She doesn’t have an easy sell.

The American Medical Association, the nation’s largest doctors lobby, agreed to support health care reform under the condition that Democrats would return later in the year to scrap the sustainable growth rate (SGR), the flawed formula dictating doctors’ Medicare payments. Trouble is, the cost of doing so runs upwards of $200 billion, and Senate budget hawks from both parties aren’t about to let such an enormous expense fly through the chamber without offsets elsewhere in the budget.

Which introduces the second problem: Where do Democrats find $200+ billion at a time when budget deficits are already well above $1 trillion? (Answer: They don’t.)

Historically, Congress has allocated temporary funds to prevent similar SGR-dictated cuts from hitting Medicare doctors, and they’ll almost certainly have to go that route again this year. But that plan risks alienating the powerful AMA, which has been crystal clear about its unwillingness to accept anything less than a full repeal of the SGR.

“The AMA cannot support a proposal that would result in steeper future payment cuts and a substantially higher cost for a permanent solution, making it more difficult, if not impossible to repeal the Medicare physician payment formula,” J. James Rohack, the president of the AMA, said in a statement.

The political pickle for Pelosi and the Democrats is this: How to prevent the Medicare cut without (1) adding too much to the deficit, and (2) reneging on a promise to the AMA that could haunt you in November?

And you thought your job was stressful.

The political advantage of that move is clear: The American Medical Association has been screaming from the rafters for Congress to step in and scrap the flawed formula that dictates Medicare payments to doctors — a formula that would have cut those payments by 21 percent this year without congressional intervention — only to see lawmakers continually apply short-term fixes instead.

The latest Band-Aid came earlier this month, when Congress delayed the scheduled pay cut until June. That’s better than actually having the cut realized, but it hasn’t satisfied AMA leaders, who endorsed the Democrats’ health care reform bill with the understanding that Congress would solve the Medicare payment problem once and for all.

“If the formula is not repealed, the problem will continue to grow,” AMA President J. James Rohack said in a statement earlier this month.

No word yet on how the Democrats would pay for the five-year fix, or even whether it would satisfy a doctors lobby that wants a permanent solution. But Van Hollen, who heads the Democratic Congressional Campaign Committee, clearly doesn’t want to step into November’s mid-term elections without at least the hint of something more long-term than another Band-Aid.

President Obama signs the health care reform bill on Tuesday. (Pete Marovich/ZUMApress.com)

With President Obama having signed an enormous, $938 billion health reform proposal into law Tuesday, it’s tempting to imagine that the long-drawn and ubiquitous debate over health care legislation is over for a while.

If only it were so.

[Congress1] Neither the bill that was signed yesterday nor the accompanying reconciliation proposal moving through the Senate this week addresses the flawed formula that dictates physician payments under Medicare — one of the most agonizing and expensive problems facing the entire health delivery system. The omission has left doctors facing a 21-percent cut in their Medicare payments at the end of the month; it’s threatened Medicare patients with access-to-care problems; and it’s inspired the powerful doctors lobby to undertake an all-out blitz in search of a permanent formula fix. It’s also put Democratic leaders in the odd position of celebrating the historic significance of their health care overhaul, while at once plotting a strategy to prevent doctors from suffering huge cuts not addressed by those reforms.

At issue is the 13-year-old formula — the so-called Sustainable Growth Rate (SGR) — that was designed to prevent Medicare doctor payments from skyrocketing by indexing reimbursements to the growth of the economy on the whole. Trouble is, health care inflation has grown by degrees faster than GDP in recent years. Indeed, the SGR has called for cuts in doctors’ Medicare pay every year beginning in 2002. That’s a perennial thorn in the side of Congress, which, having no stomach for alienating the powerful physician lobby, almost always steps in with a temporary fix.

This year, though, the temporary fix also threatens to alienate the AMA.

“The AMA cannot support proposals that aim to address only the most imminent threat to payments levels and patient access, with no regard for the future of the Medicare [program],” AMA President James Rohack wrote to Senate leaders earlier this month. “We are opposed to further short-term patches of any duration.”

Lawmakers on both sides of the aisle are well aware of the problem. Speaking to reporters at the Capitol last Friday, House Speaker Nancy Pelosi (D-Calif.) said that a permanent doc-fix remains “very important” to Democrats. “It’s not in this bill, but we will have it soon,” Pelosi said. “We have made a commitment to do this.”

The issue is hardly partisan, nor will it have any effect on the larger reform bills recently passed by the Democrats. But the fix doesn’t come cheap. Indeed, a bill passed by the House in November would scrap the SGR altogether, replacing it with a formula designed to ensure that doctors’ Medicare payments reflect the true cost of delivering care. Pricetag: $210 billion.

It was that cost — which wasn’t offset with new revenues or cuts elsewhere — that caused the budget hawks of the Senate to shoot down a similar proposal a month earlier. And it was that cost that caused Democrats — who’d vowed both to keep their reform package below $1 trillion and to offset the entire tab — to strip the doc fix from the larger reform bills.

The issue has left Democrats in a pickle: In an election year, they don’t want to alienate the AMA. But with voters already weary of deficit spending, nor can they borrow another $210 billion to fund a permanent fix.

“Any way you look at it, I don’t see how they get 60 votes [in the Senate],” said Julius Hobson, former AMA lobbyist and now a senior policy analyst at the Washington law firm Bryan Cave.

Lawmakers don’t have much time. On April 1, Medicare payments to doctors are scheduled to fall, on average, by 21 percent. Both the House and Senate have recently passed bills to delay the cut temporarily — the House by one month and the Senate by seven months. But when Senate Democrats tried Friday to adopt the House bill by unanimous consent, Republicans refused.

A spokeswoman for Senate Majority Leader Harry Reid (D-Nev.) said Tuesday that Democrats will likely try that strategy again this week, after they’ve finished the debate over the health reconciliation bill. Complicating matters, Congress is scheduled to leave Friday for spring recess, and won’t return to Washington until April 13. That timetable leaves open the possibility that Congress would have to tackle the 21-percent cut retroactively — an uncertainty that’s been a thorn in the side of doctors trying to manage their businesses.

“For the physicians in actual practice,” Hobson said, “this is a nightmare.”

By extending health coverage to the vast majority of the uninsured, improving competition and choice in the insurance marketplace, promoting prevention and wellness, reducing administrative burdens, and promoting clinical comparative effectiveness research, this bill will help patients and their physicians.

This was never a sure thing. The doctors have complained for years about Congress’ failure to scrap the flawed formula that dictates their Medicare rates (a formula that would result in a 21 percent Medicare pay cut for doctors next month without congressional action). And while the House health reform bill scrapped that formula and provided the doctors with more realistic pay updates, the Senate bill did not. That means that Congress will have to return to the issue later this year, if only to kick the problem down the road with yet another short-term fix.

It’s not AMA’s only concern. The lobbying group also has reservations about a provision of the Senate bill that creates an independent commission that will suggest Medicare reforms — and could force Congress to vote on them. The doctors — indeed, almost everyone who’s part of the nation’s $2.3 trillion medical-industrial complex — have concerns that the panel would make suggestions that, as AMA said today, “could result in misguided payment cuts that undermine access to care and destabilize health care delivery.” That is, cuts that would reduce federal payments to them.

Meantime, though, AMA is supporting the bill, which the Democrats hope to pass in the House on Sunday.

Today, Senate Majority Leader Harry Reid (D-Nev.) told reporters that he wants to fix the Medicare pay formula “for as long as we can.”

“The doctors are right,” Reid said. “And it’s not just throwing something to the doctors to be nice to them.”

Unfortunately for doctors, “as long as we can” likely won’t be a very substantial span.

Recall that in October, the Senate shot down a plan to scrap the so-called sustainable growth rate formula altogether. The reason was simple: The price tag is upwards of $240 billion over 10 years, and the Democrats hadn’t proposed to pay for it with new revenues or spending cuts elsewhere. With voters well weary of deficit spending, it’s hard to imagine such a proposal passing the Senate four months closer to November’s midterm elections.

On the other hand, the American Medical Association, the nation’s largest doctors lobby, has grown tired of Congress applying short-term patches each year to prevent Medicare cuts to physicians. In a letter to lawmakers yesterday, the group warned that “kicking the can down the road with yet another short-term action magnifies the problem and makes it very difficult for physicians to continue caring for seniors and military families.” AMA is threatening to withhold its support for health reform unless it includes a longer-term doc fix.

So the choice isn’t a good one. Either the Democrats add a quarter-trillion dollars to the debt, or they risk the attacks of the powerful doctors’ lobby in what’s already certain to be a tough election year. Funny that the only option that doesn’t seem to be on the table is finding some way to pay the $240 billion.

The AMA firmly supports critical aspects of the bill that expand access to health insurance coverage, reform insurer practices, implement administrative simplifications, and promote wellness and prevention. … However, there is still work to be done. [...]

[B]efore any health reform effort, including this one, will prove successful, Congress must address Medicare’s fatally flawed physician reimbursement formula, the Sustainable Growth Rate (SGR). This bill relies heavily on the Medicare program to drive changes in provider and patient behavior in the health care system as a whole. However, delivery reforms and incentive policies will not effectively function while the SGR is still in place.

This is a stronger endorsement than the one AMA gave to the House bill earlier in the year, when the group hinged its support for health reform on an accompanying elimination of the SGR formula. That proposal passed the House last month, but Senate lawmakers killed a similar measure a month earlier because the $245 billion cost wasn’t paid for.

Recognizing that a permanent doc-fix isn’t happening this year, AMA decided not to attach the same condition to its endorsement of the Senate bill. Instead, it attached a warning: Congress — which recently approved a 60-day patch preventing Medicare payment cuts to docs as part of its defense spending bill — must return early next year with plans to provide a permanent solution to the perennial problem.

Physicians, and increasingly patients, are rapidly losing faith in the ability of Congress to address this critical issue. It is for that reason that the AMA will oppose efforts to apply temporary band-aids beyond the 60-day extension included in the FY 2010 Defense appropriations bill. Congress must replace the SGR early next year in order to achieve the access, payment and delivery reform goals envisioned by H.R. 3590. We will not support a final Conference Report without a clear pathway for passage of a permanent repeal of the SGR formula early next year.

The doc-fix issue leaves Democrats in the awkward position of having to return to health care next year just a few weeks after they’re likely to enact the most expansive health reforms in 44 years.

Not only will that not be cheap (failed legislation providing a permanent fix scored near $250 billion), but it also puts Democrats in the awkward position of taking up an urgent health care bill just weeks after they’re likely to enact the most sweeping health care reforms in decades. That the enormous reform bill doesn’t tackle the so-called doc-fix — one of the thorniest and most expensive problems facing the nation’s health care system — will surely leave some voters scratching their heads.

Senate Majority Leader Harry Reid, Speaker of the House Nancy Pelosi (WDCpix)

The Democrats downplaying the gravity of new recommendations for breast cancer screening have left out an inconvenient fact: their health care bills would automatically adopt them.

Both the House and Senate health reform proposals would force insurance plans to follow the new mammogram guidelines for women ages 50 to 74 as part of a minimum swath of services deemed by the legislation to be medically essential. The recommendations were an unexpected wildcard in the middle of an already contentious health reform debate, and they’ve caused Democrats to de-emphasize their significance at the same time that some in the party are calling for a legislative fix to nullify them.

[Congress1]The animated reaction to the recommendations follows several weeks in which women’s reproductive health had been at the forefront of the health reform debate, after the House passed a provision limiting coverage of abortion under private plans. The saga has been a distraction to Democrats as they aim to enact the most sweeping health care reform in generations, and it’s complicated their defense against GOP-fueled charges that their proposals would lead to a rationing of care. House leaders have already passed their version of the bill, but the debate in the Senate is just beginning, with upper-chamber leaders scheduled to vote Saturday on a procedural measure to bring their bill to the floor.

The mammogram episode has also revealed the influence of a previously obscure preventive-medicine panel, raised questions about the effectiveness of the Democrats’ reform proposals to weed out unnecessary medical procedures, and highlighted the potential complications when the entrenched habits of patients and providers are called into question by medical science.

“These new recommendations,” breast cancer specialist David Gorski wrote this week, “are a classic example of what happens when the shades of gray that characterize the messy, difficult world of clinical research meet public health policy, where simple messages are needed in order to motivate public acceptance of a screening test.”

The controversy ignited on Monday, when the U.S. Preventive Services Task Force, a federally appointed panel of independent medical experts, released guidelines suggesting that women should not seek routine mammograms before the age of 50 — 10 years later than current protocols dictate. The task force also concluded that annual mammograms are unnecessary for any age group, suggesting biennial screenings instead.

Critics in Congress and the medical community were quick to pounce, arguing that the recommendations would jeopardize the lives of women, particularly those aged 40 to 49. Democrats moved swiftly to divorce their health reform proposals from the new guidelines, maintaining that they merely represent a non-binding data-bank for lawmakers to consider as they craft coverage policies, both public and private.

“I don’t think there’s any general acceptance of what was proposed,” House Speaker Nancy Pelosi (D-Calif.) told NPR Thursday.

“These individuals do not determine federal policy,” Rep. Rosa DeLauro (D-Conn.) added in a statement. “They have simply made recommendations.”

Yet the health reform language moving through Congress tells a different tale. Both the House and Senate bills create an “essential benefits package” which all insurance plans would have to offer. Neither chamber’s proposal specifies what those services would be, instead, empowering the Department of Health and Human Services to make those decisions at a later date. But the bills do outline broad categories of minimum services, including a mandate to cover those recommendations of the task force rated “A” or “B.” The new biennial-screening guidelines for 50- to 74-year olds are rated “B.”**

The 16 members currently on the panel were all appointed by the Bush administration. None specializes in oncology.

A number of Democrats have blasted the findings. Rep. Debbie Wasserman Schultz (D-Fla.), a breast cancer survivor, said the guidelines are “causing mass confusion” among women accustomed to screening more frequently and earlier in life. Rep. Frank Pallone (D-N.J.), chairman of the Energy and Commerce health subcommittee, has already indicated that he’ll hold a hearing early next month to examine the recommendations. And Rep. Jerrold Nadler (D-N.Y.) is pushing legislation to require insurance companies that cover diagnostic mammograms also to cover routine, annual mammograms to women beginning at age 40.

“Cancers can progress very far in two years,” Nadler said Friday, criticizing the panel’s recommendation for biennial screenings.

The White House has also been wary, quickly indicating that the new recommendations would have no bearing on public policy. In a statement issued Wednesday, HHS Secretary Kathleen Sebelius played down the task force as “an outside independent panel of doctors and scientists who make recommendations.”

“They do not set federal policy,” she added, “and they don’t determine what services are covered by the federal government.”

Yet they certainly can have influence. Indeed, in May, when HHS announced the controversial decision not to pay for virtual colonoscopies under Medicare, the agency leaned heavily on the judgments of the Preventive Services Task Force, which had concluded earlier that the radiation risks outweighed the benefits of the less intrusive cancer-detection procedure.

The HHS declined to comment this week on why the agency was so quick to dismiss the panel’s new mammogram recommendations.

By issuing their report in the middle of a contentious debate over health care reform, the task force didn’t do the Democrats any favors. Republicans are already blasting the reform bills for their funding of comparative effectiveness research, which compares different treatments of the same ailment to discover which work best. The critics fear that the effectiveness data could tempt insurers — both public and private — to deny coverage of certain drugs, devices and other treatments. In the eyes of the GOP, the new mammogram recommendations are just another threat to patients’ access to care.

“This is how rationing starts,” Sen. Jon Kyl (R-Ariz.) said Friday. “Delay of care … then denial of care. At first, it’s guidelines, then the insurance companies … adopt those guidelines with respect to coverage decisions.”

Private insurers, for their part, say they often use the task force recommendations to make coverage determinations. But they deny that the mammogram findings will have any effects — at least not immediately. “Whatever we do today, we’ll continue to do — as far as we can tell,” said Gloria Barone, spokeswoman for Cigna.

Susan Pisano, spokeswoman for America’s Health Insurance Plans, the industry lobby group, pointed out that the task force recommendation against routine screenings for 40-somethings is hardly an outright moratorium, instead leaving the decision to women and their doctors. “I don’t see this as limiting coverage,” Pisano said.

Under Medicaid, states have leeway to set their own coverage rules. Ann Kohler, director of the National Association of State Medicaid Directors, said state officials use the task force guidelines “often.” “However in this case,” she added, “I think they will not change their historical policy.”

Julius Hobson, former lobbyist for the American Medical Association and now a senior policy analyst at the Washington law firm Bryan Cave, suggested that the members of the task force had crunched their numbers without consideration of the broader effects of their recommendations. “They missed the psychological and social impact of what they were saying,” Hobson said.

Their timing, he added, was also a bit suspect. “You’d have to be deaf, dumb, blind and crazy not to know that Congress has spent the whole year working on health reform.”

**Clarification: An early version of this story implied that the recommendations for 40- to 49-year olds would also be adopted by the Democrats bill. That would not be the case. That recommendation is rated “C.”

The count was 243 to 183, with 11 Democrats voting against the measure, and just one Republican — Rep. Michael Burgess, a Texas physician — voting in favor of it.

The proposal has been the top legislative priority of the American Medical Association for years, and Democratic leaders are hoping today’s vote might entice the powerful doctors lobby to get behind the broader health reforms moving through Congress.

The $210 billion doc-fix bill, however, stands little chance in the Senate, where budget hawks on both sides of the aisle have been unwilling to support the measure unless it’s paid for. (The House bill is not.) Indeed, just last month the upper chamber killed a similar proposal because it was unfunded. The vote in that case was a lopsided 47 to 53 — well shy of the 60 supporters it needed to pass.

If the proposal sounds familiar, it’s because the Senate considered a nearly identical bill just a month ago. That legislation was shot down, not because lawmakers oppose the underlying concept (nearly everyone on Capitol Hill agrees that Medicare’s physician payment formula doesn’t work), but because Democratic leaders didn’t offset the substantial costs with revenue increases or federal spending cuts. That is, the new spending would have been piled onto the country’s already considerable debt.

Fast forward a month and you might think that House Democrats would take a lesson from the failed Senate bill by offering to cover the costs. But you’d be wrong; the bill is unfunded.

Here’s House Majority Leader Steny Hoyer (D-Md.) tying himself in rhetorical knots yesterday as he tried to explain to reporters why the Democrats aren’t even trying to pay for their proposal.

In our budget we contemplated that the [cost] … would not be paid for. That doesn’t mean it doesn’t have to be paid for – clearly it does. We need to address the fiscal issues confronting us. On the other hand, [the doc fix] has been passed on a regular basis not being paid for.

Here’s what he was talking about. Earlier in the year, House leaders passed pay-as-you-go budget rules, but exempted four big-ticket (and enormously expensive) items that are deemed must-pass bills. The doc-fix was among them.

As a part of the pay-go exemptions, though, the Democrats said one of three things had to happen. Either statutory pay-go has to be law (it isn’t, because the Senate hasn’t passed it); the doc-fix proposal has to be paid for (it’s not); or statutory pay-go has to be attached to the bill as a rider (the House doc-fix bill does this, with the intention that the Senate would pass the requirement that everything other than those four items be paid for through the rest of the fiscal year).

Hoyer explains:

We think it is critical to combine this with a fiscally responsible policy of providing for all but the four specific items we exempted. All other items of spending on entitlements or reductions in revenues would be covered by statutory pay-go. … We think that fiscal discipline is critically important.

This, of course, is a cop out. That is, Congress created Medicare’s flawed pay formula, but no leader of either party seems to want the responsibility of finding ways to pay to fix it.

Also unmentioned here is the political strategy behind tomorrow’s House vote. For years, the American Medical Association, the nation’s largest doctor lobby, has pushed lawmakers to eliminate the doc-payment formula, which is indexed to GDP growth rather than to faster-rising medical inflation. AMA has announced its intention to support the Democrats’ health reforms this year, but they haven’t said they’d do so without the doc-fix accompanying the larger (and very separate) bill.

The House is expected to pass its doc-fix bill tomorrow. But there’s no good reason to think that that the budget hawks in the Senate would have had a change a heart about its cost over the past month. The question is, will the mere effort to pass the bill be enough to win the AMA’s support for the larger reforms? Some are already saying no.