Actually, this is a good bill

The Senate is actually working on a good healthcare bill.  No, not the AHCA or the doppelganger of the AHCA.  The Chronic Act is winding its way through the committee process. This bill is full of little technical corrections to Medicare and tweaks for experiments.  Let’s look at what’s happening in it.

Section 101 expands a demonstration project that has good initial results.  The Independence at Home program is a pilot program that uses intensive primary care and care coordination to specifically target high risk and high cost Medicare beneficiaries for more intensive services.  Its initial evaluation found significant savings and quality improvements.  This section expands the time frame and the number of beneficiaries who can be enrolled in the study.  The goal, I think, is to see how this project can scale up and move it towards a national model.

Section 102 allows for some telehealth visits to be used to supervise/coordinate dialysis care.  This would be an option not a requirement. It should improve access and quality of life for people on dialysis who live far away from their nephrologists and clinics.  It might save a little bit of money as the telehealth visit would not be allowed to charge a facility fee.

Section 201 modifies how care coordination is managed for individuals who are dual enrolled in Mediare Advantage and Medicaid through the SNP program.  Care coordination meetings are mandated.  Rules are to be developed for a uniformed complaints and grievances process.  Eligibility is defined as either rare or costly.  There is a section that warms the cockles of my heart on statistically validity of quality measures relating to population size.

Section 301 is a Medicare Advantage benefit design waiver pilot program.  The concept of Value Based Insurance Design (VBID) is that patients should pay nothing for very high value care and a lot for low value care.  In this frame work, insulin and test strips should be no cost sharing to Type 1 diabetics.  Ten states would be allowed to experiment with benefit design.  The goal is to get people better while lowering costs.  I don’t know if this will work but it is a reasonable experiment.

Section 302 allows Medicare Advantage firms to apply for waivers to give non-medical benefits to chronically ill patients.  Again, I don’t know if this will bend the cost curve and improve outcomes but it is a reasonable thing to try.

Section 303 and 304 and 305  expands telehealth options for Medicare Advantage and Accountable Care Organizations (ACO), and stroke patients.  I like that telehealth is not being allowed to count towards network adequacy.  The trade-off will be if lower cost visits leads to more visits and more net costs with or without net patient benefit.

Section 401 allows ACO patients to be assigned prospectively.  This means the ACO could be chosen by beneficiaries at the start of the year. Attribution is a major challenge and source of technical risk.  Retrospective attribution means the ACO is responsible for a population that is only defined after the contract.  Prospective attribution allows an ACO to know its patient roster at the start of the contract.  This is weedy but useful.

Section 501 allows ACO’s to use member incentive programs for primary care and care coordination purposes.  This ties into the same general concept of Section 301 where Congress would like Medicare to make it easier for people to make good choices.

And then there are several sections authorizing the Government Accountability Office (GAO) to conduct studies on interesting questions regarding care coordination.

None of these sections are home runs.  There might be a bunt single and perhaps a well hit ball that falls in between the shortstop and the left fielder for a hit.  But this is what a decent healthcare focused bill can actually look like.  We should encourage this.



NB — we should also encourage a better name for the bill to avoid late night Taco Bell jokes.




37 replies
  1. 1
    evodevo says:

    That’s alright … I kinda like the name …. who knows maybe the yoot will get interested and actually read up about it …

  2. 2
    rikyrah says:

    Thanks for the info Mayhew

  3. 3
    Keith P. says:

    The Chronic Act is winding its way through the committee process.

    Legal weed on a federal level? (I lack the attention span to read any further down)

  4. 4
    wvng says:

    I’m stunned to know something decent can come out of a GOP controlled body. Thanks!

  5. 5
    Booger says:

    Can you comment on section 420?

  6. 6
    rikyrah says:

    Mayhew, why is it a good bill?
    How did this happen?
    The GOP NEVER does anything for the benefit of the masses. What is the scam?😠

  7. 7
    AxelFoley says:

    The Chronic Act? Who wrote this bill, Dr. Dre?

  8. 8
    Wag says:

    Multiple interesting and reasonable items in a single GOP bill– this may be what you get when policy wonks are able to work in the quiet space just outside the ever sucking vortex that D.C. had become.

  9. 9
    Dr. Ronnie James, D.O. says:

    “NB — we should also encourage a better name for the bill to avoid late night Taco Bell jokes.”

    Can I still mock Republican “Taco Bell health policy” for just recombining the same 5 ingredients?

  10. 10
    ArchTeryx says:

    @rikyrah: I actually read the thing. It’s pretty in the weeds of decent Medicare health policy and there appear to be no hidden gotchas. Orrin Hatch is actually one of the more sane Republicans on health policy – he’s not a burn-it-all-down vandal like the barbarians in the House.

    ‘Telemedicine’ is possibly the only camel’s nose in it, and it’s a pretty small one, since it’s increasingly important particularly for rural medicine. Not near the sort of Trojan Horse that ‘sell insurance across state lines’ is.

  11. 11
    But her emals!!! says:

    If the Senate has decided to create a sane and reasonable bill, one that the Democrats in the Senate could actually support, how do you get the House to sign on to it? There’s no way you can do reconciliation with these two bills. Trump isn’t a problem, as he would sign anything that reaches his desk so long as he gets to claim he repealed and replaced Obamacare so he’s not a concern. The House though seems to want it’s tax cuts and the tea party portion wants to kill some people, so how does it get through? Has there been some sort of back channel discussion that gets this brought to the House floor for a vote and passed courtesy of Democrats and some moderate Republicans?

  12. 12
    Keith P. says:

    @AxelFoley: It’s only got the choicest amendments. All the co-sponsors are totally cool.

  13. 13
    ArchTeryx says:

    @But her emals!!!: It’d probably take a discharge petition, because Ryan would never let such a bill see the light of day, and signing a discharge petition is normally signing your political death warrant if you’re a member of the majority. But we’ll see I guess.

  14. 14
    Adria McDowell (formerly Lurker Extraordinaire) says:

    I guess this is good news? Still, I sent an email to the address in yesterday’s thread about Hatch looking for input from health care stakeholders. I’m a member of the general public, and health is a public issue, so that makes me a stakeholder, damn it!

  15. 15
    Another Scott says:

    Thanks for the info.

    But I gotta go kinda OT.

    Being in committee is fine. But I would be opposed to an actual floor vote on things like this for the foreseeable future. There’s too much risk, especially in the House.

    Let’s see if the Teabaggers can pass a debt ceiling bill and a FY18 budget that doesn’t destroy the federal government and the commonweal. Let’s see if Trump and Pence and their minions can demonstrate that they aren’t traitors and if they’re willing to actually uphold their oaths. Let’s see if Ryan and McConnell are willing to perform their institutional duties to serve as a check on the executive branch that is held by their own party. After that, maybe we can risk passing legislation that affects the health care of tens or hundreds of millions of people.

    I’m not hopeful, but am willing to be surprised.


  16. 16
    J R in WV says:

    Hi David,

    Thanks for keeping this up with us during your new gig in NC.

    In a paragraph that speaks a lot of attribution, your also say “Retrospective retribution ” which I suspect is a well spelled typo brain to fingers error.

    Not important, but goofy looking in a health care bill… I know I sometimes feel that retribution is built into health care, but I think that’s a psychosocial illusion.

  17. 17

    I am skeptical of the “good” intentions and “good” bills proposed by Rs.

  18. 18
    Jhony says:

    Ok I hope it really works and a benefit for a population.

  19. 19
    Neldob says:

    Thanks. It’s so nice to have a sensible parsing person around. Tentatively hopeful, also wary.

  20. 20
    rikyrah says:


    I am skeptical of the “good” intentions and “good” bills proposed by Rs.

    See…I am not alone…

  21. 21
    JCJ says:


    The Chronic Act? Who wrote this bill, Dr. Dre?

    Co-wrote it with Snoop. I think Cypress Hill had some input as well.

  22. 22

    @rikyrah: I cannot trust people who refuse to acknowledge my humanity and would rather see me dead.

  23. 23
    Ohio Mom says:

    Perhaps they are doing the right thing for the wrong reason? That is, they are trying to build some credibility as reasoned and thoughtful legislators before they spring whatever crap they are planning as a replacement for the ACA? Like rikyrah, I am suspicious.

    But add my name to the list of people who will be happy to be surprised and to admit to being wrong, if those things turn out to be appropriate reactions.

  24. 24
    Adria McDowell (formerly Lurker Extraordinaire) says:

    AP reporting that Flynn will invoke the 5th and won’t hand over any docs.

  25. 25
    WeRateBills says:

    This is the Chronic Act. It makes several technical improvements to Medicare. Creates space to test experimental programs. Does not appear to cut 800 billion dollars from Medicaid for tax cuts. 6.5/10 doesn’t make me want to run for the border.

  26. 26
    Mike J says:

    There’s no reason this bill shouldn’t get a majority of Dem votes, which is why it will never get through Congress in its current form. Republicans think that every vote from a Democrat means they left something on the table. I can’t imagine Republicans ever passing a bill just because it was good for the country.

  27. 27
    Tom says:

    @Another Scott: What Scott said.

  28. 28
    But her emals!!! says:

    @Mike J:

    Maybe Dems should pretend they don’t like it then all vote yes when it comes up for a vote.

  29. 29
    Lizzy L says:

    Thanks David. Neither of my Senators is on the Finance Committee, but I’ve got lots of out of state friends, so I’m putting out the word.

  30. 30
    rikyrah says:

    Today is May 22nd. Didn’t you say this was D-Day with the subsidies?
    What’s the word in those insurance streets?

  31. 31
    Origuy says:

    @Adria McDowell (formerly Lurker Extraordinaire): IANAL, but aren’t those two different things? Does the Fifth Amendment cover a subpoena duces tecum?

  32. 32
    Fleeting Expletive says:

    House Waysnmeans is hearing about Medicare payment structures and rural free standing emergency rooms within a ten mile radius of a regular hospital and I wish I’d paid more attention to this so I’d have understood it better.

  33. 33
    TenguPhule says:

    No Bills, no matter how good they may seem at first glance, while under hostile occupation by Axis Republican forces.

    You KNOW they’re gonna reconcile it into an AHCA clone. YOU KNOW BETTER,

  34. 34

    @rikyrah: Expect mega rate hikes.

  35. 35


    A bill that renames a post office could be amended to institute the AHCA.

    The advantage of going through regular order is that it will require either 60 votes in the Senate and thus a plausibly decent bill as I trust the policy instincts of the 8th most vulnerable Democrat OR the destruction of the filibuster which will produce a 52-48 vote on the underlying bill and everyone will place blame and responsibility clearly.

    This is a rant that I’ll write up tonight.

  36. 36
    Another Scott says:

    @David Anderson:

    This is a rant that I’ll write up tonight.

    Looking forward to it. :-)


  37. 37

    Regardless of how good this bill is, what would come out of a conference committee would be less good. In fact, it probably would be really bad.

    And Republicans will be able to say, “See, Senate Democrats voted for it. It’s bipartisan. Neener, neener.”

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