Editor's note. The following is reprinted from the invaluable Robert Powell Center for Medical Ethics-- http://powellcenterformedicalethics.blogspot.com. Part Two talks about Dan Rather's speech to PPFA. Please send your comments to daveandrusko@gmail.com.  If you'd like, follow me at www.twitter.com/daveha.

Health care restructuring cleared another hurdle yesterday when it was voted out of the Senate Finance Committee by a vote of 14-9. Republican Olympia Snowe (Maine), along with every Democrat, voted to move the bill forward. Sen. Snowe, while maintaining that "My vote today is my vote today. It does not predict my vote tomorrow," ultimately concluded that inaction was riskier than the "imperfect bill."

Several Republican senators continued to warn of the dangers of rationing. Senator Pat Roberts (Ks.) in particular noted that the bill contains "robust tools to ration your healthcare."

Sen. Max Baucus

A good deal of time was spent in committee by Democrats criticizing an industry-commissioned report by PriceWaterhouseCoopers. The firm found health insurance premiums would increase faster under the Senate's bill than they would without it. [You can read the report at www.politico.com/static/PPM116_pwc2.html.]

Also, Sen. Jay Rockefeller (D-WV) again lamented there was no provision for end-of-life planning included. The Senator will likely offer a related amendment on the Senate floor. (For more on similar end-of-life planning provisions in the house bill see http://powellcenterformedicalethics.blogspot.com/2009/08/advanced-care-planning-provisions-must.html.)

The Senate Finance committee product contains (1) cuts to Medicare, (2) the dangerous "Death Spiral" provision [http://powellcenterformedicalethics.blogspot.com/2009/10/medicare-doctors-patients-affected-by.html], (3) a grant of nearly unlimited power to the Medicare Commission to reduce Medicare payments to fit with the limits on growth, and (4) verbal promises to consider price controls (see http://powellcenterformedicalethics.blogspot.com/2009/10/price-controls-rear-their-ugly-head.html).

Negotiations now shift to a closed-door setting. After Tuesday's vote, Senate Finance Committee Chair Max Baucus (D-Mt.), Senate Majority Leader Harry Reid (D-Nev.), and Sen. Chris Dodd (D-Ct.), along with a handful of top White House officials, will meet to meld the Finance Committee bill with an alternative bill that Dodd led through the Senate Health, Education, Labor, and Pensions (HELP) committee in July.

Leaders in the House have been meeting over the past months in an effort to merge three bills passed out of committees and to bring down projected costs. House Speaker Nancy Pelosi (D-Ca.), has said she expects a final version for consideration by the full House soon, although she has not provided a specific timetable. In an attempt to shave the $1.2 trillion plan down to $900 billion, the final bill is likely to reduce subsidies, place more people into state Medicaid programs, and employ several of the taxes raised in the Senate Finance Committee bill.

However, House leaders have rejected the Senate Finance Committee plan's to lay a 40% tax on high-value insurance plans--the one financing mechanism that would keep pace with the rising resources devoted to health care. House leaders are instead relying on a modified version of their original plan to impose a surcharge on higher-income Americans.

Sen. Olympia Snowe

The Washington Post reported that in order to come in under $900 billion dollars, House Democrats will cut out a provision that ensures that doctors receive their Medicare payment update formula. Doctors who see Medicare patients are paid directly from the government, and that payment level would take a dramatic tumble (one so big that many doctors would altogether stop seeing Medicare patients) if Congress does not approve yearly extensions.

Stopping this pay cut is very expensive and doctors have long lobbied for a long-term solution. If the Washington Post is correct, then an essential component of health reform is being put off until later.

In the Senate version, the billions required to stop those scheduled cuts in Medicare payments to physicians is only addressed for one year. If no other action is taken, doctors would then take a drastic 25% pay cut.

Not addressing this very integral and expensive aspect of healthcare in these comprehensive bills can leave the incorrect appearance that the bills are able to be paid for, when that is not the case. And when inadequate financing is present, coupled with the dangerous mechanisms, rationing becomes a very real threat.

How soon floor action will occur in either chamber is unclear, although leadership insists that they mean to act soon.

Please send your comments to daveandrusko@gmail.com.

Part Two