News & Updates

From what BlueCross BlueShield of New Mexico has found, establishing a partnership with community paramedics is not only good medicine, it’s good for business.

The insurer’s Community Paramedicine program, which started out as a pilot project in the fall of 2015, is targeted at Medicaid members who have either been identified as emergency room super-users or are at high risk for readmission within 30 days of being discharged from the hospital.

BCBSNM chose those two populations because “we thought we could track those well and see if this is working,” Duane Ross, M.D., the insurer’s medical director, told FierceHealthcare.

Now, the insurer has produced promising preliminary results.

Since the program’s full launch in 2016, BCBSNM estimates that it saved $1.7 million—after taking into account the cost of the program itself. Among the 1,100 participating members, there was a 62% reduction in ER utilization and a 63% reduction in ambulance usage.

In addition, the 30-day readmission rate among BCBSNM’s members has dropped from 15% to 11.2% since it began the paramedicine program. While the insurer has undertaken multiple initiatives to lower that percentage, “we’re confident that this program was a big part of that reduction,” Ross said.

Just as important, Ross added, is the fact that “the paramedics indicate they’re actually very happy to be able to see people proactively rather than in a reactive fashion.”

The anatomy of a house call

Most BCBSNM members involved in the Community Paramedicine program receive only one house call, Ross said—though there occasionally might be a follow-up visit.

First, though, they always call the member to ensure they’re OK with the visit taking place. As Ross puts it: “You don’t want to have a person in uniform knocking on your door unexpectedly.”

Paramedics who conduct house calls are tasked with ensuring that patients know all the information related to their diagnosis; who their primary care physician is and how to use primary care services; and how to reach a care coordinator with BCBSNM.

The primary-care discussion is particularly important for ER super-users who did not previously have insurance before signing up for Medicaid, Ross noted, because they tend to have a long-established habit of getting all their care through the emergency room.

“Sometimes it takes a visit to get them to make that switch,” he said. “Surprisingly, it actually sticks fairly well once they’re shown how to do that.”

Paramedics also conduct a home assessment to check, for instance, whether the residence has any hygiene issues, whether there are fall hazards and whether there’s food in the refrigerator. While paramedics can check patients’ vital signs, Ross noted, they don’t typically administer any other type of care.

For patients at risk of readmission, paramedics take the extra step of making sure they understand—and can follow—the hospital’s post-discharge care plan. That can involve ensuring they have a way to pick up any needed medications and know how to take them, and ensuring that they’re aware of and can find transportation to follow-up doctor visits.

Crucially, Ross, said, “we’re trying to get to them within 48 hours of the discharge, because if they lack transportation to pick up prescriptions, supplies or anything like that, the clock is ticking before they find themselves back in the hospital.”

Paramedics as partners

BCBSNM’s program is hardly the only instance of paramedics rethinking their traditional role as emergency responders.

For example, the North Memorial Health system in Minneapolis started a program in 2012 that used community paramedics to conduct home visits with patients who visited the ER nine or more times in a year. Similarly, the Valley Hospital in Ridgewood, New Jersey, launched a program 2014 to provide proactive, post-discharge home check-ups to certain patients with cardiopulmonary disease who are at high risk for readmission.

“This is actually a big movement,” Ross said. In fact, in Albuquerque, “the paramedics in the community had been looking at something like this for a while, but had not been able to get some of the logistics worked out.”

Therefore, BCBSNM figured out a “claims-based approach” to pay for home visits, which helped get the program off the ground. The result is the insurer has control over how many home visits are going to occur and who will receive them.

Besides working out a payment model, another secret to the Community Paramedicine program’s success is that the person running it is a paramedic himself, Ross noted. That helps establish trust and communication with the paramedic companies involved.

While BCBSNM is happy with the current scope of the program, in the future it’s interested in looking at the possibility of having paramedics conduct multiple visits with patients who have chronic conditions to help stabilize them, Ross said.

The insurer is also hoping to expand the program to cover more geographic areas than those in which it currently operates: Albuquerque, Belen, Rio Rancho, Las Cruces and Alamogordo. Because the paramedicine project has produced positive results and been well-received by paramedics, Ross said, “it’s easier to go out to more far-flung ambulance companies and even fire departments.”

Dr. Patrick Conway, the CMS’ chief medical officer, is headed to work for Blue Cross and Blue Shield of North Carolina as its president and CEO, starting Oct. 1.

The insurer’s current president and CEO Brad Wilson, who is retiring, will remain in his role “for an appropriate period to ensure an effective transition,” the company said Tuesday.

“Blue Cross NC’s role in transforming the healthcare system in North Carolina is a model that other plans aspire to and that I want to work with the Blue Cross NC team to further improve,” Conway said in a statement.

Conway, a pediatrician, joined the CMS in 2011. He also currently serves as the agency’s deputy administrator for innovation and quality and its director of the Center for Medicare and Medicaid Innovation.

At the CMS, he is responsible for overseeing quality of care and innovation for the Medicare, Medicaid, and Children’s Health Insurance Program programs, and the federal insurance marketplace. He is also charged with testing new value-based payment and service delivery models, such as accountable care organizations, bundled payments and primary care medical homes.

“Dr. Conway is a national and international leader in health system transformation, quality and innovation,” Frank Holding Jr., Blue Cross NC’s board chair, said in a statement. “His unique experiences as a healthcare provider and as a leader of the world’s largest healthcare payor will help Blue Cross NC fulfill its mission to improve the health and well-being of our customers and communities.”

Wilson announced in February that he would retire this year. Wilson, who began working for the health plan in 1996, has served as president and CEO since 2010.

“At this important time in healthcare and health insurance transformation, Dr. Conway brings a unique background and perspective to our company and state,” Wilson said in a statement.

While the United States ranks dead last in quality among 11 wealthy nations, a new report reveals that Louisiana is the worst state for healthcare overall.

The Pelican State has one of the highest rates of heart disease in the country, the third highest cancer rate and a significantly low number of dentists per capita, according to WalletHub’s annual list of the best and worst states for healthcare.

The personal finance website compared the 50 states and the District of Columbia for healthcare cost, access and outcomes. Among the 35 measures they considered within those categories were: costs of medical and dental visits, average emergency room wait times, physicians per capita, average monthly insurance premiums, heart disease and cancer rates, and life expectancy rates.

Louisiana was also ranked one of the worst states for nurses in a recent WalletHub report. And New Orleans held the distinction earlier this year of being one of the worst cities in the nation in which to practice medicine, according to a Medscape report.

WalletHub determined that the best state overall for healthcare was Hawaii, which has one of the highest percentages of insured children and adults and the lowest heart disease rate in the country. However, the report notes that the Aloha State also has the lowest rate of physician acceptance of Medicare.

The 10 best states in the nation overall for healthcare:
1. Hawaii
2. Iowa
3. Minnesota
4. New Hampshire
5. District of Columbia
6. Connecticut
7. South Dakota
8. Vermont
9. Massachusetts
10. Rhode Island

The 10 worst states for healthcare:
51. Louisiana
50. Mississippi
49. Alaska
48. Arkansas
47. North Carolina
46. Georgia
45. South Carolina
44. Alabama
43. Florida
42. Nevada

Anthem is rolling out restrictions on what it will cover for emergency room visits, but providers worry that the policy could cause patients with potentially life-threatening conditions to avoid care—and that the hard-line approach could violate federal law.

Anthem has deployed a reduced ER coverage policy in several of its state subsidiaries in regions that include Indiana and Missouri. The insurer said it will deny claims for minor injuries or conditions, like cuts and bruises, swimmer’s ear or athlete’s foot, that bring people to the emergency department, reports the Indianapolis Business Journal.

But physicians in those states worry that patients with potential dangerous symptoms, such as chest pain, may avoid care because they fear higher bills. Missouri provider groups, including the Missouri Hospital Association, the Missouri College of Emergency Physicians and the Missouri State Medical Association filed a letter (PDF) urging the state’s insurance commissioner to take a look at the policy.

“We see the Anthem policy as a cost-shifting tactic that will have a dangerous chilling effect on patients,” they wrote. “When policyholders learn that they might be held financially responsible for emergency department care, we worry some will delay or altogether forgo seeking vitally important and life-saving care at a time when they are most critically ill and vulnerable.”

Anthem maintains that the policy is designed to curb unnecessary ED use, which is a significant financial drain on the healthcare system.

Joseph Fox, M.D., the insurer’s medical director for its Indiana operations, told the IBJ that nearly three-quarters of ER visits are for nonemergencies, and despite prevention and outreach efforts, the number of visits for emergency care continues to climb between 4% and 8% each year. He said the payer has cut down the number of codes it will reject to a list of about 300 so that patients don’t fear visiting the ER if they really think it’s needed.

In Indiana, where Anthem dominates the market, he estimated that about 8% of visits would be flagged for review under the policy, and about 4% of claims would likely be rejected.

“It’s not a draconian program that we’re rolling out here,” Fox said. “We don’t want that to be misunderstood or misconstrued.”

State and federal laws abide by the “prudent layperson” standard, in which payers are required to cover emergency care for patients who feel their symptoms warrant immediate attention. In the letter, the groups argue that Anthem’s policy violates this standard, and “creates an untenable situation that is at best unfairly punitive, and at worst unacceptably harmful to patients.”

The American College of Physicians expressed similar concerns earlier this year when the policy was rolled out in Missouri. The group notes that a number of the some-2,000 conditions that Anthem would deem “non-urgent” could significantly harm patients.

Anthem’s ER policy is yet another example of payers trying to avoid paying for emergency care, Rebecca Parker, M.D., president of ACEP said in a statement.

“For years, they have denied claims based on final diagnoses instead of symptoms. Emergency physicians successfully fought back against these policies, which are now part of federal law,” Parker said. “Now, as healthcare reforms are being debated again, insurance companies are trying to reintroduce this practice.”

CMS has issued its Inpatient Prospective Payment System final rule for fiscal year 2018, which increases payments to acute care hospitals next year.

The 2,456-page rule also includes proposed rates for long-term care hospitals. Overall, the final rule applies to about 3,330 acute care hospitals and 420 long-term care hospitals.

Here are 10 key points from CMS’ final IPPS rule.

Payment update
1. Under the final rule, acute care hospitals that report quality data and are also meaningful users of EHRs will receive a 1.2 percent increase in Medicare operating rates in fiscal year 2018.

2. CMS arrived at its rate of 1.2 percent through the following updates: a positive 2.7 percent market basket update, a negative 0.6 percentage point update for a productivity adjustment, a positive 0.45 percentage point adjustment required by the 21st Century Cures Act, a negative 0.75 percentage point update for cuts under the ACA and a negative 0.6 percent updated to remove the adjustment to offset the estimated costs of the two-midnight rule.

3. CMS projects the rate increase, together with other changes to IPPS payment policies, will cause total Medicare spending on inpatient hospital services to increase by approximately $2.4 billion in fiscal 2018.

Medicare disproportionate share hospital payments
4. CMS will use data from its National Health Expenditure Accounts instead of data from the Congressional Budget Office to estimate the percent change in the rate of uninsurance, which is used in calculating the total amount of uncompensated care payments available to Medicare Disproportionate Share Hospitals. CMS said this change will result in Medicare DSH payments increasing by $800 million in fiscal year 2018.

5. CMS will use worksheet S-10 data to determine uncompensated care payments and distribution beginning in fiscal year 2018.

Hospital Inpatient Quality Reporting Program
6. Under the final rule, CMS will replace the pain management questions in the HCAHPS Survey to focus on the hospital’s communications with patients about the patients’ pain during the hospital stay. This change will take effect with surveys administered in January 2018.

7. CMS finalized several changes to the electronic clinical quality measures and updated the extraordinary circumstances exception policy.

Hospital Readmissions Reduction Program
8. CMS will implement the socioeconomic adjustment approach mandated by the 21st Century Cures Act for the fiscal year 2019 Hospital Readmissions Reduction Program. CMS will assess penalties based on a hospital’s performance relative to other hospitals with a similar proportion of patients who are dually eligible for Medicare and Medicaid.

EHR Incentive Program
9. For 2018, CMS modified the EHR reporting periods for hospitals attesting to meaningful use from a full year to a minimum of any continuous 90-day period during the calendar year.

Hospital Value-Based Purchasing Program
10. CMS will remove one measure in fiscal year 2019 and adopt one new measure in FY 2022 and another in FY 2023. CMS will remove the PSI 90 measure from the safety domain beginning in FY 2019, and adopt the patient safety and adverse events composite PSI 90 measure beginning in FY 2023. CMS will also adopt the hospital-level, risk-standardized payment associated with a 30-day episode of care for pneumonia measure for the efficiency and cost reduction domain in FY 2022.

For those who want more info on the PSI 90 measures, here’s more info:
https://www.qualityindicators.ahrq.gov/News/PSI90_Factsheet_FAQ.pdf

Kohlberg Kravis Roberts & Co., the private equity giant that sold most of its stock in HCA a year ago, agreed Monday to acquire WebMD for about $2.8 billion, KKR announced Monday.

KKR is paying $66.50 per share for publicly traded WebMD, a 20% premium over WebMD’s closing price Friday of $55.26.

WebMD’s shares jumped to $65.98 by 11 a.m. ET Monday.

WebMD is the nation’s largest online health information portal, serving consumers and clinicians with public and private sites and publications.

The company’s board and management put the business up for sale in February when its stock was trading about 30% below KKR’s offer Monday.

KKR’s Internet Brands is the umbrella company buying WebMD. KKR will begin a tender offer of the shares within 10 days, it said in a release Monday.

The private equity firm, which has about $100 billion under management, is no stranger to healthcare. It was one of the main investment groups that took hospital chain HCA private in 2006, then public again in a 2011 initial public offering.

A year ago, KKR sold back to HCA about 9.4 million of HCA’s common shares for $750 million.

Despite the divestiture of shares, KKR remains one of HCA’s largest institutional shareholders with 5.2 million shares outstanding or 1.5% of its stock as of Dec. 31, according to Morningstar.

The CMS is interested in launching a new pay model that will target behavioral health services and is seeking public comment on what the new effort should look like.

On Thursday, the CMS announced that its Innovation Center would like to design a payment or service delivery model to improve healthcare quality and access for Medicare, Medicaid or Children’s Health Insurance Program beneficiaries with behavioral health conditions.

The model may address the needs of beneficiaries battling substance use or mental disorders. It could also target Alzheimer’s disease and related dementias.

The Innovation Center will be soliciting ideas at a public meeting on Sept. 8 at CMS headquarters in Baltimore.

The announcement comes at a time when agency officials say they are still committed to value-based care. For months, there have been concerns the CMS would abandon its move toward value-based pay models after Dr. Tom Price became HHS secretary. Price had been critical of the Innovation Center and bundled-pay efforts when he was a member of Congress.

These concerns intensified when the CMS delayed the effective dates for four Obama-era bundled-payment initiatives covering cardiac and orthopedic care and announced it was seeking public comment on the overall future of the models. The agency also announced plans to allow up to 800,000 small and rural providers to be exempt from the new quality reporting system outlined in the Medicare Access and CHIP Reauthorization Act.

Since then, CMS officials have reiterated that clinicians who have invested millions in implementing pay models or the quality reporting system under MACRA don’t need to worry about the CMS changing course.

“The horse is out of the barn on this,” Dr. Kate Goodrich, chief medical officer at the CMS said at a bundled-pay summit in late June. “We will be continuing this progress towards value-based care under this new administration.”

However, the Trump administration’s value-based efforts may differ from the prior administration’s in terms of how much Medicare spending will be tied to new models of care.

The Obama administration wanted 30% of payments for traditional Medicare benefits to be tied to alternative payment models such as accountable care organizations or bundled-pay models by the end of 2016 and had set a goal of hitting 50% by the end of 2018.

The Obama administration hit the first goal last March, but it’s unclear if the Trump administration will shoot for the second one, according to Goodrich.

“We are currently thinking about what we want the next set of goals and targets to be,” Goodrich said.

Freezing implementation of various models was merely new leadership’s attempt to better understand them and their potential benefits, according to Christina Ritter, director of the patient care models group at the CMS.

“These kinds of delays a very typical for a new administration,” Ritter said at last month’s summit. “I want to make sure people understand that before there is a whole ton of reading tea leaves.”

Patients in rural areas face long waits for paramedics to arrive, according to a new study.

Researchers reviewed data on more than 1.7 million emergency medical services runs from 485 agencies in 2015 and found that 1 in 10 rural patients waited half an hour for emergency personnel to arrive. The average wait in urban and suburban areas was 6 minutes, while the average was 13 minutes in rural areas. The findings were published Wednesday in JAMA Surgery.

The average wait time overall was 7 minutes, according to the study. The findings underscore the importance of training more people in CPR and other potentially life-saving techniques. The American College of Emergency Physicians (ACEP) has launched a campaign called “Until Help Arrives” that aims to empower people to provide care to the ill or injured while they wait for emergency responders to arrive.

“Those 7 minutes—or even longer in rural areas—are ripe for bystander intervention, especially for bystanders trained in first aid and/or CPR,” Howard Mell, M.D., a spokesperson for ACEP and one of the study’s authors, said in an announcement.

Patients in rural areas face a number of healthcare challenges outside of trauma and emergency care, but a 2016 study found that just 29% of rural patients treated by EMS personnel are taken directly to a major trauma center, whereas 79% of patients in urban areas are taken to Level 1 or Level 2 facilities.

In addition to patients in more remote locations having limited access to care options, many rural providers are cash-strapped and at risk of closing, which could leave some people in “medical deserts” where they have no care options nearby at all.

Emergency crews in these regions are also being asked to do more with less, and a number perform procedures in patient homes, like starting intravenous antibiotics or intubating patients, based on the distances they have to travel.

A new Commonwealth Fund report finds the U.S. has the highest costs and lowest overall performance compared to Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom.

http://www.fiercehealthcare.com/healthcare/when-it-comes-to-healthcare-u-s-once-again-ranks-last-quality-care-compared-to-other

The United States spends more on healthcare than other wealthy nations, yet ranks dead last on equity, access, efficiency, care delivery and healthcare costs.

Despite progress made in providing coverage to previously uninsured Americans via the Affordable Care Act, the latest report from The Commonwealth Fund finds that the United States offers its citizens the least financial protection among the 11 high-income countries surveyed. It is also the only one without universal health insurance coverage.

Indeed, the U.S. has the highest costs and lowest overall performance compared to Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland and the United Kingdom. The U.S. spent $9,364 per person on healthcare in 2016, compared to $4,094 in the U.K., which ranked first on performance overall.

Forty-four percent of lower income Americans and 26% of higher income U.S. citizens reported financial barriers to care. Remarkably, the report noted, someone with a high income in the U.S. was more likely to report financial barriers to healthcare than a low-income person in the U.K.

“What this report tells us is that despite the substantial gains in coverage and access to care due to the Affordable Care Act, our healthcare system is still not working as well as it could for Americans, and it works especially poorly for those with middle or lower incomes,” Commonwealth Fund President David Blumenthal, M.D., said in an announcement. “The healthcare policies currently being contemplated in Congress would certainly exacerbate these challenges as millions would lose access to health insurance and affordable healthcare.”

This isn’t the first time the U.S. has fared poorly compared to other nations. Since 2004, it has ranked last in every one of six similar reports. This year the Commonwealth Fund added new measures and refined the scoring to give each country an overall score, as well as a score on five specific areas of performance. The new approach ranked the U.K. Australia and the Netherlands as top performers. New Zealand, Norway, Switzerland, Sweden and Germany were in the middle of the pack. Canada and France were near the bottom but performed better than the U.S.

Another recent global report found massive inequity within the United States in terms of access to care and the quality of care provided.

But it’s not impossible for the U.S. to move from last place to first among wealthy countries if it heeds the lessons offered from top performing countries, notes Eric Schneider, M.D., the lead author of the study and senior vice president for policy and research at the Commonwealth Fund, and David Squires, former senior researcher to the president at the Commonwealth Fund, in a piece for The New England Journal of Medicine.

This would mean the U.S. must expand health insurance coverage, such as universal coverage that provides citizens with healthcare they need at little or no cost; invest more in primary care so that it is accessible on nights and weekends; cut down on the administrative paperwork that physicians must complete so they can spend time on providing care; and invest more in social services to reduce healthcare disparities.

“If we are going to be the best, we have to do better for patients,” Schneider said in the announcement. “We are not the U.K., Australia or the Netherlands, and we don’t have to be. Each of those countries follows a different path to top performance. A country that spends as much as we do could be the best in the world. We can adapt what works in other countries and build on our own strengths to achieve a healthcare system that provides affordable, high-quality healthcare for everyone.”

A low-income person, eligible for Medicaid but not enrolled, is hit by a car or a bullet. Gravely injured, she arrives at the hospital unconscious. Thanks to expert, intensive care that lasts for days or weeks, she gradually recovers. Eventually, her health improves to the point where she can complete the paperwork needed to apply for Medicaid.

Such a hospital can be paid today, thanks to Medicaid’s “retroactive eligibility.” Even if the combination of medical problems and bureaucratic delays prevents an application from being filed and completed for several months, Medicaid will cover the care if the patient was eligible when services were provided.

The newest version of the Senate health bill—the Better Care and Reconciliation Act, or BCRA—would end this longstanding feature of the Medicaid program for beneficiaries who are neither elderly nor people with disabilities. If services are received in one calendar month and the application is completed the following month, the hospital would be denied all payment, even if the patient was eligible and the services were both essential and costly.

It does not matter if the state is led by a governor who understands the devastating impact of this change on hospital infrastructure, especially in rural areas where many hospitals are hanging on by a thread. Today, states have the flexibility to seek waivers that limit retroactive eligibility. Under the BCRA, that flexibility would disappear, as states are forced to end retroactive coverage, whether they like it or not.

Almost certainly, this provision would come as a surprise to most senators who are being asked to support the BCRA. It is only one of many unpleasant surprises lurking largely undiscovered throughout the bill.

Following are other selected examples.

A Massive Expansion In Federal Power Over State Budgets
The BCRA grants the federal government startling new power over state Medicaid programs and state budgets. Federal dollars per person would be capped, based on state data about prior spending. But in setting the initial cap for each state, the secretary of Health and Human Services (HHS) could change the amount to rectify what the secretary views as problems in the “quality” of state data. In later years, many states could have their caps adjusted up or down by as much as 2 percent per year. That may sound like a small number, but when applied to billions of federal Medicaid dollars going to a state, it could make or break a state’s entire budget. Medicaid costs triggered by a public health emergency are exempt from the cap, but only if “the Secretary determines that such an exemption would be appropriate.” No statutory limits bound the Secretary’s use of this decision-making authority, which can have an extraordinary fiscal impact on states experiencing an epidemic or other public health crisis.

These provisions would give HHS remarkable new leverage over states, which current or future administrations could use to compel state policy changes in any desired direction. The aggressive use of available leverage has been an unfortunate feature of past administrations’ relationships to state Medicaid programs, but it could become substantially more pronounced with the increased federal authority granted by the Senate bill.

Adding To Uncertainties Surrounding State Expenditures
One recurring theme in Medicaid’s history involves state efforts to claim federal matching funds without spending the requisite state dollars. The Senate bill appears to increase this risk. Under Section 207 in the Senate bill, new opportunities emerge for states desperate to counteract the loss of billions of federal dollars. The bill authorizes unprecedented waivers involving federal funding for tax credits that help consumers buy private health insurance. So long as officials complete a form explaining how the waiver’s replacement of federal safeguards would provide an “alternative means” of increasing “access to comprehensive coverage, reducing average premiums, and increasing enrollment,” a state arguably could convert some or all of this federal money into so-called “pass-through” funds that can be used for purposes unrelated to health care. Unlike the Senate bill’s new public health emergency provisions, which require federal audits of state expenditures, states’ use of pass-through dollars has no statutory audit requirement. A state could convert subsidies meant for health insurance to other uses, or simply use the money to close a budget shortfall. As the Congressional Budget Office (CBO) explained about the virtually identical prior version of this section, the Senate health care bill would “substantially reduce the number of people insured” if states “reduced subsidies, received pass-through funds, and used those funds for purposes other than health insurance coverage.”

Medicaid Treatment For Mental Health And Substance Use Disorders
The bill repeals the current requirement that Medicaid programs must cover all “essential health benefits,” including treatment of mental health and substance use disorders. CBO found that, as the per capita limits in the Senate bill grow progressively tighter, federal Medicaid funding would eventually decline by more than a third, compared to current law. States facing such an enormous drop in federal support may see themselves as having no alternative but to cut services classified as optional, which the Senate bill redefines to include mental health and substance abuse treatment.

A Disordered Process
These problems could have been averted had the legislative process followed regular order, with hearings, legislative staff explaining the bill’s provisions, expert testimony, a public markup, and opportunities to address policy and drafting anomalies. Embedded in a measure with underlying policy goals that the authors of this blog post find fundamentally questionable, the picture that emerges is extraordinarily troubling—a legislative effort to divert more than a trillion dollars away from health care for people who are sicker, poorer, older, and indigent, while leaving states with such massive funding deficits and federal leverage that some states may attempt to stem their losses in ways that harm their vulnerable residents even more.

Even people sympathetic to the bill’s core aims, however, have good reason to oppose the Senate making such consequential decisions without taking the elementary legislative steps needed to detect and avoid terrible mistakes. Continuing to shun all the protections of regular order, the Senate appears poised to act on a bill that almost certainly includes additional unpleasant surprises going beyond those discussed here. With legislation that governs one-sixth of the US economy and that directly affects the health and economic security of millions of constituents, Senators are being asked to vote largely in the dark.