Feinstein feels left out of healthcare talks

Sen. Dianne FeinsteinDianne FeinsteinIntel leaders push controversial encryption draft Democrats block energy spending bill over Iran amendment Durbin: Iran amendment could kill energy bill MORE (D-Calif.), who has proven critical in forging compromise on major issues in the past, says she feels cut out of negotiations to overhaul the nation’s healthcare system.

Feinstein fired off a warning Tuesday by threatening to vote against the bill if it takes tens of billions of dollars in Medicare funds away from high-cost areas such as New York and California to cover uninsured patients in low-cost and rural areas of the country.

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Feinstein’s concern represents the possible re-emergence of a longstanding feud over how to pay for healthcare that has traditionally pitted large, populous states against their small, rural counterparts. Senate Democratic leaders are trying to tamp down these tensions before they threaten to derail healthcare reform.

Senators working on healthcare reform that could include a new public insurance program are considering reimbursing doctors based on the outcome of treatment instead of on quantity, which could punish populous states.

“The surest way to tank healthcare reform is to let us break down into arguments between big states and small states. That has been in every major health discussion for years and years,” said Sen. Ron WydenRon WydenAbortion fight stalls Obama nominee Overnight Healthcare: More trouble for Zika funding Wyden introduces bill to cap drug costs under Medicare MORE (D-Ore.), a member of the Senate Finance Committee.

Tensions between lawmakers from big and small states are likely to heighten in the wake of a Congressional Budget Office analysis estimating that Democrats need to find $1 trillion over the next 10 years to pay for their leading healthcare reform proposal.

A split between urban and rural states could complicate talks between the Senate Finance and House Ways and Means committees, both of which are tasked with paying for healthcare reform. While Finance’s leaders come from small states, the senior Democrats on Ways and Means come from New York City, California and Michigan.

One member of the Finance Committee predicted that discussion over payments to large and small states would escalate into a major debate between Sen. Max BaucusMax BaucusWyden unveils business tax proposal College endowments under scrutiny The chaotic fight for ObamaCare MORE (D), chairman of the Finance Committee, who represents rural Montana, and Sen. Charles SchumerCharles SchumerCruz's dad: Trump 'would be worse than Hillary Clinton' With Ryan’s blessing, lawmakers press ahead with tax reform talks Big business will never appease the Left MORE (D-N.Y.), another panel member.

Feinstein said she’s seriously worried that states like California, which is already considering cuts to public healthcare because of a state budget crisis, could be hurt by the emerging healthcare reform bill.

“All of us are very concerned. We don’t know the specifics of the plan,” said Feinstein, who does not sit on either of the Senate panels with primary jurisdiction over the issue. “This is one of the big frustrations that accompany healthcare reform for those of us not on [the Finance] committee [who represent] big states with complicated and very serious healthcare industries.”

The New York Times reported last week that lawmakers are seriously considering proposals to rein in the cost of health spending by shifting tens of billions of dollars of Medicare money away from high-cost areas to cover the uninsured in low-cost regions.

Feinstein said if leaders decide to shift billions of Medicare dollars away from California, “I can’t vote for it.”

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Healthcare isn’t the only major legislative issue threatened by Democratic infighting along regional lines. The opposite seems to be happening in the House with a climate change bill that is a top priority for Speaker Nancy Pelosi (D-Calif.). It has come under fire from farm-state members who claim the bill’s sponsors are favoring their coastal states.

Sen. Tom HarkinTom HarkinDo candidates care about our health or just how much it costs? The Hill's 12:30 Report Mark Mellman: Parsing the primary processes MORE (D-Iowa) said he has followed that debate and agrees with House Agriculture Committee Chairman Collin Peterson (D-Minn.) that the legislative language in that bill needs to be more equitable, considering the interests of large urban areas and more rural states. But he acknowledged those places have competing interests.

“The bigger states and the industrial states are going to have differences with Southern states and mountain states in the West,” he said. “Big differences.”  

Feinstein said she would like Democratic leaders to slow down the pace of healthcare reform legislation so that she has time to meet with constituents in California to better understand how it affects them.

 “I have a hard time understanding the need to push something through,” she said, warning that healthcare reform could crash and burn if lawmakers aren’t given enough time to satisfy various questions and concerns.

California’s other senator, Barbara BoxerBarbara BoxerSenate panel backs B water bill with Flint aid The Hill's 12:30 Report Fiorina fires back at Barbara Boxer MORE (D), also said her state should have more of say in early discussions.

“I do feel that we do have to get more involved and I have been trying to do it via members on the committee, but I think she’s absolutely right, because whatever policy is made, we’re going to feel it more than any other state because we’re so large.”

Finance’s senior members — Baucus, ranking Republican Sen. Chuck GrassleyChuck GrassleySenators roll out changes to criminal justice bill Senate pressured to take up email privacy bill after overwhelming House vote Abortion fight stalls Obama nominee MORE (Iowa), Sen. Jay RockefellerJay RockefellerLobbying world Overnight Tech: Senators place holds on FCC commissioner Overnight Tech: Senate panel to vote on Dem FCC commissioner MORE (D-W.Va.) and Sen. Kent Conrad (D-N.D.) — hail from small, rural states. They will be charged with finding ways to pay for the $1 trillion-plus costs of reform.

Finance does have several junior members from populous states, including Democratic Sens. Bill NelsonBill NelsonThree more Republican senators to meet with Supreme Court nominee This week: Congress on track to miss Puerto Rico deadline Senate looks for easy wins amid 2016 gridlock MORE (Fla.) and Robert MenendezRobert MenendezDemocrats block energy spending bill over Iran amendment Senate close to voting on Mexico ambassador Senate panel approves identity-theft, taxpayer protection bills MORE (N.J.).

Sen. Debbie StabenowDebbie StabenowOvernight Energy: Flint aid attached to water bill 0 million Flint aid package included in water bill Senate Finance panel announces mental health hearing MORE (D-Mich.), another member of Finance who represents a populous state, said it’s not certain how altering the reimbursement formula will affect big states. She said it is an oversimplification to characterize the proposed change to reimbursement formulas as a shift of Medicare money away from populous states.

Conrad noted that treatments at Mayo clinics cost “about half as much” as at the University of California Los Angeles and “get better outcomes.”

Mayo is headquartered in Rochester, Minn., a small city of about 100,000.

But Conrad argued that a new reimbursement scheme wouldn’t necessarily favor more rural areas. He noted that Mayo operates a successful clinic in Jacksonville, Fla., which has about 800,000 residents.