Feinstein feels left out of healthcare talks

Sen. Dianne FeinsteinDianne FeinsteinDems get it wrong: 'Originalism' is mainstream, even for liberal judges Human rights leaders warn against confirming Gorsuch Feinstein sees slipping support among California voters: poll 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 WydenThe Hill’s Whip List: Where Dems stand on Trump’s Supreme Court nominee Overnight Regulation: Senate moves to strike Obama-era internet privacy rules Overnight Tech: Senate votes to eliminate Obama internet privacy rules | FCC chief wants to stay out of 'political debate' on fake news | Wikileaks reveals new CIA docs 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 BaucusGOP hasn’t reached out to centrist Dem senators Five reasons why Tillerson is likely to get through Business groups express support for Branstad nomination MORE (D), chairman of the Finance Committee, who represents rural Montana, and Sen. Charles SchumerCharles SchumerWarren: 'Today is a great day... but I'm not doing a touchdown dance' Schumer calls Trump admin 'incompetent' after healthcare bill pulled Trump blames Democrats for ObamaCare defeat 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 HarkinGrassley challenger no stranger to defying odds Clinton ally stands between Sanders and chairmanship dream Do candidates care about our health or just how much it costs? 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 BoxerAnother day, another dollar for retirement advice rip-offs Carly Fiorina 'certainly looking at' Virginia Senate run Top Obama adviser signs with Hollywood talent agency: report 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 GrassleyGOP senators pitch alternatives after House pulls ObamaCare repeal bill Friends, foes spar in fight on Trump’s Supreme Court nominee Live coverage: Day three of Supreme Court nominee hearing MORE (Iowa), Sen. Jay RockefellerJay RockefellerObama to preserve torture report in presidential papers Lobbying world Overnight Tech: Senators place holds on 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 NelsonThe Hill’s Whip List: Where Dems stand on Trump’s Supreme Court nominee Overnight Tech: Senate votes to eliminate Obama internet privacy rules | FCC chief wants to stay out of 'political debate' on fake news | Wikileaks reveals new CIA docs FCC chairman: Whether NY Times, CNN, NBC are 'fake news' is a ‘political debate’ MORE (Fla.) and Robert MenendezRobert MenendezSteve Mnuchin, foreclosure king, now runs your US Treasury Senate Dems move to nix Trump's deportation order Senators to Trump: We support additional Iran sanctions MORE (N.J.).

Sen. Debbie StabenowDebbie StabenowThe Hill’s Whip List: Where Dems stand on Trump’s Supreme Court nominee Perdue says he will advocate for agriculture spending RNC drops six-figure ad buy for Supreme Court, healthcare fight 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.