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As Washington continues to debate a debt deal, the Obama administration has been preparing the country for the worst, with officials essentially saying the sky is about to fall.

But so far, oddly enough, nothing has happened. Despite warnings that a deal would need to be brokered by Sunday night before the Asian markets opened, stocks merely stumbled on Monday — the type of weakness usually associated with soft corporate earnings instead of an economic apocalypse.

Wall Street’s blasé response presents a serious challenge for the administration. The government has been ringing the alarm bells of an impending catastrophe to add urgency to its efforts to get Republicans to hash out a compromise.

President Obama, in his address on Monday night, again warned of dire consequences if a deal is not reached.

“We would risk sparking a deep economic crisis, this one caused almost entirely by Washington,” he said.

While the sky indeed may fall if the sides cannot compromise, the fact that the market has been calm has served only to deepen the resistance to a deal. People who perhaps should be worried don’t seem to be, and worse, appear to have stopped listening to the warnings.

How did it come to this?

The administration may have made a strategic mistake in warning too soon that the market would react negatively. It ultimately undercuts the government’s negotiating position because the doomsday scenario has not played out, even though the deadline is fast approaching.

“They have lost all credibility,” said Neil M. Barofsky, the former special inspector general for the Troubled Asset Relief Program. “It’s so typical of the way Treasury and the Fed treat everything — it is always to warn that Armageddon is coming.”

The Treasury secretary, Timothy F. Geithner, is among those who may have miscalculated.

He has consistently held out Aug. 2 as the cutoff date for lawmakers to reach a compromise. After that, Mr. Geithner has said the government might not be able to continue sending out Social Security checks or Medicare payments. “On Aug. 2, we’re left running on fumes,” he told the CBS program “Face the Nation.”

He told me back in May that he was expecting to reach a deal by mid-July, way ahead of the final deadline. “Why would you want to experiment? In July, you’d want this done.”

But increasingly, the market seems to believe it was a false deadline. Some economists have said the government would have enough cash on hand to continue making payments for several days at least. The administration could also decide how to prioritize payments. The government, for instance, could opt to pay interest on Treasuries and put off other bills.

In other words, the United States has some wiggle room.

“The Aug. 2 deadline is not as hard as indicated by Secretary Geithner,” said Mohamed El-Erian, the chief executive of Pimco, the large bond manager.

It doesn’t help the government’s case that investors believe the debate over the debt ceiling amounts to political posturing. Wall Street is counting on lawmakers to work out a deal, albeit at the last minute — a big reason the markets remain sanguine.

“The markets believe the political parties will reach a compromise agreement to avert a default,” Mr. El-Erian said, especially considering that they may have a bit more time on the doomsday clock.

Investors have good reason to ignore the drama. In years past, politicians have rubber-stamped an increase in the debt ceiling with little discussion or dissent. Since 1962, Congress has voted to increase the limit 74 times, according to the Congressional Research Service, a division of the Library of Congress. It happened 17 times under President Ronald Reagan and four times during the Clinton administration.

But investors may have been lulled into a false sense of security and, as a result, they may have missed the bigger picture.

Whether lawmakers reach an agreement about the debt ceiling may be beside the point. Republicans and Democrats are likely to comprise at some eventual date.

The question is how rating agencies will view the country’s creditworthiness, even if a deal is reached.

To some extent, that’s why lawmakers are wrangling over whether to pursue a stop-gap measure for the next couple of months versus a long-term plan. Standard & Poor’s threatened that it would cut the United States rating if lawmakers didn’t come up with a “credible” solution.

“What I think is underappreciated until now is a possible outcome whereby the debt ceiling is increased, debt default is avoided, but one of the rating agencies feels compelled to downgrade America’s AAA because of insufficient agreement on medium-term fiscal reform,” Mr. El-Erian said.

If the country were to lose its vaunted rating, the federal government, companies, homeowners and innumerable others would see their costs skyrocket — a situation that would certainly send the markets into a downward spiral.

How rating agencies will view the country’s creditworthiness will end up being a bigger deal than the current back and forth over the debt ceiling.

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Source: The New York Times

In a big step to carry out the new health care law, the Obama administration unveiled standards on Monday for insurance marketplaces that will allow individuals, families and small businesses in every state to shop for insurance, compare prices and benefits and buy coverage.

Kathleen Sebelius, the secretary of health and human services, said the insurance exchanges, the centerpiece of the new law, “will offer Americans competition, choice and clout.”

In theory, the exchanges will pool insurance risks and premiums so that individuals and small businesses will have “the same purchasing power as big businesses,” Ms. Sebelius said.

Issuance of the proposed rules shows how President Obama is moving inexorably to carry out his health care overhaul, despite attacks on the new law in Congress and the courts, where more than two dozen states are challenging the constitutionality of a requirement for most Americans to carry insurance.

In principle, liberals and conservatives support the exchanges, which they see as a way to increase the purchasing power of individuals and small businesses, but they disagree on how the exchanges should be configured. The regulations issued Monday, which provide a fair amount of latitude to states, were welcomed by consumer groups, patient advocates and some business lobbyists.

But they may not satisfy liberals who argue that the exchanges should tightly regulate insurance and contract with selected health plans that offer the best deals. And they may not satisfy conservatives who want the exchanges to be wide open to any insurers that want to participate and meet minimum federal standards.

Every state will have an exchange by Jan. 1, 2014. Federal officials will assess states’ “operational readiness” as of Jan. 1, 2013, and will run the exchange in any state that is unable or unwilling to do so.

Many states have been pondering how to proceed, and the regulations will provide guidance. The National Conference of State Legislatures says 12 states have enacted laws to establish exchanges. Bills failed in nine states and are pending in 11 others, the organization said.

The Congressional Budget Office predicts that by 2019, about 24 million people will have insurance through exchanges, with four-fifths of them getting federal subsidies that average $6,400 a year per person. People with incomes up to four times the poverty level (about $89,000 a year for a family of four) will be eligible for subsidies to make insurance more affordable.

Each state exchange will certify “qualified health plans,” provide the public with “standardized comparative information” on costs and benefits, and rate each plan based on the quality and price of care. In addition, the exchange will help people determine if they are eligible for Medicaid or the Children’s Health Insurance Program, or for federal tax credits to subsidize the purchase of private insurance.

Federal officials said they would issue a separate rule later this year specifying the “essential health benefits” that must be offered by all health plans.

Trumpeting the advent of the exchanges, the administration said Monday that they would “give Americans the same insurance choices as members of Congress.” However, in response to questions after a news conference on Monday, health officials acknowledged that this claim was not necessarily correct.

A small employer will be able to pick “a level of coverage” for its employees. A higher level will pay more of the consumer’s medical costs. Under the law, members of Congress must generally get their coverage through an exchange. But a small business could legally choose a level of coverage lower than those offered to federal employees, including members of Congress.

Under the rules, an employer may allow employees to choose any health plan at a given level of coverage. But an exchange may also allow an employer to limit its workers to one or two health plans — far fewer than the number available to members of Congress and other federal workers.

With some states like Florida balking at the new law, federal officials went out of their way Monday to strike a conciliatory note, promising to be flexible. If a state is not ready by January 2013, Ms. Sebelius said, it still might qualify for “conditional approval” if it was on track to operate an exchange by January 2014. In addition, federal officials said, a state could set up and operate its own exchange in 2015 or later years if it is not ready in 2104.

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Source:  The New York Times

Obama administration officials are offering to cut tens of billions of dollars from Medicare and Medicaid in negotiations to reduce the federal budget deficit, but the depth of the cuts depends on whether Republicans are willing to accept any increases in tax revenues.

Administration officials and Republican negotiators say the money can be taken from health care providers like hospitals and nursing homes without directly imposing new costs on needy beneficiaries or radically restructuring either program.

Before the talks led by Vice President Joseph R. Biden Jr. broke off 12 days ago, negotiators said, they had reached substantial agreement on many cuts in the growth of Medicare, which provides care to people 65 and older, and Medicaid, which covers lower-income people. Those proposals are still on the table when Congress reconvenes this week, aides said, and are serious options that Democrats could accept in exchange for Republican concessions that raise revenues.

“Congress smells blood,” said William L. Minnix Jr., the chief lobbyist for nonprofit nursing homes.

Mr. Minnix, the president of a trade group known as LeadingAge, is urging nursing homes to “bombard your senators with the message that Medicaid cannot be cut by $100 billion” over 10 years, as President Obama and many Republican lawmakers have suggested.

A coalition of hospital lobbyists, worried about the direction of the budget talks, has begun a national advertising campaign to block further cuts in the two health care programs, which account for about 55 percent of hospital revenues. The hospitals have made a commitment to spend up to $1 million a week through August on television, print and online advertising.

“This is white-knuckle time for a lot of people,” said Bryant Hall, a health care lobbyist whose clients include drug and biotechnology companies. “Stakeholders and beneficiaries are anxiously watching the budget negotiations.”

They may have reason to be anxious.

Senator Charles E. Schumer of New York, the No. 3 Senate Democrat, said: “We are very willing to entertain savings in Medicare. Medicare gives very good health care very inefficiently.”

In return, Mr. Schumer said, Republicans should be willing to consider some additional revenue.

Negotiators said they were seriously considering cuts in Medicare payments to hospitals for uncollectible patient debt and the training of doctors; steps to eliminate Medicare “overpayments” to nursing homes; a reduction in the federal share of some Medicaid spending; and new restrictions on states’ ability to finance Medicaid by imposing taxes on hospitals and other health care providers.

Medicare and Medicaid insure more than 100 million people, account for 23 percent of all federal spending and are likely to be an important part of any budget deal. Military spending, which accounts for about 20 percent of federal expenditures, is likely to be included as well.

Most Republicans have ruled out tax rate increases to reduce the deficit. Mr. Obama has rejected the idea of Medicare vouchers, Medicaid block grants or any rollback of the new health care law. But he and the Republicans say they still hope to find some common ground.

Mr. Obama has embraced the goal of reducing deficits by a total of $4 trillion over 12 years — an ambitious goal that suggests the size of any grand bargain.

In a speech in April, Mr. Obama offered to slow the growth of Medicare and Medicaid without cutting benefits. He said his ideas would save $340 billion over 10 years and a total of nearly $500 billion in the two programs by 2023. His numbers quickly became a starting point in the negotiations.

As for Medicaid, administration officials have indicated that they could accept savings of $100 billion or more over 10 years, much to the dismay of many House Democrats. The lawmakers say the cuts would impair access to care for the poor and shift costs to the states, which are facing a huge expansion in Medicaid eligibility and enrollment, scheduled to start in 2014 under the new health care law.

While insisting on new revenue at his news conference last week, Mr. Obama also said, “We’ll have to tackle entitlements,” adding that “health care cuts” need to be part of any deal.

Senator Joseph I. Lieberman, the Connecticut independent, described a fiscal and political imperative: “We can’t balance the budget without dealing with mandatory spending programs like Medicare. We can’t save Medicare as we know it. We can save Medicare only if we change it.”

The new health care law trimmed Medicare payments to most providers. Many states, in fiscal distress, are cutting Medicaid, which is financed jointly by the federal government and the states. If Congress and the president now make additional cuts, hospitals say, they will close some services and increase charges to patients with private insurance.

Hospital executives from around the country plan to visit Capitol Hill next week to deliver this message: “Cutting Medicare and Medicaid payments to hospitals will hurt the ones we love, especially the most vulnerable — children, seniors, the poor and disabled.”

Mr. Minnix, the lobbyist for nonprofit nursing homes, said: “The issue is not money. The issue is the effects on people, vulnerable people.”

The American Medical Association and AARP, the lobby for older Americans, have joined hospitals and nursing homes in fighting other proposals that would limit federal spending as a percentage of the gross domestic product. Members of Congress of both parties have introduced bills that would automatically cut spending across the board if such limits were about to be breached.

While details have yet to be decided, lawmakers and administration officials said they were seriously considering these proposals:

¶ Gradually eliminate Medicare payments to hospitals for bad debts that result when beneficiaries fail to pay deductibles and co-payments. Medicare reimburses hospitals for 70 percent of such debts after the hospitals make reasonable efforts to collect the unpaid amounts.

¶ Reduce Medicare payments to teaching hospitals for the costs of training doctors, caring for sicker patients and providing specialized services like trauma care and organ transplants. Medicare spends $9.5 billion a year for its share of those costs.

¶ Reduce the federal share of payments to health care providers treating low-income people under Medicaid and the Children’s Health Insurance Program. The administration wants to establish a single “blended rate” for each state. The federal government now reimburses states at different rates for different groups of people and different services in the two programs.

Representative Henry A. Waxman of California, the senior Democrat on the Energy and Commerce Committee and an architect of Medicaid, said he was “very concerned” that this proposal would reduce the federal contribution to Medicaid and shift costs to states.

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Source:  The New York Times

THE last year and a half has brought a rapid sequence of reversals in the Obama administration’s policy toward oil and gas exploration on public lands and in United States waters.

Since the beginning of 2010, Washington has caromed from a restrictive approach to drilling to a permissive policy closely mirroring that of the Bush administration to a near-total shutdown of offshore drilling after the Deepwater Horizon blowout in the Gulf of Mexico. After that fatal accident, the administration decreed a deepwater drilling moratorium, lifted it six months later, then took five more months before beginning to issue drilling permits.

Throughout that time, the American public’s attitudes toward domestic oil and gas development have been remarkably consistent: Americans are in favor of it, though Democrats and those on the coasts are much less likely than Republicans and those in the South and Southwest to be supportive.

National support for offshore drilling and for domestic oil and gas development generally dipped for a time after the BP disaster — from a strong majority to a bare majority — but quickly rebounded.

A Gallup poll taken immediately after the gulf spill showed that 50 percent of Americans supported offshore drilling while 46 percent opposed it. By March of this year, public support had risen to 60 percent versus 37 percent.

The administration’s offshore drilling policy, like its fervor for domestic production more generally, has gone through rapid changes. In March 2010, President Obama announced that the United States would make vast tracts of the Gulf of Mexico and the Atlantic and Arctic oceans available for leasing by oil and gas companies. After the BP spill began on April 20, 2010, he declared those areas off-limits for at least five years. Then, last month, the president announced that he would permit accelerated development in Alaska, the gulf and along parts of the Atlantic coast.

Administration officials defend the policy changes as reasonable responses to changed circumstances.

Mr. Obama came to office as a proponent of increased domestic oil and gas development, as part of a broader strategy to reduce oil imports. Accordingly, they said, he took steps to accelerate development. He then imposed a sharp cutback after the BP disaster to give regulators and oil companies time to put new safeguards in place.

After the president was satisfied that drilling could resume safely, and in response to public anxiety about high fuel costs, he shifted back to a more pro-development stance, the aides said.

“These spikes in gas prices are often temporary,” Mr. Obama said on May 14 in a radio and Internet address, “and while there are no quick fixes to the problem, there are a few steps we should take that make good sense.”

The public’s support for offshore drilling has tracked changes in the price of gasoline. When gas prices were near record highs in the summer of 2008 and again this spring, support for domestic drilling was highest.

Conversely, unease about the effects of offshore drilling peaked after the BP accident, which killed 11 rig workers and spewed nearly five million barrels of crude into the gulf.

“News of that incident has faded, possibly lessening Americans’ resistance to coastal area drilling,” Gallup said when releasing its poll in March that showed 60 percent of Americans supportive.

The poll found that 49 percent of Americans favor opening the Arctic National Wildlife Refuge for oil exploration, a step the Obama administration strongly opposes. That is the highest level of support for drilling in the Arctic refuge since Gallup first asked the question in 2002.

The nationwide poll of 1,021 adults was conducted by telephone in early March.

“Timing is everything,” said Jack N. Gerard, president of the American Petroleum Institute, the industry’s most prominent lobbying group in Washington. “As the price of gasoline has increased, public attention has turned once again to the question of energy. When they hear their elected officials continue to resist development of American resources, they are appalled.”

The Gallup survey found that men are more likely than women to support drilling offshore and in Alaska and support is much higher among Republicans than Democrats. It also found regional variations, with the strongest backing for aggressive oil exploration in the South and the most significant opposition along the East and West Coasts.

And while the public appears to support exploiting domestic oil and gas resources, there is also skepticism about the economic and environmental costs of America’s continued reliance on oil. A New York Times/CBS News poll taken in March asked how important it was for the United States to develop an alternative to oil as a major source of energy. Fully 94 percent of respondents said it was very or somewhat important to do so.

The Times/CBS News poll was conducted by telephone with 1,266 adults nationwide.

Daniel J. Weiss, a senior fellow in Washington at the Center for American Progress, said that while the public tends to support more domestic oil and gas drilling, they see it as only one egg in a basket of policies to lower energy costs, reduce dependence on foreign oil and clean up the environment.

“Americans generally support an all-of-the-above strategy,” Mr. Weiss said. “They say, ‘Let’s have more offshore drilling, but also higher mileage standards for our cars and trucks. Let’s crack down on the speculators and invest in electric cars, natural gas trucks and biofuels.’ ”

Mr. Gerard said that Mr. Obama’s sporadic and reluctant support for increased domestic production was largely politically driven and not part of a comprehensive energy strategy. But he praised the president for at least appearing responsive to public opinion in calling for more American oil and gas.

“Until the economy gets back on track, until the unemployment rate comes down, and with the price of energy high, I think you’ll see the president focus more and more on the supply side,” he said. “And as pressure continues to mount as we get closer to Election Day, I think you’ll see more of that.”
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Source: The New York Times

Faced with a deepening recession two years ago, the Obama administration injected billions of dollars into Medicaid, the nation’s low-income health program. The money runs out at the end of this month, and benefits are being cut for millions of people, even though unemployment has increased.

From New Jersey to California, state officials are bracing for the end to more than $90 billion in federal largess specifically designated for Medicaid. To hold down costs, states are cutting Medicaid payments to doctors and hospitals, limiting benefits for Medicaid recipients, reducing the scope of covered services, requiring beneficiaries to pay larger co-payments and expanding the use of managed care.

As a result, costs can be expected to rise in other parts of the health care system. Cuts in Medicaid payments to doctors, for example, make it less likely that they will accept Medicaid patients and more likely that people will turn to hospital emergency rooms for care. Hospitals and other health care providers often try to make up for the loss of Medicaid revenue by increasing charges to other patients, including those with private insurance, experts say.

Neither the White House nor Congress has tried to extend the extra federal financing for Medicaid, even though the number of beneficiaries is higher now than when Congress approved the aid as part of an economic recovery package in February 2009.

The Congressional Budget Office estimates that federal Medicaid spending will decline in 2012 for only the second time in the 46-year history of the program. But states say they will have to have to spend more on Medicaid as they struggle to make up for the loss of federal money.

State officials say they are resigned to the loss of the extra federal matching payments, given the climate in Congress, where deficit reduction is a paramount goal.

“We all see the reality of what’s going on in Congress,” said Mark W. Rupp, director of the Washington office of Gov. Christine Gregoire of Washington State, a Democrat who is chairwoman of the National Governors Association. “It’s more about cutting than spending. Why put a lot of effort into something that did not seem likely to have a positive outcome? It would have been fairly futile.”

Although Medicaid provides health insurance to one in five Americans at some point in a year, it is more vulnerable to cuts than Medicare and Social Security, which have broader political support.

“Medicaid is very much on the chopping block,” said Senator John D. Rockefeller IV, Democrat of West Virginia and chairman of the Senate Finance Subcommittee on Health Care. “Seniors vote. But if you are poor and disabled, you might not vote, and if you are a child, you do not vote — that’s a lot of Medicaid’s population. They don’t have money to do lobbying.”

Medicaid is financed jointly by the federal government and the states, with the federal government paying a larger share in poorer states like Mississippi and West Virginia and a smaller share in higher-income states like New York and Connecticut.

The aid ending next month increased the federal share of Medicaid spending in all states, with additional help for states where unemployment rates had risen sharply. The extra aid was scheduled to expire last December, but Congress extended it for six months at the urging of the White House and state officials.

The additional money pushed the average federal share of Medicaid spending nationwide to 67 percent. It will revert to 57 percent next month. The cutback in federal Medicaid money has put pressure on states to cut the budget for other programs, including education and social services.

Toby J. Douglas, director of the California Department of Health Care Services, said the federal Medicaid cut was causing “very consequential reductions in health care and other public programs.”

California is cutting Medicaid payments to doctors and many other providers by 10 percent; has established new co-payments for drugs, doctors’ services and hospital care; and will limit beneficiaries to seven doctor’s office visits a year unless a doctor certifies a need for more.

With 7.6 million Medicaid beneficiaries — 50 percent more than any other state — California faces bigger problems, but its response has been typical. A survey issued this month by the National Association of State Budget Officers found that 24 states were reducing Medicaid payments to providers, while 20 were limiting benefits in some way.

R. Andrew Allison, who is executive director of the Kansas Health Policy Authority and president of the National Association of Medicaid Directors, said Medicaid was gobbling up new revenues as states recovered slowly from the recession.

Kansas illustrates the predicament most states are facing. Federal Medicaid payments in Kansas are expected to decline by more than $250 million, or 13 percent, in the state’s new fiscal year, which starts July 1, Mr. Allison said. But the amount of state revenue spent on Medicaid is expected to increase by more than $300 million, or 39 percent.

New York has just imposed a cap on state Medicaid spending, with a separate limit for each sector like hospitals, nursing homes and managed care plans. Under a new state law, if it appears that the state share of Medicaid spending will exceed the cap, New York officials must devise and carry out a plan to reduce spending, by modifying benefits, provider payment rates or other features of the program.

“This is an enormous sea change for Medicaid,” said Jeffrey Gordon, a spokesman for the New York State Health Department.

In New Jersey, Gov. Chris Christie, a Republican, said, “Medicaid’s growth is out of control,” and he has proposed numerous changes “to fill in the hole created by the loss of over a billion dollars of federal stimulus money” for the program. He would tighten eligibility, reduce Medicaid payment rates for nursing homes, move older and disabled Medicaid recipients into managed care, and charge co-payments for medical day care services.

The New Jersey Legislature appears likely to accept some of the changes in a budget to be adopted this month.

Connecticut has avoided major cuts in Medicaid, but the State Legislature has set new limits on vision and dental coverage for adults.
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Source: Th New York Times

For the first time in its history, Medicare will soon track spending on millions of individual beneficiaries, reward hospitals that hold down costs and penalize those whose patients prove most expensive.

The administration plans to establish “Medicare spending per beneficiary” as a new measure of hospital performance, just like the mortality rate for heart attack patients and the infection rate for surgery patients.

Hospitals could be held accountable not only for the cost of the care they provide, but also for the cost of services performed by doctors and other health care providers in the 90 days after a Medicare patient leaves the hospital.

This plan has drawn fire from hospitals, which say they have little control over services provided after a patient’s discharge — and, in many cases, do not even know about them. More generally, they are apprehensive about Medicare’s plans to reward and penalize hospitals based on untested measures of efficiency that include spending per beneficiary.

A major goal of the new health care law, often overlooked, is to improve “the quality and efficiency of health care” by linking payments to the performance of health care providers. The new Medicare initiative, known as value-based purchasing, will redistribute money among more than 3,100 hospitals.

Medicare will begin computing performance scores in July, for monetary rewards and penalties that start in October 2012.

The desire to reward hospitals for high-quality care is not new or controversial. The idea can be traced back to a bipartisan bill introduced in Congress in 2005, when Democrats and Republicans were still working together on health care. However, adding in “efficiency” is entirely new and controversial, as no consensus exists on how to define or measure the efficiency of health care providers.

The new health care law directs the secretary of health and human services to develop “efficiency measures, including measures of Medicare spending per beneficiary.” Obama administration officials will decide how to calculate spending per beneficiary and how to use it in paying hospitals.

Administration officials hope such efforts will slow the growth of Medicare without risking the political firestorm that burned Republicans who tried to remake the program this year.

In calculating Medicare spending per beneficiary, the administration said, it wants to count costs generated during a hospital stay, the three days before it and the 90 days afterward. This, it said, will encourage hospitals to coordinate care “in an efficient manner over an extended time period.”

If, for example, an 83-year-old woman is admitted to a hospital with a broken hip, she might have hip replacement surgery and then be released to a nursing home or a rehabilitation hospital. When she recovers, she might return to her own home, but still visit doctors and physical therapists or receive care from a home health agency. If she develops a serious infection, she might go back to the hospital within 90 days.

The new measure of Medicare spending per beneficiary would include all these costs, which — federal officials say — could be reduced by better coordination of care and communication among providers.

Here, in simplified form, is an example offered by federal officials to show how the rewards might work. If Medicare spends an average of $9,125 per beneficiary at a particular hospital and if the comparable figure for all hospitals nationwide is $12,467, the hospital would receive high marks — 9 points out of a possible 10 awarded for efficiency. This measure, combined with measures of quality, would be used to compute an overall performance score for the hospital. Based on this score, Medicare would pay a higher or lower percentage of each claim filed by the hospital.

Federal officials are still working out details, including how to distribute the money.

Charles N. Kahn III, president of the Federation of American Hospitals, which represents investor-owned companies, said he supported efforts to pay hospitals according to their performance. But he said the administration was “off track” in trying to hold hospitals accountable for what Medicare spends on patients two or three months after they leave the hospital.

“That’s unrealistic, beyond the pale,” Mr. Kahn said.

Since 2004, Medicare has provided financial incentives to hospitals to report on the quality of care, using widely accepted clinical measures.

Much of the information is posted on a government Web site (hospitalcompare.hhs.gov), but it has not been used as a basis for paying hospitals.

For years, federal health officials have emphasized the importance of higher-quality care, mentioning efficiency as an afterthought. Now, alarmed at the trajectory of Medicare costs, they emphasize efficiency as an equally important goal.

Under the new health law, Medicare will reduce payments to hospitals if too many patients are readmitted after treatment for heart attacks, heart failure or pneumonia. In addition, Medicare will cut payments to hospitals if they do not replace paper files with electronic health records, and it will further reduce payments to hospitals with high rates of preventable errors, injuries and infections.

Hospital payments account for the largest share of Medicare spending, and Medicare is the single largest payer for hospital services.

Senators Max Baucus, Democrat of Montana and chairman of the Finance Committee, and Charles E. Grassley, Republican of Iowa, have led efforts to pay health care providers for their performance — for the quality of services, rather than the quantity. House members from Iowa, Minnesota, Washington and Wisconsin have pushed for measures of efficiency, saying Medicare should reward low-cost, high-quality care of the type they say is provided in their states.

Without opposing the change, lawmakers from higher-cost states like Massachusetts and New York say the payment formula needs more work.

Teaching hospitals worry that the new policy will penalize them because they treat sicker, more expensive patients. Medicare officials tried to allay this concern, saying they would adjust the data to take account of patients’ age and the severity of their illnesses, as well as geographic differences in hospital wages.

Still, Kenneth E. Raske, president of the Greater New York Hospital Association, said the formula “tends to discriminate against inner-city hospitals with large numbers of immigrant, poor and uninsured patients.”

By contrast, J. Kirk Norris, president of the Iowa Hospital Association, welcomed the new plan. “Medicare ought to pay for value,” he said.

Administration officials said they were aware of concerns that some hospitals might try to increase their performance scores by avoiding high-risk patients. The officials said they would watch closely for signs of such a problem.
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Source: The Nerw York Times

The latest economic numbers have not been good. Jobless claims rose last week, the Labor Department said on Thursday. Another report showed that economic growth at the start of the year was no faster than the Commerce Department initially reported — “a real surprise,” said Ian Shepherdson of High Frequency Economics.

Perhaps the most worrisome number was the one Macroeconomic Advisers released on Wednesday. That firm tries to estimate the growth rate of the current quarter in real time, and it now says annualized second-quarter growth is running at only 2.8 percent, up from 1.8 percent in the first quarter. Not so long ago, the firm’s economists thought second-quarter growth would be almost 4 percent.

An economy that is growing this slowly will not add jobs quickly. For the next couple of months, employment growth could slow from about 230,000 recently to something like 150,000 jobs a month, only slightly faster than normal population growth. That is certainly not fast enough to make a big dent in the still huge number of unemployed people.

Are any policy makers paying attention?

When the economy weakened in the first quarter, Ben S. Bernanke, the Federal Reserve chairman, and Obama administration officials said the slowdown was just a blip and growth would soon pick up. Today, many Wall Street economists are saying much the same thing: any day now, things will improve.

Maybe they will. But the history of financial crises shows that they produce weak, uneven recoveries, with unemployment remaining high for years. That history also shows that aggressive government action — the kind of action Washington took in 2008 and 2009, but not for most of 2010 — can make the situation much better than it otherwise would be.

The latest signs of weakness suggest that policy makers remain too sanguine. It is easy to see how the rest of 2011 could end up disappointing, much as 2010 did.

For one thing, there are specific forces holding back growth. Oil prices, though down in the last few weeks, are still 40 percent higher than a year ago and continue to siphon money away from the American economy to overseas economies. When I filled my gas tank last weekend, it cost $74, more than I think I have ever paid.

The housing market also remains in terrible shape. Europe is still struggling with its debt troubles. State and local governments continue to cut jobs.

These specific problems worsen the broader insecurity of both households and business executives — insecurity that is typical in the wake of a financial crisis. Long after the crisis itself is over, businesses are slow to hire and quick to fire. Thursday’s report on new jobless claims showed that they rose by 10,000, to 424,000, which is not a number associated with a solid recovery.

“Labor market gains may be faltering somewhat,” Joshua Shapiro, chief United States economist at MFR, a New York research firm, wrote to clients after the report’s release.

For households, already coping with miserly wage growth, that is another reason not to spend. The Commerce Department’s updated gross domestic product figures showed that consumer spending grew at an annual inflation-adjusted rate of only 2.2 percent in the first quarter, not the 2.7 percent rate the department initially reported.

The economy does still have some bright spots, and they could grow in coming months, just as policy makers and private forecasters are, once again, predicting. If North Africa and the Middle East do not become more chaotic, oil prices may continue falling. Vehicle production will probably pick up as the parts shortages caused by the Japanese earthquake end. The falling dollar will continue to help American exporters, as well as any domestic businesses that compete with foreign importers.

But there is no doubt that the economy has performed considerably worse in the last few months than most policy makers expected. The situation is now uncomfortably similar to last year’s, when the economy sped up in the first few months only to stall in the spring and summer.

The most sensible response for Washington would be to begin thinking more seriously about taking out an insurance policy on the recovery. The Fed could stop worrying so much about inflation, which remains historically low, and look at how else it might encourage spending. As Mr. Bernanke has said before, the Fed “retains considerable power” to lift growth.

The White House and Congress, meanwhile, could begin talking about extending last year’s temporary extension of business tax credits, household tax cuts and jobless benefits beyond Dec. 31. It would be easy enough to pair such an extension with longer-term deficit reduction.

Any temporary measures will eventually need to lapse, of course. But the current moment remains a textbook time to use them — when the economy is struggling to emerge from the aftermath of a terrible recession. The one thing not to do is to turn to deficit reduction too quickly after a crisis, as Europe is painfully learning.

Almost four years after the mortgage market first began to quiver and unemployment began to rise, Americans are understandably eager for good economic news. But wishing for it doesn’t make it so. You have to wonder whether the people in Washington have learned that lesson yet.
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Source: The New York Times

One day after Republicans lost a special election that was dominated by debate over their 2012 budget proposal, the Senate on Wednesday rejected the House Republican budget blueprint, a mostly symbolic vote that nonetheless underscores the political peril entailed in the GOP proposal to turn Medicare into a voucher program.

The budget plan, which was drafted by House Budget Committee Chairman Paul Ryan (R-Wis.) and which passed the House in April with the support of all but four Republicans, was rejected by the Senate Wednesday on a 40-to-57 vote.

As was the case in the House vote, all Democrats present in the Senate voted against the measure; they were joined by five Republicans, a sign of the wariness with which some Republicans have come to view the budget plan, particularly members who may face tough reelection bids in 2012.

The Republicans voting against the plan Wednesday were moderate Sens. Scott Brown (Mass.), Susan Collins (Maine), Olympia Snowe (Maine) and Lisa Murkowski (Alaska), as well as conservative freshman Sen. Rand Paul (Ky.), who argued that the plan did not go far enough in cutting spending.

Immediately after the vote on the Ryan budget, the Senate unanimously rejected President Obama’s 2012 budget proposal. The Obama budget did not secure the support of a single lawmaker, with all 97 senators present voting “no.”

The Senate also rejected two other conservative Republican budget plans Wednesday evening. A budget proposed by Sen. Pat Toomey (R-Pa.) that would have balanced the budget within nine years failed on a 42-to-55 vote. All Democrats present and three Republicans voted “no.” Another, even more aggressive plan put forth by Paul was overwhelmingly rejected, with only seven Republicans (including Paul) voting “yes.”

The votes come as lawmakers and the Obama administration are sparring over how to address the country’s record $14.3 trillion debt. The Treasury Department has set a deadline of Aug. 2 for Congress to vote to raise the debt limit or else put the country at risk of default. The debate on Capitol Hill has been dominated in recent weeks by the issue.

The House-passed Republican budget plan would address the debt problem by making sweeping cuts to the federal budget, but it is a provision that would overhaul Medicare and other federal entitlement programs for future seniors that has drawn the greatest political controversy — a point underscored by the fact that Wednesday’s vote was called not by Senate Republicans, but by Democratic leaders.

Public polling shows that while voters are deeply concerned about the debt, they strongly oppose cuts to Medicare and other federal entitlement programs, even as they favor the broader notion of federal budget cuts.

That opposition to Medicare changes was on display in Tuesday’s special election in a conservative House district in upstate New York, which Democrats had sought to turn into a referendum on the House Republican budget plan. Senate Democrats on Wednesday argued that the vote demonstrated that voters across the country were turning against the plan.

“I mention New York not because this was a win for Democrats or a loss for Republicans, but because this was a win for our seniors and because the stakes are too high,” Sen. Mark Begich (D-Alaska) said on the Senate floor ahead of Wednesday’s vote. “Americans all across the country are saying ‘no’ to the current Republican plan that could fail to automatically enroll our seniors in Medicare and instead force them to buy health care from a private insurance company.”

Republicans have countered that Democrats are resorting to “scare tactics” and that their proposed budget would not affect current seniors, a point that Democrats have disputed.

In a speech on the Senate floor Wednesday, Toomey, who voted for the House Republican budget, argued that Senate Democrats have not only failed to produce a budget of their own but have also offered no ideas on how to save Medicare.

“This is an extraordinary abandonment of a very fundamental responsibility,” Toomey said. “And I have to say, I have a hard time listening to the criticism of the House budget by people who have offered no budget as an alternative.”

“Is it the perfect plan? Is it the only plan?” he continued. “I’m sure it’s not, but it would work.”

While Wednesday’s vote has clear political implications — it gives Democrats on the campaign trail the opportunity to hammer the 40 Republicans who voted for the plan — it’s unclear whether the plan will have any further policy implications, particularly in the ongoing deficit-reduction talks between congressional leaders and Vice President Biden.

Republicans have thus far called for Medicare and other entitlement programs to be on the table in those talks, an idea to which Democrats have objected.
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Source: The Washington Post

Alarmed at soaring premiums and profits in the health insurance industry, the Obama administration demanded on Thursday that insurers justify proposed rate increases of more than 10 percent, starting in September.

Kathleen Sebelius, the secretary of health and human services, issued a final rule establishing procedures for federal and state insurance experts to scrutinize premiums. Insurers, she said, will have to justify rate increases in an environment in which they are doing well financially, with profits exceeding the expectations of many Wall Street analysts.

“Health insurance companies have recently reported some of their highest profits in years and are holding record reserves,” Ms. Sebelius said. “Insurers are seeing lower medical costs as people put off care and treatment in a recovering economy, but many insurance companies continue to raise their rates. Often, these increases come without any explanation or justification.”

Federal health officials proposed the 10 percent threshold in December. The insurance industry criticized it as an arbitrary test that could brand a majority of rate increases as presumptively unreasonable. But the administration rejected the criticism and insisted on the 10 percent standard in the final rule, issued Thursday.

Starting in September 2012, the federal government will set a separate threshold for each state, reflecting trends in insurance and health care costs.

In some states like New Hampshire, groups of more than 20 workers have experienced premium increases of around 20 percent this year, while smaller groups have seen increases of 40 percent or more. At the same time, insurance agents say, coverage is shrinking as deductibles have increased and insurers limit the choice of hospitals.

To ensure that “consumers get value for their dollars,” the new health care law required annual reviews of “unreasonable increases in premiums.”

Under the new rule, federal and state officials will review rates in the individual and small-group insurance markets. In effect, the administration said, large employers can take care of themselves, as they are more sophisticated purchasers and have more leverage in negotiating with insurers.

Federal officials acknowledged that they did not have the authority to block rates that were found to be unjustified. But they said many states had such authority, and the federal government is providing $250 million to states to strengthen their capacity. A small number of states, opposed to the federal health care law, have turned down the money.

The new rule says a rate increase is unreasonable if it is excessive, unjustified or “unfairly discriminatory.” An increase is deemed excessive if it is “unreasonably high in relation to the benefits provided.”

Consumer advocates generally welcomed the rule. “The days of insurance companies running roughshod over consumers and jacking up rates whenever they want are over,” said Ethan S. Rome, executive director of Health Care for America Now, a coalition that includes labor unions and civil rights groups.

Insurers said the rule did nothing to address the underlying costs of health care, which they described as the main factor driving up premiums.

“If we believe health care costs are crushing the economy, we ought to have a debate about how to bring costs under control,” said Karen M. Ignagni, president of America’s Health Insurance Plans, a trade group. “Focusing on premiums diverts attention from that debate.”

In many cases, Ms. Ignagni said, rate increases of more than 10 percent may be justified by rising health costs and the tendency of younger, healthier people to drop coverage, forcing up costs for other policyholders.

States will have the primary responsibility for reviewing rate increases. “But if a state does not have the authority or the resources to conduct a review, our department will step in,” said Ms. Sebelius, a former state insurance commissioner in Kansas.

Under the rule, as part of an effective rate review program, states must have “a mechanism for receiving public comments” on proposed rate increases.

Elizabeth P. Sammis, the acting insurance commissioner in Maryland, said this would be a big change. In many cases, she said, consumers learn of premium increases when they receive notices in the mail, and then they call the commissioner’s office to ask, “Why are rates going up?”
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Source: The New York Times

The Obama administration will begin to tap federal retiree programs to help fund operations after the government loses its ability Monday to borrow more money from the public, adding urgency to efforts in Washington to fashion a compromise over the debt.

Treasury Secretary Timothy F. Geithner has warned for months that the government would soon hit the $14.3 trillion debt ceiling — a legal limit on how much it can borrow. With the government poised to reach that limit Monday, Geithner is undertaking special measures in an effort to postpone the day when he will no longer have enough funds to pay all of the government’s bills.

Geithner, who has already suspended a program that helps state and local government manage their finances, will begin to borrow from retirement funds for federal workers. The measure won’t have an impact on retirees because the Treasury is legally required to reimburse the program.

The maneuver buys Geithner only a few months of time. If Congress does not vote by Aug. 2 to raise the debt limit, Geithner says the government is likely to default on some of its obligations, which he says would cause enormous economic harm and the suspension of government services, including the disbursal of Social Security funds.

Many congressional Republicans, however, have been skeptical that breaching the Aug. 2 deadline would be as catastrophic as Geithner suggests. What’s more, Republican leaders are insisting that Congress cut spending by as much as the Obama administration wants to raise the debt limit, without any new taxes. Obama is proposing spending cuts and tax increases to rein in the debt.

“Everything should be on the table, except raising taxes,” House Speaker John Boehner (R-Ohio) said on CBS’s “Face the Nation.” “Because raising taxes will hurt our economy and hurt our ability to create jobs in our country.”

The Obama administration has warned that it is dangerous to make a vote on raising the debt limit contingent on other proposals. But Boehner is demanding that Congress use the debt vote as a way to bring down government spending.

“I’m ready to cut the deal today,” Boehner said. “We don’t have to wait until the 11th hour. But I am not going to walk away from this moment. We have a moment, a window of opportunity to act, because if we don’t act, the markets are going to act for us.”

Geithner’s plan to tap federal retiree programs as a temporary means to avoid a government default comes as the Obama administration has shown growing interest in altering those programs to curb the debt in the long run.

Administration officials have expressed interest in raising the amount that federal employees contribute to their pensions, sources told The Washington Post.

The Republicans have suggested that the civilian workforce contribute more to its retirement in the future, effectively trimming 5 percent from salaries. The administration has not been willing to go that far in talks being led by Vice President Biden.

Treasury secretaries have tapped special programs to avoid default six times since 1985. The most protracted delay in raising the debt limit came in 1995 after congressional Republicans swept to power during the Clinton administration.

But today, the government needs far more money to cover its obligations than in the past, making the special measures less effective than they used to be. The government needs about $125 billion more a month than it takes in each month.

In a letter released last week to Sen. Michael Bennet (D-Colo.), Geithner wrote that a default would risk a “double-dip” recession.

“Default would not only increase borrowing costs for the federal government, but also for families, businesses and local governments — reducing investment and job creation throughout the economy,” Geithner wrote.

But several prominent congressional Republicans have dismissed the Obama administration’s assertion that the country would face dire consequences if Congress does not vote to raise the federal limit on government borrowing by August. Many of the skeptics are affiliated with the tea party.

In the Senate, freshman Sen. Pat Toomey (R-Pa.) has said the Obama administration has been exaggerating the effects of hitting the default mark. He says breaching the limit would cause only a partial government shutdown.

Other freshman Republicans have said that Geithner could raise money to avoid defaulting by selling investments in private companies. The Republican Study Committee, which represents more than 150 lawmakers, sent a letter to Geithner last week pressing for more details about the Aug. 2 deadline.
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Source: The Washington Post