Tuesday, March 31, 2015

Hoping To Live, These Doctors Want A Choice In How They Die

Editor’s Note: The Texas Medical Association emphatically opposes physician-assisted suicide, but we share this article and Dr. Nava's commentary in hopes that it will promote ongoing conversations between physicians and patients about death and dying.

Both of these doctors [featured in the story below] are to be congratulated for opening their personal lives to patients everywhere.

It will take all of us to prepare for the difficult discussions in the future.  When I say difficult, I mean for both the physicians and the patients.  Neither group has the comfort level to broach the subject head on, for fears of being drowned under that huge wave of newness.  But if we have the patience to wait until we rise to the surface, the next part of the puzzle can be fitted, and we move on.

That common thread of unfamiliarity can only strengthen the physician-patient relationship during such a challenging time.  We have to lead, because no one else will do it so well.

John J. Nava, MD
San Antonio Physician
Member, TMA Council on Health Promotion

Hoping To Live, These Doctors Want A Choice In How They Die

By Anna Gorman
Kaiser Health News

Content provided by Kaiser Health News

SAN FRANCISCO — Dan Swangard knows what death looks like.

As a physician, he has seen patients die in hospitals, hooked to morphine drips and overcome with anxiety. He has watched dying drag on for weeks or months as terrified relatives stand by helplessly.
Dan Swangard, a 48-year-old physician from San Francisco, was diagnosed in 2013 with a rare form of metastatic cancer.

Dan Swangard, a 48-year-old physician from San Francisco, was diagnosed in 2013 with a rare form of metastatic cancer (Photo by Anna Gorman/KHN).

Recently, however, his thoughts about how seriously ill people die have become personal. Swangard was diagnosed in 2013 with a rare form of metastatic cancer.

To remove the cancer, surgeons took out parts of his pancreas and liver, as well as his entire spleen and gallbladder. The operation was successful but Swangard, 48, knows there’s a strong chance the disease will return. And if he gets to a point where there’s nothing more medicine can do, he wants to be able to control when and how his life ends.

“It’s very real for me,” said Swangard, who lives in Bolinas, Calif. “This could be my own issue a year from now.”

That’s one of the reasons Swangard joined a California lawsuit last month seeking to let doctors prescribe lethal medications to certain patients who want to hasten death. If he were given only months to live, Swangard said, he can’t say for certain whether he would take them.

“But I want to be able to make that choice,” he said.

The right-to-die movement has gained renewed momentum in California and around the nation following the highly publicized death of an East Bay woman with brain cancer. Brittany Maynard, 29, moved to Oregon to take advantage of its “Death with Dignity” law and died in November after taking a fatal dose of barbiturates prescribed by her doctor.

The California lawsuit asks the court to protect physicians from liability if they prescribe lethal medications to patients who are both terminally ill and mentally competent to decide their fate.

The lawsuit argues that while it is against the law in California for anyone to assist in another’s suicide, these cases are not suicides. Rather, the suit argues, they are choices by a dying person on how his or her life should end and decisions about one’s own body protected under the state constitution.

Separately, two California state senators have proposed a bill that would allow doctors to prescribe lethal medication to certain terminally ill adults.

Three states – Oregon, Washington and Vermont – already have laws allowing physician-assisted deaths. Courts in New Mexico and Montana also have ruled that aid in dying is legal, and a suit was also recently filed in New York.

Legislation is pending in several other states. Kathryn Tucker, an attorney on several of the court cases, is also spearheading the California lawsuit. This time, she and her legal team decided to include among the plaintiffs two doctors with life-threatening illnesses, Swangard and a retired San Francisco obstetrician.

Physicians “have a very deep and broad understanding about what the journey to death can be like,” said Tucker, executive director of the Disability Rights Legal Center. “The curtain is pulled back. For lay people, death is much more mysterious.”

Historically, doctors have been some of the most vocal critics of assisted suicide, also called aid-in-dying. The American Medical Association still says that “physician-assisted suicide is fundamentally incompatible with the physician’s role as healer.” Similarly, though it hasn’t taken a position on currently proposed legislation, the California Medical Association has said that helping patients die conflicts with doctors’ commitment to do no harm. “It is the physicians’ job to take care of the patient and that is amplified when that patient is most sick,” said spokeswoman Molly Weedn.

But a recent survey of 21,000 doctors in the U.S. and Europe shows views may be shifting. According to Medscape, the organization that did the survey, 54 percent of American doctors support assisted suicide, up from 46 percent four years earlier.

Swangard is among those who believe that taking care of patients means letting them choose how their lives should end. That’s not the same as killing patients or facilitating suicide, he said.

Swangard completed his medical residency in San Francisco in the middle of the AIDS crisis; young men were dying all around him. Throughout his career as an internal medicine doctor, a hospice volunteer and now an anesthesiologist, he has become frustrated with how the medical system handles death. Doctors spend so much time trying to extend life that few focus on what patients want in their last days, he said.

“I don’t think we know how to die,” he said. “We fight tooth and nail to keep that from happening.”

Swangard’s own illness was discovered in early 2013 during a long overdue check-up. He hadn’t been worried about his health – he was obsessed with fitness, swimming regularly and seeing a trainer twice a week. But when the doctor pressed on Swangard’s stomach, he felt a mango-sized mass.

He had a visceral feeling, he said, “something bad was happening.”

Within a week, a surgeon found a neuroendocrine tumor in the pancreas and metastasis in the liver. It was the same cancer that took Steve Jobs’ life – one that doesn’t generally respond to chemotherapy or radiation. “My fears became real,” he said.

The doctors told him they believed they got all the cancerous cells. But Swangard was tormented by questions: Am I going to be alive in a year? Is my cancer going to come back?

“I wasn’t sleeping, I wasn’t exercising, I was marinating in my own sadness and fear of what this all meant,” he said. “I thought, ‘This is going to kill me.’”

Since his diagnosis, Swangard said he has had a greater understanding of his patients’ struggles. Occasionally, he holds their hands and tells them he has been where they are.

Earlier this year, a physician friend asked him if he’d be willing to join the California case. Swangard didn’t hesitate. He didn’t go into medicine to help dying people linger and wants to help change that approach — for his patients and for himself.

When he dies, Swangard said, he wants to be surrounded by people he loves. He doesn’t want to be in a drug-induced haze, nor consumed by worry about what’s next. He wants to be able to say goodbye.

“It is a little bit of a blessing to know how I might die,” he said. “I don’t think a lot of patients have insight into what to expect.”

These days, he wears a Buddhist prayer bracelet, a reminder to focus on the present. He cut his work hours, swims as often as he can and meditates regularly. At home, he stares out at the ocean, often watching dolphins pass by. He makes every effort to stay calm and healthy.

He is in remission but he knows that what happens with the cancer is largely outside his control. An MRI last year showed a small lesion in his liver, which doctors are watching closely.

“It’s this big unknown,” he said.

Dr. Robert Liner, a fellow plaintiff who only recently met Swangard, lives with the same uncertainty.

On his 69th birthday in May 2013, the retired obstetrician had a bad cough. He felt tired and short of breath. His wife took him to the hospital, where doctors discovered malignant masses on his kidneys — advanced-stage lymphoma.

After radiation and chemotherapy, the tumors shrank. He also is in remission. But if the cancer comes back, he said, “the prospects are not going to be good.”

He often thinks of a former patient, a 25-year-old woman with metastatic ovarian cancer. She wanted to die while she still was able to communicate. Liner wasn’t able to help ease her death because the law wouldn’t let him. “I felt like I’d failed her,” he said.

Years before his diagnosis, Liner, now 70, became involved with Compassion & Choices, an organization that promotes aid-in-dying. He has a shelf of books in his San Francisco home devoted to the subject: Being Mortal, Dying Right, Knocking on Heaven’s Door.

He keeps a stack of notecards with quotes about the end of life, which he often recites in speeches to church groups or senior centers. One reads, “The best preparation for death is a life well-lived.”

He believes having medication to hasten death helps terminally ill people live fully in their last weeks or months without being immobilized by fear. “If you are riddled with anxiety, you are not free to concentrate on what’s most meaningful to you,” he said.

Like Swangard, Liner doesn’t know if he would take the medication. He recently married the woman he calls his “beloved” and said he has lots of plans for his retirement years, including writing a screenplay and improving his piano playing.

“My wife says I’d be hanging on to life by my fingernails,” he said.

But that decision should be his to make, with his family and his doctor, he said. “I want the comfort of knowing it’s up to me when enough is enough,” he said.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

Thursday, March 26, 2015

Did Early Immunization Help America Win Independence From Great Britain?

In the midst of the American Revolutionary War, scores of soldiers in Gen. George Washington’s Continental Army were falling victim to smallpox, killing them before they had a chance to fight for our independence, reports Frontline and Public Radio International’s The World.

In the video below, The World’s Christopher Woolf tells the story of how Washington’s decision to inoculate his troops helped stop the spread of smallpox in the camps, saving soldiers’ lives and ultimately contributing to a U.S. victory.

“We all know that George Washington is America’s founding father,” says Woolf. “But did you know he’s also the founding father of mass immunization in America?”

Wednesday, March 25, 2015

Five Reasons Congress Should Support the Medicare Reform Plan

By Bradford S. Patt, MD

Texas physicians, of course, are applauding the recent Washington announcement of a bipartisan plan to repeal Medicare’s Sustainable Growth Rate (SGR) formula.

Houston-area physicians are proud that our own Reps. Kevin Brady and Gene Green are major sponsors of this proposal.

Congress enacted the SGR 18 years ago. It hasn’t controlled Medicare costs. It’s time to repeal it. Physicians are tired of the never-ending uncertainty, the never-ending threats, the never-ending need to lobby Congress on the same, never-ending problem. Our patients are tired of the never-ending fear of losing their doctor. Eighteen years and 17 patches is enough.

The current threatened pay cut – 22.4 percent scheduled to take effect April 1 – likely won’t take effect. Congress could put yet another last-minute patch on it. Your physicians, though, hope that this time, with a good plan in place, Congress will finally repeal the SGR.

This would be great news for the 4 million Texans whose access to health care is endangered by the SGR. This would be great news for the 270,000 Texans who work in doctors’ offices.

Unfortunately, some Washington players are threatening to scuttle the deal brokered by U.S. House Speaker John Boehner and Minority Leader Nancy Pelosi because they don’t like the budget numbers behind it. Those are false arguments. Here are five solid reasons Congress should embrace this plan and vote for its passage:

1. The SGR is a failed attempt at government price control.

The SGR has never held down the cost of providing health care to military families and patients on Medicare. Government-imposed price controls don’t work. Price controls distort the free market; in this case they’ve forced physicians to find creative ways to bill Medicare for the services their patients need.

2. The “cost” of repealing the SGR is fake.

As Americans for Tax Reform reminds us, “Congress has delayed the onset of SGR 17 times over more than a decade. It is blindingly obvious … that Congress will continue to not impose SGR cuts. To pretend that it will, and then demand spending cuts to ‘pay for’ repealing it, is cognitive dissonance of the highest order.”

3. The SGR hides the true cost of Medicare.

Pretending that the SGR will someday take effect and someday hold down Medicare spending makes Medicare look much stronger than it actually is. “That allowed for the Obama Administration and allies on Capitol Hill to justify the creation of Obamacare (paid for in large part by Medicare cuts, incidentally) because of this rosy long-term cost scenario,” said Americans for Tax Reform.

4. The SGR repeal bill makes significant changes in Medicare financing.

The package does more than eliminate the SGR; it profoundly reforms how Medicare pays physicians for health care services. The Wall Street Journal describes it as a way to “reward doctors for providing more valuable care, rather than cutting the same fee-for-service check regardless of performance.” That will keep taxpayers healthier in more ways than one.

The plan pays for some of the cost of SGR repeal with changes in Medicare premiums and Medigap coverage for the wealthiest retirees. It would not affect those Medicare recipients who are not well-off.

“Because these policies are phased in, they don’t affect Medicare much in the first 10 years,” said Douglas Holtz-Eakin, president of the American Action Forum and budget director under President George W. Bush. “But the savings will continue to rise, grow faster than physician reimbursements, and on balance lower projected Medicare spending … by $230 billion over the second 10 years, 2026-2035.”

5. The SGR stands in the way of real health care reforms.

The constant negotiations over the “doc fix” bills distract Congress from significant structural reforms conservatives want.

“If you’re a conservative interested in repealing Obamacare, reforming Medicare, or block granting Medicaid to the states, removing the SGR kabuki theater from the congressional agenda is absolutely essential,” says Americans for Tax Reform.

As the Journal editorialized, “Congress is close to repealing a two-decade budget cheat and reforming the entitlement state for the first time in the Obama Presidency.”

Let’s not let fake government accounting get in the way.

Dr. Patt, an otolaryngologist in Houston, is the current president of the Harris County Medical Society.

Tuesday, March 24, 2015

Pair of Bills Improve Texas’ Vaccine Data ― To Help Keep All Texans Safe and Healthy

Keller, TX pediatrician Jason Terk, MD, testified in support of two bills before the Texas Legislature’s House Public Health Committee that would improve infectious disease reporting in Texas and the state’s immunization registry (ImmTrac).

Don’t Toss 18 Year-Olds’ Valuable Shot Records 

House Bill 2171 by Rep. J.D. Sheffield, DO (R-Gatesville), would ensure Texas children’s immunization records are safely maintained as they transition into adulthood. Currently, when young Texans turn 18, their immunization record is removed, despite the parents’ original intention of creating the record.

“That presents a problem, because if their former physician is no longer in practice it can be difficult to get that record, which is something that young people oftentimes need for entry into institutions of higher learning as well as jobs,” said Dr. Terk.

Under current law, these youths suddenly discover after they turn 18 that their records are no longer available to show proof of immunizations to enroll in college, enter the military, or apply for a first job. HB 2171 extends the time before these records are deleted to 26 years of age.

“I don’t think very many of us at the age of 18 are thinking, ‘Oh my gosh, I’ve got to get right to the registry to retain my immunization information.’ They have a lot of other things going on,” said Dr. Terk.

Improve Tracking of Disease Outbreaks, Vaccine Exemptions

TMA also testified in support of House Bill 2474, also by Representative Sheffield, who is a primary care physician. The bill would require the Texas Department of State Health Services (DSHS) to regularly provide information about vaccine-preventable disease outbreaks and the number of individuals with a vaccination exemption.

“That’s obviously a very topical thing because of the recent outbreak of measles arising from Disneyland,” said Dr. Terk. “Fortunately, there have been no Disneyland-associated measles cases in this state, but there are pockets of less-than-optimally vaccinated populations in this state. [HB 2474] would help with understanding and fine-tuning the risk for disease outbreaks as well as responding to disease outbreaks if they were to occur.”

The bill also would require DSHS to amp up its reporting of vaccine exemptions. This would give parents more information when selecting schools they might deem safer for children whose immune systems are compromised or who are more susceptible to disease.

“The parent of a medically fragile child is going to be very concerned to make sure they are in a safe environment when they are going to school, and if they can look up the information about the school and say, ‘Oh my gosh, the personal belief exemption rate is a lot higher in this school versus another one. I need to make a proactive decision to protect my child’ ― that’s going to be important for them.”

Thursday, March 19, 2015

Poll Gauges America’s View on Latest ACA Court Case

Earlier this month, the Supreme Court heard oral arguments in King v. Burwell. The case will decide if people in Texas and other states not running their own health insurance marketplace can use tax credit subsidies to help pay for coverage on the federal marketplace.

According to the March ACA tracking poll by Kaiser Family Foundation (KFF), the court case is not on Americans’ radar. More than half (53 percent) of people surveyed admitted they hadn’t heard anything at all about King v. Burwell.

Still, Americans did have opinions about possible outcomes for the case. When asked if they believe a ruling against subsidies for federal marketplace insurance would have a negative or positive impact, 52 percent said the ruling would have no impact on themselves and their family, but 46 percent said the ruling would have a major negative impact on the country as a whole.

In the event of a ruling against subsidies for federal marketplace insurance, 65 percent of respondents said Congress should pass a law making people in federal-run marketplace states eligible for financial help to buy marketplace insurance. However, according to KFF, “The public has little faith that lawmakers could work together to resolve the issues created by a ruling in favor of the plaintiffs. Over half (56 percent) say they are not at all confident that Democrats and Republicans in Congress can work together on any issues raised by the ruling and a similar share (51 percent) are not at all confident that Republicans in Congress and President Obama can work together.”

Read more on the latest opinion poll at KFF.

Wednesday, March 18, 2015

Texas Tobacco-Free Kids Day

Today, children and teens across Texas are pledging to live tobacco-free lifestyles and encouraging their peers to join them as part of Texas Tobacco-Free Kids Day (TTFKD).

Created in 2013 by Sen. Rodney Ellis (D-Houston) and sponsored by the Texas Department of State Health Services and the Texas School Safety Center, the purpose of TTFKD is “to get every school in Texas involved in the effort to help students make healthy choices by not using tobacco today and in the future.” Texas school children are encouraged to share the tobacco-free message through activities like smoke-free sit-ins, writing to elected officials, announcements over the school loud speaker, messages on school and city billboards, and even flash mobs.

Texas physicians know a major way to decrease smoking-attributable illnesses and deaths is by preventing minors and young adults from ever taking up the tobacco habit. More than two out of three of Texas’ adult smokers started smoking regularly at age 18 or younger, and 85 percent started at age 21 or younger. The Centers for Disease Control and Prevention estimates about 23,000 Texas minors start smoking each year.

Monday, March 16, 2015

FAQ: Could Congress Be Ready To Fix Medicare Pay For Doctors?

By Mary Agnes Carey
Kaiser Health News

Content provided by Kaiser Health News

With a deadline fast approaching, bipartisan negotiations are heating up in the House to find a permanent replacement for Medicare’s physician payment formula. But the tentative package being hammered out behind closed doors contains some key provisions that are likely to raise objections from both Republicans and Democrats.

Unless Congress takes action by the end of this month, doctors who treat Medicare patients will see a 21 percent payment cut.

For doctors, the nail-biter has become a familiar but frustrating rite. Lawmakers invariably defer the cuts prescribed by the 1997 reimbursement formula, which everyone agrees is broken beyond repair. But the deferrals have always been temporary because Congress has not agreed to offsetting cuts to pay for a permanent fix. In 2010, Congress delayed scheduled cuts five times.

The current proposal for a permanent fix may not include full financing for repealing the payment formula, according to congressional aides and industry lobbyists who have been briefed on the talks but spoke on the condition of not being named because of the sensitivity of the discussions. That provision could run into concerns from many Republicans and some Democrats.

Doc Fix shadow 570In addition, Senate Democrats are leery of another provision reportedly part of the negotiations – charging wealthier Medicare beneficiaries more for their coverage, according to top Senate aides who briefed reporters Sunday. They also noted that although Democrats are eager to attach to a deal an unrelated measure to extend the Children’s Health Insurance Program, they would like it to cover four years, not the two years that the House is reportedly considering.

Still, they said, with some changes in the package, Senate Democrats might be able to support the developing House package.

“Our members would like to get there,” one of the aides said.

Here are some answers to frequently asked questions about the congressional ritual known as the doc fix.

Q: How did this become an issue?

Today’s problem is a result of efforts years ago to control federal spending – a 1997 deficit reduction law that called for setting Medicare physician payment rates through a formula based on economic growth, known as the “sustainable growth rate” (SGR). For the first few years, Medicare expenditures did not exceed the target and doctors received modest pay increases. But in 2002, doctors were furious when they came in for a 4.8 percent pay cut. Every year since, Congress has staved off the scheduled cuts. But each deferral just increased the size of the fix needed the next time.

The Medicare Payment Advisory Commission (MedPAC), which advises Congress, says the SGR is “fundamentally flawed” and has called for its repeal. The SGR provides “no incentive for providers to restrain volume,” the agency said.

Q. Why don’t lawmakers simply eliminate the formula?

Money is the biggest problem. An earlier bipartisan, bicameral SGR overhaul plan produced jointly by three key congressional committees would cost $175 billion over the next decade, according to the Congressional Budget Office. While that’s far less than previous estimates for an SGR repeal, it is difficult to find consensus on how to finance a fix.

For physicians, the prospect of facing big payment cuts is a source of mounting frustration. Some say the uncertainty has led them to quit the program, while others are threatening to do so. Still, defections have not been significant to date, according to MedPAC.

In a March 2014 report, the panel stated that beneficiaries’ access to physician services is “stable and similar to (or better than) access among privately insured individuals ages 50 to 64.” Those findings could change, however, if the full force of SGR cuts were ever implemented.

Q: What are the options that Congress is looking at?

A: The bipartisan negotiations among key House leadership and staff from committees with jurisdiction over the SGR have been behind closed doors, and the offices of both House Speaker John Boehner, D-Ohio, and House Minority Leader Nancy Pelosi, D-Calif., declined to comment on the negotiations. But some details are emerging.

Late Friday, the bipartisan leadership of the House Ways and Means and Energy and Commerce committees – the two House panels with jurisdiction over the SGR – said in a statement that “we are now engaging in active discussions on a bipartisan basis – following up on the work done by leadership – to try to achieve an effective permanent resolution to the SGR problem, strengthen Medicare for our seniors, and extend the popular Children’s Health Insurance Program.”

Last year’s proposal from the House Energy and Commerce and Ways and Means committees and the Senate Finance Committee is reportedly the basis of the current SGR talks, according to the lobbyists and aides, in part because it enjoyed bipartisan support and would encourage better care coordination and chronic care management, ideas that experts have said are needed in the Medicare program.

That proposal would have scrapped the SGR and given doctors an 0.5 percent bump for each of the next five years as Medicare transitions to a payment system designed to reward physicians based on the quality of care provided, rather than the quantity of procedures performed, as the current payment formula does.

Tacking on a package of other health measures – known as extenders – that Congress renews each year during the SGR debate would push the cost even higher. They include additional funding for therapy services, ambulance services and rural hospitals, as well as continuing a program that allows low-income people to keep their Medicaid coverage as they transition into employment and earn more money.

As part of the proposal, the House members are also talking about adding two years of funding for the Children’s Health Insurance Program, a federal-state program that provides insurance for low-income children whose families earned too much money to qualify for Medicaid, according to the lobbyists. While the health law continues CHIP authorization through 2019, funding for the program has not been extended beyond the end of September.

The length of the extension could cause strains with Senate Democrats. Last month, the Senate Democratic caucus signed on to legislation from Sen. Sherrod Brown, D-Ohio, calling for a four-year extension of the current CHIP program, according to senior Senate Democratic aides. Democrats want that CHIP language in the SGR deal because “this may be the only health care vehicle moving,” said one of the Senate aides.

Just two years of additional CHIP funding is non-starter for Democrats. “We need to make sure that Children’s Health Insurance Program is on a sustainable path,” the aide said.

Q: How would Congress pay for all of that?

A: It might not. That would be a major departure from the GOP’s mantra that all legislation must be financed. Tired of the yearly SGR battle, veteran members in both chambers may be willing to repeal the SGR on the basis that it’s a budget gimmick – the cuts are never made – and therefore financing is unnecessary.

But that strategy could run into stiff opposition from Republican lawmakers and some Democrats. Most lawmakers are expected to feel the need to find financing for the Medicare extenders, the CHIP extension and any increase in physician payments over the current pay schedule. Those items would account for about $60 billion of financing in an approximately $200 billion package.

Conservative groups are urging Republicans to fully pay for any SGR repeal.

“Americans didn’t hand Republicans a historic House majority to engage in more deficit spending and budget gimmickry,” Dan Holler, communications director for Heritage Action for America, said in a statement. “Any deal that offsets a fraction of the cost, like the one currently being discussed behind closed doors and leaked to the press, is a non-starter for conservatives.”

But physicians and other analysts make the point that Congress has already paid out billions on temporary patches that don’t fix the problem.

“Congress has spent a staggering $170 billion on 17 patches in a 12-year period, the cost of which has far exceeded the cost of eliminating the SGR altogether,” American Medical Association President Robert M. Wah wrote last month. “This continuous cycle of putting a Band-Aid on the real problem, creates an unpredictable environment that makes it difficult for physicians to budget and plan for practice innovations that could improve quality and reduce costs.”

Q. Will seniors and Medicare providers have to help pay for the plan?

According to the lobbyists and aides, the potential financing options being looked at by House negotiators include charging wealthier Medicare beneficiaries – who already pay a higher premium – even more and introducing a surcharge on the popular “first-dollar” supplemental Medicare insurance known as “Medigap.” Experts contend that the “first-dollar” plans, which cover nearly all deductibles and co-payments, keep beneficiaries from being judicious when making medical decisions. The change could convince them to reduce opt against treatment they don’t need, thus saving Medicare money. President Barack Obama’s fiscal 2016 budget plan includes similar provisions.

Congress could also extend the automatic 2 percent Medicare cuts in place as part of budget sequestration, but those cuts would face stiff opposition from Medicare providers and the groups they serve.

Senate aides said Democrats there are likely to take issue with the provisions to reduce reimbursements to Medicare providers and to require seniors to pay more.

Medicare beneficiaries already pay 25 percent of all Part B costs (physician services are included in Medicare Part B), so an increase in Medicare reimbursements to physicians would increase what seniors in the traditional Medicare program pay for premiums, deductibles and co-insurance, according to an analysis from the Kaiser Family Foundation. According to the report, half of all people on Medicare live on incomes of about $23,500 or less, and seniors spend three times more than younger households on health care as a share of their household budgets. (KHN is an editorially independent program of the foundation.)

Asking seniors to pay more for their Medicare in exchange for higher Medicare payments to physicians “doesn’t seem like a very fair thing to do for seniors,” a senior Senate Democratic aide said.  Using payment cuts to other Medicare providers, like hospitals, may be problematic as well because such steps “always sort of generate opposition and heartburn for both sides of the aisle,” the aide said.

Q. How quickly could Congress act?

Legislation to repeal the SGR could move in the House as early as the week of March 16, the lobbyists said.

The Senate Democratic aides said that they expected Democrats and Republicans in that chamber will want to offer amendments to the emerging House package, making it extremely difficult to pass any overhaul before the Senate’s two-week break scheduled to begin starting March 30.

If the SGR issue can’t be resolved by March 31, expect Congress to pass a temporary patch as negotiations continue.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

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