Four Critical Steps Insurers Must Take Now

Les Masterson, for HealthLeaders Media, August 5, 2009

With a public insurance option hanging over their heads and a sputtering employer-based market, health insurers are rightfully concerned about their future. But there is another issue slated for 2013 that could prove as difficult for health insurers.

On October 1, 2013, the Department of Health and Human Services will mandate that healthcare companies comply with ICD-10 diagnosis and inpatient hospital procedure codes.

Health insurers are understandably edgy just thinking about the breadth of this change. This transformation will potentially touch nearly all operational systems and procedures, according to Deloitte Consulting LLP, which recently joined forces with America's Health Insurance Plans to serve as its ICD-10 and 5010 training partner.

Deloitte said ICD-10 implementation requires a "massive wave of system reviews, new medical coding or extensive updates to existing software, and changes to many system interfaces.

"Because of the complex structure of ICD-10 codes, implementing and testing the changes in EMRs, billing systems, reporting packages, decision and analytical systems will require more effort than simply testing data–it will involve installing new code sets, training coders, re-mapping interfaces and recreating reports/extracts used by all constituents who access diagnosis codes," said Deloitte in its ICD-10: Turning Regulatory Compliance into Strategic Advantage.

Just how large is the ICD-10 change over? It should easily surpass the Y2K system upgrades of 1999-2000. David Biel, principal of the ICD-10 service offering for Deloitte in Chicago, says this is because health plans will have to deal with business processes and staffing. In other words, ICD-10 is more than technological improvements. "These codes are embedded in all of their financial transaction systems as well as their clinical systems. In order to order a drug in a hospital, you need to have a diagnosis. All of those things are going to change. This means huge people changes and huge training issues that they will have to deal with," he adds.

But with the ICD-10 changeover also comes an opportunity. Deloitte said ICD-10 could be a "potential platform for future strategic innovation." Though most health insurers will simply comply with the ICD-10 standards, Deloitte estimated that 10 to 15% of health insurers will become "innovators." Deloitte predicts that these innovators will "approach ICD-10 compliance as a strategic initiative and, as a result, could increase patient satisfaction and quality of care, while moving their business and clinical model into new markets."

To become an innovator, however, health insurers will need significant capital and personnel investments, which many insurers might not be able to achieve. What's important is to think of the ICD-10 change not as merely a bottom line concern, says Biel. "We're out in the market talking to a lot of insurers about ICD-10, and they're a number of them asking, 'what can I get out of this' rather than just thinking of costs," he says.

One potential benefit for health plans is having more accurate and a wider breadth of health data. This could help insurers learn more about member health issues and could allow insurers to break down the data into smaller groups for more targeted interventions. This could especially help disease management and care management programs find at-risk members and link them to programs that could improve their health outcomes.

Whether a health plan wants to merely comply or become an innovator, the company needs to prepare now. The North Carolina Healthcare Information and Communications Alliance, Inc., and The Workgroup for Electronic Data Interchange recently released a timeline for ICD-10 preparation. The groups estimate that it could take four years for providers to implement ICD-10.

Biel concurs with the assessment. "Even though we're four years away technically, the magnitude of the change is large enough that if you don't start looking at the impact now, then you won't have created a budget for 2010 to start the process," he says.

So, what can health insurers do now? Biel offers these four steps:

1. Review your technology to understand the impacted areas and how they are embedded in your systems.
   

• Conduct an operational assessment to see the business processes that are touched by this change.


• Conduct a people assessment to see the people who will need training in ICD-10.


• Conduct a strategic assessment and figure out how your company wants to handle ICD-10 (i.e. comply, collaborate, or innovate) and review what would go into each option.

But don't wait to start this process. If your company has not already started the process to implement ICD-10, you are already behind your competitors. Get to work now.
"I believe all health plans before the 2010 budgeting cycle should have an idea of what the impact is, what their road map is to compliance, and how much they need to budget over the next three years—especially the next year," says Biel.

Facing End-of-Life Talks, Doctors Choose to Wait

It’s a conversation that most people dread, doctors and patients alike. The cancer is terminal, time is short, and tough decisions loom — about accepting treatment or rejecting it, and choosing where and how to die.

When is the right time — if there is one — to bring up these painful issues with someone who is terminally ill?

Guidelines for doctors say the discussion should begin when a patient has a year or less to live. That way, patients and their families can plan whether they want to do everything possible to stay alive, or to avoid respirators, resuscitation, additional chemotherapy and the web of tubes, needles, pumps and other machines that often accompany death in the hospital.

But many doctors, especially older ones and specialists, say they would postpone those conversations, according to a study published online Monday in the journal Cancer.

It’s not entirely clear whether these doctors are remiss for not speaking up — or whether the guidelines are unrealistic. Advice that sounds good on paper may be no match for the emotions on both sides when it comes to facing patients and their families and admitting that it will soon be over, that all medicine can offer is a bit of comfort while the patient waits to die.

Dr. Nancy L. Keating, the first author of the study and an associate professor of medicine and health care policy at Harvard, said not much was known about how, when or even if doctors were having these difficult talks with dying patients. But she said that her research team suspected that communication was falling short, because studies have shown that even though most people want to die at home, most wind up dying in the hospital.

The researchers surveyed 4,074 doctors who took care of cancer patients, instructing them to imagine one who had only four to six months left, but was still feeling well. Then the doctors were asked when they would discuss the prognosis, whether the patient wanted resuscitation or hospice care, and where he or she wanted to die.

The results came as a surprise: the doctors were even more reluctant to ask certain questions than the researchers had expected. Although 65 percent said they would talk about the prognosis “now,” far fewer would discuss the other issues at the same time: resuscitation, 44 percent; hospice, 26 percent; site of death, 21 percent. Instead, most of the doctors said they would rather wait until the patients felt worse or there were no more cancer treatments to offer.

They were not asked for their reasoning, but Dr. Keating offered several possibilities. One is that doctors may disagree with the guidelines, which are based on expert opinion rather than data.

“Or they may not be comfortable discussing it,” she said. “These conversations are time-consuming and difficult. Some doctors may feel patients will lose hope. It’s easier to say, ‘Let’s try another round of chemotherapy,’ instead of having a heart-to-heart discussion.” Training may also be a factor, Dr. Keating said. Medical schools spend more time on end-of-life issues than they did in the past, and the greater willingness of younger doctors to broach the subject may reflect that change.

Dr. Daniel Laheru, an associate professor at the Kimmel Cancer Center at Johns Hopkins and a specialist in pancreatic and colorectal cancers, said he was not surprised by the study.

“The natural tendency is not to provide more information about this than you have to,” he said. “It’s such an uncomfortable conversation and it takes such a long time to do it right.”

He added, “People come to us with hope, and if you kind of yank that away from them right away, it’s very unsettling.”

A terminal diagnosis plus the grim details of “do not resuscitate” orders and hospice care may be too much for a patient to hear in one day. Dr. Laheru said he tried to prepare patients on their first visit for the idea that during later visits they would discuss different possible outcomes.

“They don’t always hear that part,” he said.

Dr. John Boockvar, a neurosurgeon at NewYork-Presbyterian/Weill Cornell Medical Center who treats many patients with malignant brain tumors, said he favored postponing such discussions until the end was drawing close. During his own late father’s illness with leukemia, he said, his family was upset by an oncologist who brought up end-of-life issues early.

“As a patient and a family member, I don’t know if I would have wanted to hear a doctor say, ‘In 18 months we’ll be dealing with hospice or end-of-life discussions — do you want to have that discussion now?’ ” Dr. Boockvar said. “I don’t know what the emotional benefit is to the family. I don’t think it’s been studied.”

As a doctor treating patients who are terminally ill, he went on, he did not hesitate to discuss end-of-life issues. But he said, “As the time approaches, there’s usually ample time.”

But Dr. David R. Hilden, an internist at Hennepin County Medical Center in Minneapolis and an assistant professor of medicine at the University of Minnesota, is not so sure.

“I think many of us wait until there’s just a few weeks left and then you have no choice,” he said. “It’s going to happen in a week or two, and they’re in the hospital and they’re on their last legs. The time to talk is much earlier.”

Without planning, Dr. Hilden said, dying patients may wind up in exactly the situation they dreaded most, tethered to machines in a hospital instead of being kept comfortable at home in their own beds.

“This last week, I had a patient with prostate cancer and end-stage heart disease, who probably has less than a year,” he said. “I talked to him and his wife. ‘How do you want your remaining days to be? How much do you want us to do?’ He and his wife were very receptive. Many patients appreciate it. We had a good conversation. It’s easier when the patient is older and it’s not entirely unexpected. He’s 86.”

The patient said he did not want tubes or machines, but just wanted to be comfortable for his last few months.

“They were at peace with it,” Dr. Hilden said, adding that many patients who get aggressive treatment for advanced cancer might in retrospect have made a different choice.

“They might say: ‘After that last three or four months of radiation and chemotherapy, I’m sick, I’m nauseated, my hair fell out and it didn’t extend my life. I might not have done it if I’d known, if I had had the chance.’ ”

Dr. Keating agreed, saying she thought that often when terminally ill patients choose to continue chemotherapy, they don’t understand its limits.

“They say, ‘I want to do everything,’ and they mean ‘everything to cure me,’ ” she said. “They don’t understand it’s not curative.”

Despite the difficulties, she went on, doctors should level with their patients.

“When you know someone’s going to die of their disease, it’s only fair to the patients to help them understand that,” Dr. Keating said. “But these conversations are very challenging. Figuring out how to do it well — it’s so tricky. It’s definitely not something everybody believes in.”

HHS unveils nation's first health security strategy

WASHINGTON – Health and Human Services Secretary Kathleen Sebelius has unveiled The National Health Security Strategy, focused on protecting people's health during a large-scale emergency.

Sebelius said the "comprehensive" document, the first for the nation, sets priorities for government and non-government activities over the next four years.

"As we've learned in the response to the 2009 H1N1 pandemic, responsibility for improving our nation's ability to address existing and emerging health threats must be broadly shared by everyone – governments, communities, families and individuals," Sshe said. "The National Health Security Strategy is a call to action for each of us so that every community becomes fully prepared and ready to recover quickly after an emergency."

National health security focuses on preparing for health threats or incidents with potentially negative health consequences, such as bioterrorism and natural disasters. The strategy provides a framework for actions designed to build community resilience, strengthen and sustain health emergency response systems and fill  gaps in healthcare delivery.

"Events which threaten the health of the people of this nation could very easily compromise our national security. Whether it's a pandemic or a premeditated chemical attack, our public health system must be prepared to respond to protect the interests of the American people. In order to be prepared to both respond to an incident and to recover, we need a strong national health system with individuals and families ready to handle the health effects of a disaster," Sebelius said.

The National Health Security Strategy and an accompanying interim implementation guide outline 10 objectives to achieve health security:

1. Foster informed, empowered individuals and communities.


2. Develop and maintain the workforce needed for national health security.


3. Ensure situational awareness so responders are aware of changes in an emergency situation.


4. Foster integrated healthcare delivery systems that can respond to a disaster of any size.


5. Ensure timely and effective communications.


6. Promote an effective countermeasures enterprise, which is a process to develop, buy and distribute medical countermeasures.


7. Ensure prevention or mitigation of environmental and other emerging threats to health.


8. Incorporate post-incident health recovery into planning and response.


9. Work with cross-border and global partners to enhance national, continental and global health security.


10. Ensure that all systems that support national health security are based upon the best available science, evaluation and quality improvement methods.

The National Health Security Strategy also highlights specific actions that the nation – including individuals, communities, non-government organizations and government agencies – should take to prevent, protect against, respond to and recover from health threats.

Those actions include conducting a review to improve the system for developing and delivering countermeasures such as medications, vaccines, supplies and equipment for health emergencies; coordinating across government and with communities to identify and prioritize the capabilities, research and investments needed to achieve national health security; and evaluating the impact of these investments.

Federal, state, local, tribal and territorial government agencies, as well as medical, public health and community-based organizations, collaborated to develop the strategy and interim implementation guide. To determine additional issues and themes the strategy should address, the HHS solicited input from non-federal participants during six regional workshops. HHS officials also worked with the Institute of Medicine to engage the medical community.

The Pandemic and All Hazards Preparedness Act directed the HHS secretary to develop the National Health Security Strategy with an accompanying implementation plan by 2009 and revise the documents every four years. The HHS, however, will update the implementation plan every two years to reflect advances in public health and medicine.

Obama Urges Excise Tax on High-Cost Insurance

WASHINGTON — President Obama told House Democratic leaders at a meeting on Wednesday that they should include a tax on high-priced insurance policies favored by the Senate in the final version of far-reaching health care legislation, aides said.

The White House has long expressed a preference for the excise tax on high-cost plans, which health economists say could be an important tool in controlling long-term health care spending for the government and for individuals and families.

But House Democrats have resisted the idea, which is also strongly opposed by many organized labor groups — an important part of the party’s base — because the tax may hit a number of more generous union-sponsored health plans.

The Senate proposal would impose a 40 percent excise tax on the cost of individual insurance policies above $8,500 and on family policies above $23,000, with higher thresholds for retirees and employees in high-risk fields like police officers.

The tax would raise $149 billion over 10 years, according to the Congressional Budget Office. The Senate bill would cost $871 billion over 10 years, while the House bill would cost nearly $1.1 trillion.

The meeting among Mr. Obama, Speaker Nancy Pelosi and top committee chairmen responsible for the health care bill came as Congressional leaders have stepped up efforts to reconcile differences between the House and Senate bills.

Ms. Pelosi, emerging from the meeting, said she expected those differences to be worked out soon.

“We have had a very intense couple of days with meetings in our leadership, meetings with our staff,” she said. “After our leadership meeting this morning, our staff engaged with the Senate and the administration’s staff to review the legislation, suggest legislative language. I think we’re very close to reconciliation.”

Mr. Obama has mostly tried to avoid taking public positions on potential disputes between the chambers, to the point that some lawmakers, including some Congressional leaders, have complained that the White House has not provided enough guidance.

Instead, the president and some of his advisers have talked circuitously about what they believe to be some of the more useful policy goals.

The budget director, Peter R. Orszag, for instance, has repeatedly extolled the potential economic merits of the proposed tax on high-cost insurance plans, as well as an independent agency to recommend potential government savings in Medicare.

Both of those ideas were included in the Senate bill, but not the House measure.

Senate Democrats are generally believed to have greater leverage in the negotiations to reconcile the two bills because they cannot afford to lose a single vote and some centrists have warned that they would turn against the bill depending on how it changes.

The Senate approved its bill on a party-line vote, 60 to 39, on Dec. 24.

But the House does not have much wiggle room either. It approved its bill on Nov. 7 by a vote of 220 to 215, with just one Republican joining 219 Democrats in favor. That means Ms. Pelosi could spare just two votes without jeopardizing the bill’s chances.

Among the big differences between the two bills are the provisions to pay for the legislation. Both measures rely on huge reductions to slow the growth in government spending on Medicare.

The Senate also proposed an increase in the Medicare payroll tax for individuals earning more than $200,000 and couples earning more than $250,000. The House proposed an income surcharge on individuals earning more than $500,000 and couples earning more than $1 million.

Joining Mr. Obama and Ms. Pelosi at the meeting on Wednesday were the principal authors of the health care bill: Representative George Miller of California, the chairman of the Education and Labor Committee; Representative Charles B. Rangel of New York, the chairman of the tax-writing Ways and Means Committee; and Representative Henry A. Waxman of California, chairman of the Energy and Commerce Committee.

Representative Louise Slaughter of New York, the chairwoman of the House Rules Committee, also attended.

Mr. Rangel, who has expressed frustration at the pressure on the House to defer to the Senate, said he appreciated Mr. Obama’s time and attention.

“The president has been very patient with his time and understanding that we have to get 218 votes and we really have to be able to sell it — not just to our Democratic caucus, but to the American people,” Mr. Rangel said. “And we could not have asked the president to be more cooperative — even though he’s doing more listening than talking.”

Mr. Obama may have little choice but to emerge from listening mode in the days ahead. Senate leaders return to Washington next week, and pressure will only mount on him to help broker the final differences between the bills.

New Health Rule: Quit Worrying About Your Health

By TARA PARKER-POPE

Stuart Bradford

Have you had your five to nine servings of vegetables today? Exercised for an hour? Cut back on saturated fat and gotten eight hours of sleep?

Dictating the rules for healthful living has become a cottage industry, with Web sites, talk shows and books (and health columns like this one) devoted to the dos and don’ts of staying healthy.

But when it comes to achieving these goals, many of us feel we are falling far short. Whether you’re a busy parent who can’t find time for exercise, a chronic dieter struggling to lose 20 pounds or a multitasker who gets by on six hours of sleep, it is virtually impossible to follow the rules.

Now Dr. Susan M. Love, one of the country’s most respected women’s health specialists, offers a new rule: stop worrying about your health.

In the new book, “Live a Little! Breaking the Rules Won’t Break Your Health” (Crown), Dr. Love makes the case that perfect health is a myth and that most of us are living far more healthful lives than we realize.

Dr. Love, a clinical professor of surgery at the David Geffen School of Medicine at the University of California, Los Angeles, says that failing to live by the various health rules is a major source of stress and guilt, particularly for women. For most of us, “pretty healthy” is healthy enough.

“Is the goal to live forever?” she said in a recent interview. “I would contend it’s not. It’s really to live as long as you can with the best quality of life you can. The problem was all of these women I kept meeting who were scared to death if they didn’t eat a cup of blueberries a day they would drop dead.”

The book, written with Alice D. Domar, a Harvard professor and senior staff psychologist at Beth Israel Deaconess Medical Center, explores the research and advice in six areas of health — sleep, stress, prevention, nutrition, exercise and relationships. In all six, they write, the biggest risks are on the extremes, and the middle ground is bigger than we think.

“Everything is a U-shaped curve,” Dr. Love said. “There may be times in your life when you’ve gotten too much of this or too little of that, but being in the middle is better, and most of us are probably there already.”

Take the issue of sleep. Most people believe that it’s best to get at least eight hours a day. But the studies on which this belief is based look at how much men and women sleep under ideal conditions — silence, darkness and no responsibilities other than taking part in a sleep study. These studies tell us how much people will sleep when they have nothing else to do, but they don’t tell us anything about how much sleep we really need on a daily basis or what will happen if we get less.

A 2002 report in Archives of General Psychiatry tried to address those issues by comparing sleep habits and mortality risk. The study found that people who slept seven hours a night were the least likely to die during the six-year study period. Sleeping more than seven hours or less than five increased mortality risk. It wasn’t clear from the study whether more or less sleep increased risk or whether an underlying health problem was affecting sleep habits, but the findings did call the old “eight hours” rule into question.

The reality is that individual sleep needs can vary. Some people need very little while others need more than the average. “The issue of sleep causes a lot of guilt by women,” Dr. Love said. “We need to be more realistic. If you’re sleepy all the time, you’re not getting enough sleep for you. If you’re fine on six hours, don’t worry about it.”

Likewise, while exercise is important, many people don’t place enough value on the fitness that comes from everyday tasks like lifting and chasing children, lugging groceries and cleaning house.

And there is nothing magic about losing weight. People who are obese or underweight have higher mortality rates, but people who are overweight are just as healthy as those of normal weight — and sometimes healthier. “The goal is to be as healthy and have as good of a quality of life as you can have,” Dr. Love said. “It’s not to be thin.”
Health experts agree that moderation is important and that people should not panic about their health habits. But Dr. Elizabeth Barrett-Connor, professor of family medicine at the University of California, San Diego, cautions against interpreting a relaxed health message as an excuse to overeat or stay sedentary. “I think the problem is the slippery slope,” Dr. Barrett-Connor said. “In the process of translating this message simply to the masses, they may feel they’ve been forgiven. They shouldn’t feel like they’re sinning, but they shouldn’t feel like this is a license not to try to do better.”

Miriam E. Nelson, director of the John Hancock Research Center on Physical Activity, Nutrition and Obesity Prevention at Tufts University, who has read the book, says it may help people realize that it is easier to be healthy than they thought. “There is a large part of the population that doesn’t do anything because they’ve been overwhelmed,” Dr. Nelson said. “This book could get them interested because it’s not so complicated anymore.”

Dr. Love said she and Dr. Domar decided to write the book because many people seemed to have lost sight of what it meant to be healthy. “The point of this is to use your common sense, and if you feel good, then you’re fine,” she said. “The goal is not to get to heaven and say, ‘I’m perfect.’ It’s to use your body, have some fun and to live a little.”

Source: http://well.blogs.nytimes.com/

Program for Children Has Uncertain Future

January 3, 2010, 9:25 pm

Program for Children Has Uncertain Future

By DAVID M. HERSZENHORN

WASHINGTON — As Democratic Congressional leaders work to merge the House and Senate versions of major health care legislation, a big question is what they will do about the Children’s Health Insurance Program, which now provides coverage to more than nine million children and pregnant women and is expected to cover more than 14 million by 2013.

The Senate bill would preserve the program, known as CHIP, and would extend federal financing through 2015, two years past its expiration date under current law. Two Democrats, Senators John D. Rockefeller IV of West Virginia and Bob Casey of Pennsylvania, fought hard to protect CHIP in the bill.

The House bill, by contrast, would end CHIP and redirect the millions of children either to Medicaid, the federal-state insurance program for the poor, or to new health insurance exchanges where moderate-income Americans would be able to buy private coverage using new federal subsidies to help offset the cost.

Unlike many of the issues facing Senate and House negotiators, the question of what to do with CHIP is not just a cerebral policy point. In recent years, states have made huge strides in covering children, particularly those in low- and moderate-income families, and experts say those gains could be put at risk.

“Attention must be paid to the possibility that some children who lose CHIP coverage could fall through the cracks and become uninsured,” Genevieve M. Kenney and Allison Cook wrote last month in a brief prepared for the Urban Institute, the Washington research group.

Some House Democrats, including Representative Henry A. Waxman of California, the chairman of the Energy and Commerce Committee and a lead author of the health care legislation, have said it is difficult to defend a stand-alone government insurance program for children once subsidies are available for entire families.

In Transition, Risks
But many children’s health advocates cite numerous risks. Simply shifting children from one program to another could result in some losing coverage, even on a temporary basis. And there is a chance that parents, even with new subsidies, will find coverage unaffordable and choose not to buy it for themselves or their children, despite a new mandate in both bills that nearly everyone obtain coverage.

Then there are more complicated situations, like those of children whose parents have mixed immigrant status. Under both the Senate and House bills, illegal immigrants would not be eligible for the insurance subsidies.

Some experts project that as many as 14 percent of children with health care through government programs come from such families. And while the bills would provide for the creation of child-only insurance policies, it is unclear how those policies would work and whether children would face difficulties obtaining coverage that way.

The bills also seek to push people with access to employer-sponsored health insurance to buy it, allowing exemptions only for families for whom such coverage would be extremely expensive. Many low-income workers already choose to enroll their children in CHIP because private coverage is too costly.

“The country has made remarkable progress in covering kids in recent years because of the success of CHIP and its companion program, Medicaid,” said Jocelyn A. Guyer, co-executive director of the Center for Children and Families at Georgetown University. “It would be a major problem if health reform undercut these gains by shutting CHIP down too abruptly or by moving kids into coverage that isn’t as affordable and as well-designed to get them the care they need to develop and grow.”

In an effort to tilt the debate in favor of maintaining CHIP as a standalone program, Mr. Rockefeller and Mr. Casey prevailed upon the Senate majority leader, Harry Reid of Nevada, to include two more years of federal financing — through 2015 — which would serve as a bridge beyond the creation of insurance exchanges, where people would be able to buy subsidized private coverage.

Under the Senate bill, state-based exchanges would begin in 2014. The House bill calls for a national insurance exchange to begin in 2013.

Factoring in Medicaid
Tied directly to the question of CHIP’s future is the proposed expansion of Medicaid to include many more low-income Americans, particularly childless adults.

Medicaid would grow under both measures, with eligibility expanded to individuals and families earning up to 133 percent of the federal poverty level (currently about $29,327) under the Senate bill, and up to 150 percent of the poverty level ($33,075) under the House bill.

States have generally expressed apprehension about the proposed Medicaid expansion, because they would eventually share in the cost of covering new enrollees. Medicaid generally provides more comprehensive coverage than CHIP, but potentially offers fewer choices of doctors and other health providers because of Medicaid’s low payment rates. States currently must provide Medicaid coverage to all children through age 5, from families earning up to 133 percent of the poverty level, and to children ages 6 to 18 with family income up to 100 percent of the poverty level.

The House bill, in addition to more broadly expanding Medicaid eligibility, would also increase payment rates for primary care physicians — a step that many health advocates say is needed to improve access to providers for children and adults. The Senate bill does not increase Medicaid payment rates.

In a statement after the Senate adopted its health care bill on Dec. 24, Dr. Irwin Redlener, president of the Children’s Health Fund, a New York-based advocacy group, praised the preservation of CHIP, but criticized the Senate bill for not lifting Medicaid payment rates. “Unfortunately, the Senate bill fails to improve reimbursement rates for Medicaid providers and omits a provision to automatically enroll otherwise uninsured infants, both of which were in the House bill,” Dr. Redlener said.

The Fight Ahead
Mr. Rockefeller, in an interview just before the Senate adopted its bill, said that he was prepared to battle against his colleagues in the House to preserve CHIP in the final health care legislation. “I am not going to drop kids,” he said.

But Mr. Rockefeller also said he was optimistic that House Democratic leaders, however reluctant, would make the adjustments needed to get the final legislation through the Senate, where Democrats cannot afford to lose a single vote.

“The House doesn’t like the Senate, anyway,” he said. “I don’t blame them.”