Run for the hills: the doctors are coming

By Robert Laszewski

What is the one thing no human being should want to be next week?

A Republican Senator at a Fourth of July Picnic.

In the most amazing turn of events I have seen in 20 years of following health care policy in Washington, the Democrats have the Republicans backed into an awful corner over the issue of the July 1st automatic 10.6% Medicare physician fee cut and corresponding private Medicare cuts to pay for nixing it. Also at stake is another 5% physician fee cut set for January 1, 2009.

On Tuesday, when the House voted 355-59 in favor of the Senate Democratic bill to stop the physician fee cut, suspend the durable medical equipment competitive bidding system, and pay for the doc cut by ending the private fee-for-service version of Medicare Advantage in 2011, no one was more surprised then the Senate Democrats themselves.

On seeing that vote, Senate Democrats scrapped the bipartisan compromise that Baucus and Grassley worked out to avoid the cuts, freeze 2009 physician payments, and bypass the Medicare Advantage changes to pay for it. Democrats and Republicans were ready to be happy with that and go home for the week-long holiday recess.

But then Senate Democrats saw a huge election-year opportunity to stick the Republicans out on a limb and start sawing it off.

Senate Majority Leader Reid and the Senate Democrats decided to shelve the Baucus/Grassley compromise and bring the just passed House bill back for another Senate vote (the first attempt to get the 60 votes necessary for cloture failed garnering only 54 Senators).

Late Thursday night, they did just that and missed getting the necessary 60 votes by just one Senator. It is notable that Senator Kennedy was not present and could have been the 60th vote. It was a very undignified scene on the Senate floor as Republicans felt betrayed thinking they had an amicable deal to get past the cuts and go home.

It is also important to remember that Senate Democratic Leader Reid came in for lots of criticism by House Democrats late last year when he chose not to take on the Republicans and a threatened Bush veto and settled on a modest SCHIP compromise. Many in the House thought Senate Democrats should have been tougher. This may be Reid's chance to show the House how tough he can be -- especially since the House handed him such a lopsided veto-proof margin on this vote.

So, the Senate recessed on Friday with the docs facing a 10.6% fee cut in just four days.

The Democratic plan is, with the docs looking down the barrel of a 10.6% fee cut on Tuesday, to let the Senate Republicans stew in a provider lobbying onslaught of unprecedented proportions during the week-long recess.

How effective is the doctor lobby? 355-59, that's how effective. About every other health care provider is onside with the docs as well -- durable medical equipment because of their bailout in the House bill, and every other provider because they'd like to see the precedent established that it is the HMO industry that has the money to give back to Medicare--not them. AARP is also backing the docs, giving members political cover with seniors to vote against the private Medicare plans.

I am continually asked: Would Congress really cut private Medicare with almost 10 million seniors in it? 355-59 -- any other questions?

Bush also reaffirmed his veto threat for any bill that cuts private Medicare. HHS, trying to get some heat off Republicans and save CMS from a real payment mess, deferred the physician cuts for 10 days.

What's going to happen when the Congress returns on July 7th?

There will quickly be another Senate vote on the House bill.

If it passes, it goes to Bush who, as long as the vote isn't enormously lopsided, will veto it. In that case the docs will need to have scared enough Republicans to get a veto-proof 67 votes or the docs are out 10.6%.

For two years I have been telling you that the Dems were going to get private Medicare. In November 2006, I thought the big showdown would come during the 2007 budget deliberations. More recently, I figured the Democrats would just bide their time until they had a stronger hand -- after the coming elections.

Turns out I was six months off the first time.

Will the doctors suffer the 10.6% cut if the next Senate vote fails to move the bill? Could well be. Sure, the Baucus/Grassley compromise is laying there but I can't see the Democrats backing down now. The train has left the station on the Democratic argument that it is the Republicans who are blocking a physician fee fix and I think they will continue down that track.

If you are a doctor, I would go find your Republican Senator at the nearest Fourth of July picnic and get at it.

If 7 or 8 Republican Senators don't come back to Washington on July 7th with a changed mind, you are out 10.6% on July 1st and another 5% on January 1, 2009.

We will have extraordinary political theater the week of July 7.