that the bipartisan coalition has yet to reach a deal and as a result the full Finance Committee will not consider legislation next week. The Committee will reconvene after the four week summer recess


The Academy's goals for health reform are to achieve coverage for all children; age-appropriate benefits in a medical home; and appropriate payment.  We strongly believe that no child should be worse off after reform, and if all of these things can be achieved, many children and pediatricians stand to benefit from the reform effort. While the Academy has not endorsed any specific piece of legislation, AAP has provided direct feedback to the specific House and Senate committees on the bills and is supportive of the overall process.
As an example, when the three House Committees issued a first draft of legislation, AAP responded with a letter commenting on the positive and negative provisions included.  The following list includes several positive aspects that come from the AAP comment letter (many of which are included in updated version of the legislation, HR 3200):

* Prohibiting Pre-Existing Condition Exclusions (Sec. 111 in the draft bill).
* Payments to Primary Care Practitioners (Sec.1821. in the draft bill).
* Medicaid Medical Home Pilot Program - $1.235 billion over 5 years (Sec. 1822. in the draft bill).
* Recognition that outreach to special populations, including children, is essential to improve enrollment (Sec. 205(a)(1) in the draft bill).
* Recognition that a child's medical home should not change due to a process of automatic enrollment (Sec. 205(b)(3)(A) in the draft bill).
* Recognition that some families will need culturally and linguistically appropriate assistance in signing up for Exchange plans (Sec. 205(c)(3) in the draft bill).
* Recognition that services such as well-child services may not be listed in Medicare fee schedules, and should be included in new insurance products (Sec. 223(a)(3) in the draft bill).
* Recognition that primary care pediatricians would not be eligible for increased payment rates stemming from Medicare changes but for Sec. 223 (b)(1)(C) in the draft bill.
* The inclusion of dependent coverage in the employer mandate (Sec. 312 in the draft bill).
* Allowance for ERISA plans to elect to be subject to health coverage participation requirements (Sec. 321 in the draft bill). Pediatricians report that they currently have difficulty obtaining immunization payments from ERISA plans, and this should alleviate that situation to some degree.
* Inclusion of family coverage in the individual mandate (Sec. 401 in the draft bill).
* Streamlining of enrollment procedures and other steps to make it easier for children and families to obtain insurance. (Sec. 501 in the draft bill).
* Inclusion of different age groups in research priorities as designated by the Center for Comparative Effectiveness Research (Sec. 1401(c)(4) in the draft bill).
* Inclusion of tobacco cessation drugs in Medicaid coverage for enrollees and particularly for pregnant women (Sec. 1812 in the draft bill).
* Inclusion of grants and an option for states to fund nurse home visitation services as well as family planning services (Secs. 1704, 1813 and 1814 in the draft bill).
* Increased funding for electronic eligibility systems (Sec. 1833 in the draft bill).
* Workforce solutions for primary care pediatricians (Secs. 2212-2215 in the draft bill).
* Enhancement of cultural and linguistic competence through training grants (Sec. 2251 in the draft bill).
* Funding for the prevention and wellness trust, and the inclusion of a child and adolescent health professional on the Task Force on Clinical Preventive Services (Sec. 2301 in the draft bill).
* Expansion of the 340B program to allow discounted drugs to be purchased by children's hospitals and Title V grantees (Sec. 2501 in the draft bill).

While there are clearly many positive provisions within H.R. 3200, there is a reason AAP has not endorsed the bill. For example, H.R. 3200 includes new federal funding to increase Medicaid payments for primary care services to be, at a minimum, 100% of Medicare rates.  This provision was originally drafted to apply to all primary care providers, which would have included nurse practitioners.  The Academy was successful at urging Congress to change this section to apply only to the provision of services by physicians paid for by primary care codes.  Thus, pediatric specialty surgeons and subspecialty physicians could also receive the increased payment from the primary care codes while nurse practitioners would not be eligible.  Even with this win, the Academy does not believe that this provision goes far enough, since the provision should apply to all Medicaid payments to physicians.  The Academy is working to improve many components of this and other health reform legislation.

There have also been some misleading press reports on the issue of the ability of physicians to privately contract with those they care for. H.R. 3200 does not make private insurance illegal.  Rather, one main thrust of the legislation is the regulation of health insurance coverage in the individual and micro-group markets.  It is true that except for some "grandfathered" existing policies, individual coverage could only be offered through the Health Insurance Exchange established by the House bill.  (The Health Insurance Exchange is a regulated market place for people to purchase private coverage that meets minimum criteria. It is called the "Gateway" in the Senate HELP committee legislation). This provision responds to the fact that there have been many problems with the individual market, and there is a strong consensus that these plans do not work to the benefit of enrollees or physicians. (See http://www.eurekalert.org/pub_releases/2009-07/cf-nri072009.php). It is likely that the provisions regarding a reformed individual and micro-group market in the legislation would make great strides in regulating insurers so that they treat patients and providers more fairly.

The Academy will continue to work in the hopes that the best provisions for children and pediatricians from the three bills are included in the final product and improved along the way. But we can not do it alone! That is why we need your help to keep the momentum up and our message heard!


The upcoming August recess will be critical. Significant behind-the-scenes work will continue with Congressional members, but it also provides AAP an opportunity to turn up the heat in their districts. We must continue to act on behalf of our nation's children, and continue to remind our Congressional members of the importance of providing children with the services they need and deserve in health reform.


1. Call your local district offices to schedule a meeting during the August recess. The time members spend in their districts in August is critical—it is imperative they hear from as many pediatricians as possible in the coming weeks!

2. Call or email your member of Congress and tell them that children need comprehensive health care reform, and we must get this done!

3. Submit an Op-Ed to Your Local Newspaper. You can find suggested talking points and suggested tips on submitting an Op-Ed by logging into the AAP Members Center and clicking the Health Care Reform.

4. Forward this memo to other AAP Members!

Learn more about the issues in health care reform! Log on to the AAP Members Center Federal Advocacy Page to get the latest background information and tools you need to make a difference!

* AAP Health Care Reform backgrounder
* AAP Access Principles
* AAP Priorities on Health Care Reform
* Talking Points
* Chapter sign-on letter
* Specific Senate and House legislation and official AAP responses
* Kaiser Family Foundation side-by-side of the Senate and House legislation

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Key Contacts are AAP members who have agreed to take their advocacy to the next level. By becoming a Key Contact, you will receive important assignments and can provide critical information to AAP based on your results. In the coming months, we will be calling on Key Contacts with specific requests to make an impact on the health care reform debate. Being a Key Contact requires a very small time commitment but can yield big results! Join today by logging into the AAP Members Center and going to the Federal Advocacy page.

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