The Cantwell Amendments

There was a time, just a few months ago, when liberal backers of
Senator Maria Cantwell were baffled by her stance on health-insurance
reform. Why was Washington’s junior sen-ator hedging, dodging, and
making contradictory statements about the public option, a central
pillar of real reform? Why couldn’t she just do what other members of
Washington’s congressional delegation had already done and come out
strongly and unambiguously in favor of a government-run
health-insurance plan that would compete with private insurers to bring
down costs for everyone?

Cantwell, who in 2006 scored a seat on the powerful Senate Finance
Committee, appeared to be trying to avoid a public fight with her
committee chairman, Max Baucus (D-­Montana), who had set out to
find a “bipartisan” solution on health-insurance reform by cooking up a
reform bill that didn’t include a public option. How far would Cantwell
go with this deference?

Not very far, it turned out. When Baucus, after months of delays and
a notable failure to find strong bipartisan support, finally introduced
his bill on September 16, Cantwell pounced. She made it clear that she
wouldn’t vote for a bill that didn’t include a public option, and she
filed a raft of amendments intended to pull the so-called Baucus bill
to the left. Here are some of her best ideas, translated out of wonky
jargon into plain English:

The public-option amendment. This was Cantwell’s most
important amendment, one that she cosponsored with Senator Charles
Schumer (D-New York). It tried to strip the Baucus bill of an unpopular
half-measure known as the “co-op compromise” and insert in its place a
strong public option. The amendment was defeated on September 29 by a
committee vote of 13–10, but its existence helped the overall
effort to keep the public option at the forefront of congressional
debate. Just as important, it was the clear public rebuke of her
committee chairman that Cantwell’s constituents, including
small-business owners in Seattle, had long been waiting for. Ice-cream
entrepreneur Molly Moon, who over the summer slammed Cantwell for
failing to lead and ignoring the needs of small-business owners, was
among the mollified. “Senator Cantwell is showing real leadership and
loyalty to her constituents,” Moon said in a statement.

The fixing-the-backward-Medicare-payment-­system amendment. Currently, Medicare uses a “fee for service” system
that encourages doctors who want to make more money to simply perform
more services—unnecessary tests, senseless procedures—and
has the overall effect of screwing responsible doctors (such as those
in Washington State, who on average bill Medicare a relatively low
amount per patient) while setting Medicare on a path toward insolvency.
Cantwell’s proposal is to jettison that for a smarter reimbursement
structure that bases payments on the usefulness of the services
provided. It makes so much sense that Baucus has already incorporated
the idea into the most recent draft of his bill.

The community-care-for-the-elderly amendment. It
currently costs Medicaid about $70,000 a year to keep an elderly
American in a nursing home. What if there were a system of care for the
elderly that saved money for Medicaid and kept people out of nursing
homes they didn’t need to be in? In fact, there is such a thing, and
Washington State has been pushing it. Cantwell wants to get the federal
government to follow suit and provide matching funds to states that
offer services like fall-prevention classes, nutrition classes,
exercise classes, and home health-care visits for elderly people who
need them (for example, a nurse to occasionally come and monitor a
person’s diabetes medications). “It’s a quality-of-life issue,” said
Cantwell spokesperson Ciaran Clayton. “I think more people would rather
get care at home, or through their primary-care doctor, or at their
community center, than in a nursing home.” And, of course, it could
save money.

The “pharmacy benefit management” amendment. What’s a
pharmacy benefit manager? Exactly. Turns out they work in an
unregulated corner of the health-care supply chain and make money in
crafty, complicated ways. Basically, a PBM acts as the middleman
between health-insurance plans (like Aetna) and pharmaceutical
retailers (like Rite Aid). A PBM sets prices, chooses brands, figures
out who gets what instead of what. No surprise, there is a lot of
potential for devious deeds, and as PBMs aren’t well-regulated, devious
deeds have been occurring. “It’s been found that sometimes
prescriptions will be switched, without a patient’s knowledge, to save
money for the pharmacy,” said Clayton. Under this Cantwell amendment,
which Senator Baucus has also incorporated into his draft bill, PBMs
will have to share information about their methods with oversight
agencies. Why wasn’t this happening before? Take a wild guess.

But thanks to Cantwell, it may be happening soon—along with a
number of other important health-insurance-reform ideas. Her amendments
number more than a dozen, and also include proposed action on
überwonky matters such as using tax-exempt bonds to pay for
fixed-wing air ambulances and broadening inheritance rights for health
reimbursement accounts. Go to
www.finance
.senate.gov/sitepages/legislation.htm if you want to
dive into those weeds.