U.S. Health Care Quality Analysis: Legislative History

Following up to the 1999 release of the Institute of Medicine (IOM) report, To Err Is Human, in 2002 a Kaiser Family Foundation survey found that only about 5% of physicians considered medical errors as a primary healthcare concern.[1] Congress, however, did not share the physicians’ nonchalant attitude and gave the Agency for Healthcare Research and Quality (AHRQ) an estimated $50 million towards minimizing medical errors.[2] Senator James Jeffords (R-VT) of the 107th Congress introduced the Patient Safety and Quality Improvement Act (S.2590) to the Senate on June 4, 2002[3] attempting to improve the safety of patients and “…reduce the incidence of events that adversely effect patient safety.”[4] In 2003, President Bush signed into law the Medicare Prescription Drug Improvement and Modernization Act (P.L 108-173).[5] A section of this law authorized AHRQ to research effectiveness in treatments in order to set a guideline to improve the quality of care.[6] John Eisenberg helped build this program that generates summaries that can help provide health care providers with evidence-based practices that help improve quality of care delivered.[7] Realizing the importance of this research to quality of care, the president signed the Under the American Recovery and Reinvestment Act of 2009 (H.R. 1) into law on February 17, 2009, providing additional funding to continue effective research.[8] This helps to demonstrate the IOM’s report effectively indicated to Congress that legislation revamping was needed in order to help not only reduce medical errors and improve overall health care quality, but also the high costs associated with these preventable errors. With a democrat majority in the Senate, and republican majority in the House making up the 113th Congress[9], and the passage of PPACA, health care quality has become once again a salient legislative issue. Historically, political parties were thought to have debilitated powers in the legislative process[10]; however recently experts negate that argument and provide evidence these parties assist individuals collectively analyze and voice their particular issue of interest.[11] This can almost be thought of as strength in numbers, as parties help with gaining support and can help differentiate issues from other issues by other parties; also helping to solve three problems in Congress: “…coordination, collective action, and collective choice.”11 Procedural issues, such as rules that shape legislation, are top priorities for party leaders[12] and they expect full cooperation and support from party members or retaliation is inevitable.11 When it comes to health care policies, Republicans typically favor minimal governmental roles and prefer the market-based approaches to solve any healthcare issues that may arise; an increase in government in regards to healthcare means less competition and therefore less market power.[13] Democrats, on the other hand, prefer larger governmental role in healthcare.[14] The PPACA is an example of this: greater government influence, which supports democrats’ preference; while republicans feel that it “…puts the federal government between you and your doctor…limiting a physician’s options for treating patients…”[15] Although parties have various views on the degree of government part in health care, there are incidences where both parties agree on avenues towards greater quality of care. For example in 2005, Senators Edward (Ted) Kennedy (D-MA)[16] and Michael Enzi (R-WY) introduced the Wired for Health Care Quality Act (S.1418), with the purpose of national adoption of health information technology to improve quality of healthcare provided and reduce the risk of medical errors; however it was not passed in the House.[17] More recently in January 2013, and demonstrating the disagreement with democrats, Senator Orrin Hatch (R-Utah) from the Senate Finance Committee and Senator Lamar Alexander (R-TN) from the Senate Health, Education, Labor, and Pensions (HELP) Committee introduced the American Liberty Restoration Act (S.40) in response to provisions in the PPACA’s individual mandate, citing the law expands the health care system so that quality of care for patients is reduced.[18] Although the act was introduced recently, it has already gained support from 23 senators in the 113th Congress.[19] Both the 1970s and 1980s were plagued with large numbers of medical malpractice claims and as a consequence resulted in larger increases in medical malpractice insurance premiums, an astounding estimated 300% increase between 1974 and 1975.[20] Claims against physicians rose from about 7.9 per 100 physicians in 1976 to 17.8 in 1985 and malpractice premiums became about 9% of physicians’ total costs.20 Witnessing this “medical malpractice crisis”20, Senator Ron Wyden (D-OR) introduced the Health Care Quality Improvement Act of 1986 (HCQIA) in September 17, 1986 to the 99th Congress.[21] The bill required physicians to undergo peer reviews with limited immunity from damages, and restricted movement across state lines for those physicians found incompetent.[22] On October 8-9, 1986, a hearing in the House before the Subcommittee on Civil and Constitutional Rights, four witnesses testified in regards to the HCQIA. The first witness was the director of the Public Citizen Health Research Group, Dr. Wolfe, who was in strong favor of physician peer reviews.[23] The second witness Mr. Bogan, Vice President of the National Coalition of Hispanic Health and Human Services Organization, supported the HCQIA; however had concerns with the immunity provision and the effect this provision would have in regards to quality of care for Hispanic Americans and recommended changing it in order to avoid limiting protections under the civil rights law.23 The third witness, Mr. Weinstein, with the Lawyers’ Committee for Civil Rights Under Law, also expressed his apprehensions towards the immunity provision and concerns to potential discriminatory actions that might occur during peer review processes.[24] The fourth witness, Dr. Mixson with the American College of Obstetricians and Gynecologists, like Mr. Weinstein supported the HCQIA, believing it would result in higher quality care, but saw no need for the immunity provision and feared it would result in discrimination against minority physicians.23 On October 14, 1986 the House passed the HCQIA; however the bill was never passed by the Senate.21 Malpractice premiums continued to increase, at a slower rate, and concerns caused the 108th and 109th Congresses to introduce an estimated 26 bills directed specifically at the increase.[25] For example in March 2003, Representative John Conyers Jr. (D-MI) introduced the Medical Malpractice and Insurance Reform Act of 2003 (H.R. 1219)[26] which aimed to limit the number of trivial medical malpractice claims; however this bill failed to become enacted and was re-introduced in the 109th Congress in July 2005 (H.R. 3359).[27] Another bill introduced in February 2003 by Representative James Greenwood (R-PA), the Help Efficient, Accessible, Low-cost, Timely Healthcare (HEALTH) Act of 2003 (H.R. 5)[28], aimed to improve care by limiting the liability issue that may burden the delivery system.[29] The bill was passed by the House in March 2003; however was failed to be passed by the Senate.29 The quality of healthcare consideration in both the House and Senate varies as it is dependent on the majority, democrats favor government interference and republicans do not. The 99th Congress was made up of 241 democrats in the House and 63 democrats in the Senate[30], for example, when the HCQIA was introduced. The Senate is estimated to have only passed about 57% of bills that were passed in the House over the past recent six Congresses.[31] The 113th Congress is said to be one of the most diverse in history, by race, age, gender, etc.[32] The House is comprised of 233 republicans and 200 democrats[33]; while the Senate has 53 democrats and 45 republicans.[34] Because the house is so large, there is very little debate and centralized; while the Senate smaller, decentralized and leadership tends to be weaker in the Senate when compared to the House.[35] It is hopeful that the diversity in the 113th Congress will enable more bills to pass as well as higher interest in the quality of care delivered. Threats of filibuster, which is any act that can stop floor actions, have recently become more used than actual filibusters in the Senate.[36] Clotures, which end filibusters by limiting the debate, require at least three-fifths of Senators’ votes to invoke a closure.[37] In recent Congresses, cloture motions have primarily been used in regards to malpractice bills. In the 108th Congress two bills with regards to malpractice liability in obstetrics/gynecology (S.2061 and S.2207), both introduced by Judd Gregg (R-NH)[38] and consisted of cloture motions that failed when voted on in the Senate.[39] Also in the 108th Congress, in 2003, the Patients First Act (S.11) that looked to reduce the effects of liability costs ensuring patients had affordable, high quality care also consisted of a cloture motion that failed due to majority votes.39 The Medical Malpractice Liability Reform Bill (S.22)[40] also aimed to improve quality of care by decreasing the burden of liability had a cloture presented on May 5, 2006 and failed on May 8, 2006.[41] Reconciliation bills compile legislative recommendations in regards to budgets and cannot be filibustered in the Senate.[42] The reconciliation bill has been used in most changes to Medicare and Medicaid; and although the PPACA aims to crack down on poor quality of care in these programs, the reconciliation bill was not used.42 In October 1990, The Omnibus Budget Reconciliation Act of 1990 (H.R. 5835) was introduced by Representative Leon Panetta (D-CA); which provided reconciliation to section four of the act,[43] that concerned Medicare and Medicaid programs and the reimbursement rates according to care.[44] The act expanded functions of the Prospective Payment Assessment Commission (PPAC) to develop reimbursement policies that is conducive to effective high-quality care and reporting these costs to Congress. There are numerous ways in which PPACA is working with the CMS to help lower costs and improve quality of care for Medicare recipients. One of the most promising methods, value-based purchasing (VBP), provides rewards for those hospitals that have better health outcomes such as closely following established best clinical practices and enhancing patients’ experience of care.[45] The VBP program, measuring quality on six factors: safety, patient-and caregiver-centered experience and outcomes, care coordination, clinical care, population/community health, and efficiency and cost reduction[46]; has already demonstrated improved quality of care in end-stage renal failure, as 55-96% of facilities showed improvement in the above criteria compared to two years prior.[47] CMS estimates the PPACA provisions will save close to $8 billion within the next two years; while improving quality of care by, for example, reducing the number of readmissions by establishing a “hospital readmission reduction program” that ideally will make follow-up transitional care more coordinated.[48] Hospital re-admissions as well as medical errors are not the only factors increasing healthcare costs; according to the Senator Max Baucus (D-MT), of the Senate Committee on Finance, Representatives Henry Waxman (D-CA), Sander Levin (D-MI), and John Dingell (D-MI), the PPACA provides up to 50% discount on brand-name drugs once the coverage gap is reached and these discounts will continue to increase, closing the “donut hole”.[49] Representative Levin stated “Obamacare meets its promise of…affordability and quality health care for millions of Americans on Medicare by closing the ‘donut hole’”49 According to the CBO, PPACA provisions will overall save an estimated $1,677 billion between 2013 and 2022.[50] The deficit is another major driving force for the PPACA, as it aims to decrease the deficit by an estimated $143 billion between the 2010-2019 periods by changing spending for healthcare, while ideally improving quality delivered.[51] To House democrats, PPACA has helped improve health care to millions of Americans already; however the party feels that it has not been utilized to its full potential. A government-run public option was cut from the final bill that was set to increase competition in the private market and cut costs.[52] Representatives Janice Schakowsky (D-IL) and Harry Waxman (D-CA) re-introduced this option as the Public Option Deficit Reduction Act (H.R. 261) on January 15, 2013 in order to increase the choices Americans are able to make in regards to their health care, while addressing the deficit.[53] Rep. Schakowsky estimates it could save an additional $104 billion in the next ten years.[54] Health is a multi-jurisdictional issue, as most committees have some control; however there are only about eight committees and six subcommittees that have the largest impact on health legislation.[55] The Subcommittee on Health in the House Energy and Commerce Committee has most jurisdiction over the quality of care delivered to Americans as it primarily concerned about medical errors.[56] The House Committee on Ways and Means Subcommittee on Health primarily looks at bills related to health care programs, as well as delivery systems, and health research.[57] The Senate Committee on Finance Subcommittee on Health Care is concerned with revenue measurements in regards to health programs such as Medicaid and Medicare that is financed by taxes and social security.[58] The Subcommittee on Labor, Department of Health, Human Services, and Education and Related Agencies of the Senate Committee on Appropriations has jurisdiction on fund allocation for certain agencies, specifically AHRQ and the Department of Health and Human Services (HHS) in regards to healthcare quality.[59] The House also has a Committee on Appropriations, also with Subcommittee on Labor, Department of Health, Human Services, and Education and Related Agencies with jurisdiction on HHS as well.[60] There is obvious overlap in quality of care interest; however typically the House Energy and Commerce Committee tackle any of the quality issues that arise. Congressional members are motivated by numerous things such as his/her own preference, interest group and party preferences when deciding what issues to focus on.[61] For example, according to AHRQ, Congressional interest in improving children’s health care is to invest in future productive members of society.[62] This demonstrates Congress’ ultimate goal is not necessarily looking at improved lives for Americans, but performing a cost-benefit analysis and determining how productive society can be if an investment (in this case healthcare) is made now. Public opinion can also shape what members choose to focus on, especially if an election is near.[63] Improving quality of care has been pushed to the back burner; however with an increasing deficit and the higher percentage of GDP spent on healthcare with no indication of improved statues, quality of care is once again a hot topic. Members are motivated to cut health care spending; while ameliorating worries of poor quality of care. Recently, democrats used the memory of Senator Kennedy to help pass the PPACA. Senator Kennedy was a strong advocate for high quality of care for all Americans and after his passing in 2009, democrats coined the slogan “win one for Teddy” to help give the legislation a push forward.[64] Most republicans responded positively when Senator Kennedy was the topic, out of respect. Others, who realized the democrats’ new tactic, took to criticizing topics Senator Kennedy had advocated for such as abortion. Those republicans credit the passing of Senator Kennedy as the driver for the passing of the PPACA. Caucuses provide opportunities for members to express and promote ideas; however most do not meet and mostly stay in contact by e-mail exchanges.[65] There are numerous caucuses involved in the quality of healthcare delivered, as quality can apply any medical ailment such as diabetes. The Congressional Diabetes Caucus is one of the largest caucus and aims to improve the treatment for diabetes.[66] The Congressional Health Care Caucus, chaired by Congressman Michael Burgess (R-TX), is designed to educate Republicans about health care, including maintaining and/or improving quality of healthcare.[67] The Children’s Health Care Caucus is a bipartisan caucus providing support for legislation that helps improve the quality of care children receive in facilities.[68] For example, the caucus supported the Wakefield Act (H.R. 2464) introduced by Representative Jim Matheson (D-UT) in 2007 and re-introduced in 2009 (H.R. 479); which wanted to improve emergency services provided to children.[69] The Congressional Mental Health Caucus, established in 2003, aims reduce stigma associated with mental disorders to ideally help improve the quality of care delivered.[70] Congresswoman Lois Capps (D-CA) and Congressman Steven LaTourette (R-OH) both chair the House Nursing Caucus that allows discussion of nursing issues, as well as patient safety issues and improving quality of care.[71] The GOP Doctors Caucus was formed in March 2009 and emphasizes patient-centered health care to help improve healthcare quality.[72]

Legislative History: ϖ July 30, 1965: H.R. 6675 (P.L. 89-97) signed into law to help continue improvement of care ϖ September 1986: Health Care Quality Improvement Act (HCQIA) of 1986 – Peer review physicians ⎫ October 1986: hearings for the HCQIA; passed in the House, never passed in Senate ϖ October 1990: The Omnibus Budget Reconciliation Act of 1990 (H.R 5835) – expanding functions of the PPAC to develop reimbursement of Medicare and Medicaid services based on care ϖ May 22, 1991: Health Care Liability Reform and Quality of Care Improvement Act (S.1123) – improving quality of and access to care by reducing liability costs; not enacted ϖ June 1991: National Commission on Board and Care Facility Quality Act (H.R. 2552) – board assembly to improve quality of care ϖ November 1991: Medicaid Managed Care Improvement Act (S.2077) – improve requirements for coordinator care to improve quality of care; not enacted ϖ May 1993: Medical Injury Compensation Fairness Act (H.R. 1989) – provide compensation for medical injuries; not enacted ϖ July 1994: Medical Malpractice Fairness Act (H.R. 4791) – establishing federal standards to resolve healthcare malpractice claims; not enacted ϖ March 1999: Quality Health-Care Coalition Act (H.R. 1304) – continued quality of care between health care providers and insurance companies by negotiations and coordinating care ⎫ June 2000: H.R. 1304 passed House 276/136; never passed by Senate ϖ July 2000: Nursing Home Quality Protection Act (H.R. 4949) – improve quality of care in nursing homes; not enacted ϖ October 2001: Nurse Retention and Quality of Care Act (S. 1594) -- providing programs to retain nurses and improve quality of care ϖ June 2002: Patient Safety and Quality Improvement Act (S. 2590) – improvement of care by reducing the incidence of negative events that affect patient safety; not enacted ϖ September 2002: Quality of Care for Individuals with Cancer Act (S. 2965) – improved quality of care for individuals with cancer; not enacted ϖ 2003: Medicare Prescription Drug Improvement and Modernization Act (P.L. 108-173) – allocating funds to AHRQ to improve health care quality ϖ February 2003: HEALTH Act (H.R. 5) – Improving care by limiting malpractice liability ⎫ March 2003: H.R. 5 passed in House; failed to pass in Senate ϖ March 2003: Medical Malpractice and Insurance Reform Act of 2003 (H.R. 1219) – limitations on trivial medical malpractice claims to improve quality of care ϖ June 2003: Patients First Act (S.11) – ensuring patients receive high quality care by reducing liability cost effects ϖ February 2004: Healthy Mothers and Healthy Babies Access to Care Act 2003 (S. 2061) –limiting lawsuits for OB/GYN malpractice to ensure high quality of care; failed ϖ March 2004: Pregnancy & Trauma Care Access Protection Act of 2004 (S.2207) – same as S.2061; failed in Senate ϖ July 2005: Medical Malpractice and Insurance Reform Act reintroduced (H.R. 3359) ϖ 2005: Wired for Health Care Quality (S.1418) – national adaptation of EMRs to improve quality of care ϖ March 2006: Medical Malpractice Liability Reform Bill (S.22) – improving quality of care decreasing burden of malpractice lawsuits ⎫ May 2006: S.22 failed to pass in Senate ϖ June 2009: Advance Planning and Compassionate Care Act (H.R. 2911) – Improving end-of-life quality of care; not enacted ϖ January 04, 2013: Medical Checklist Act of 2013 (H.R. 116) introduced to House – study on developing medical checklists to improve quality ϖ January 15, 2013: Public Option Deficit Reduction Act (H.R. 261) – increase choices for healthcare and addressing the deficit ϖ January 22, 2013: American Liberty Restoration Act (S. 40) – against the individual mandate of the PPACA

----------------------- [1] Woo, A., Ranji, U., & Salganicoff, A. (2008, May). Reducing Medical Errors‮湉䬠楡敳⁲效污桴丠睥⹳删瑥楲癥摥䘠扥畲牡⁹㔱‬〲㌱‬牦浯ጠ䠠偙剅䥌䭎∠瑨灴⼺眯睷欮楡敳敲畤漮杲䤯獳敵䴭摯汵獥刯摥捵湩ⵧ敍楤慣⵬牅潲獲䈯捡杫潲湵ⵤ牂敩⹦獡硰ᐢ瑨灴⼺眯睷欮楡敳敲畤漮杲䤯獳敵䴭摯汵獥刯摥捵湩ⵧ敍楤慣⵬牅潲獲䈯捡杫潲湵ⵤ牂敩⹦獡硰―ȍ†潗Ɐ䄠Ⱞ删湡楪‬⹕‬…慓杬湡捩景ⱦ䄠‮㈨〰ⰸ䴠祡⸩删摥捵湩⁧敍楤慣牅潲獲‮湉䬠楡敳⁲效污桴丠睥⹳删瑥楲癥摥䘠. In Kaiser Health News. Retrieved February 15, 2013, from http://www.kaiseredu.org/Issue-Modules/Reducing-Medical-Errors/Background-Brief.aspx

[2] Woo, A., Ranji, U., & Salganicoff, A. (2008, May). Reducing Medical Errors. In Kaiser Health News. Retrieved February 15, 2013, from http://www.kaiseredu.org/Issue-Modules/Reducing-Medical-Errors/Background-Brief.aspx

[3] S.2590 - Patient Safety and Quality Improvement Act. In Congress.gov: United States Legislative Information. Retrieved February 22, 2013, from http://beta.congress.gov/bill/107th-congress/senate-bill/2590/text

[4] S. 2590 (107th): Patient Safety and Quality Improvement Act (2002, June 5). In govtrack.us. Retrieved February 20, 2013, from http://www.govtrack.us/congress/bills/107/s2590/text

[5] Summaries of the Medicare Prescription Drug Improvement & Modernization Act of 2003 (2004, January). In The Henry J. Kaiser Family Foundation. Retrieved February 25, 2013, from http://www.kff.org/medicare/med011604pkg.cfm

[6] History of the Effective Health Care Program (n.d.). In AHRQ. Retrieved February 25, 2013, from http://effectivehealthcare.ahrq.gov/index.cfm/what-is-the-effective-health-care-program1/history-of-the-effective-health-care-program/

[7] John Meyer Eisenbery. (2002, March). BMJ, 324, p.793. Retrieved February 25, 2013, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1122727/pdf/793.pdf

[8] H.R. 1 (111th): American Recovery and Reinvestment Act of 2009 (2009, January 26). In govtrack.us. Retrieved February 25, 2013, from http://www.govtrack.us/congress/bills/111/hr1

[9] Blackwill, S. (2013, January 3). 113th Congress: By the Numbers. In MSNBC. Retrieved February 22, 2013, from http://tv.msnbc.com/2013/01/03/113th-congress-by-the-numbers/

[10] Weissert, W. G., & Weissert, C. S. (2012). Governing Health: The Politics of Health Policy (4th ed., p. 51). Baltimore, MD: The Johns Hopkins University Press.

[11] Weissert, W. G., & Weissert, C. S. (2012). Governing Health: The Politics of Health Policy (4th ed., p. 52). Baltimore, MD: The Johns Hopkins University Press.

[12] Weissert, W. G., & Weissert, C. S. (2012). Governing Health: The Politics of Health Policy (4th ed., p. 53). Baltimore, MD: The Johns Hopkins University Press.

[13] GOP.com: Our Party. Retrieved February 22, 2013, from http://www.gop.com/our-party/

[14] Weissert, W. G., & Weissert, C. S. (2012). Governing Health: The Politics of Health Policy (4th ed., p. 301). Baltimore, MD: The Johns Hopkins University Press.

[15] "Assessing the New Health Care Law: Will it improve care and reduce spending?" CQ Researcher 22.33 (2012): p.792.

[16] Senator Kennedy Highlights Importance of Health IT Health IT Cuts Costs and Improves Quality of Care (2005, October 24). In US Senate Committee on Health, Education, Labor & Pensions. Retrieved February 22, 2013, from http://www.help.senate.gov/newsroom/press/release/?id=47d2e3ab-aa60-4f2f-b368-a1888df9becd&groups=Ranking

[17] S.1418 (109th): Wired for Health Care Quality Act (2005, July 18). In govtrack.us. Retrieved February 22, 2013, from http://www.govtrack.us/congress/bills/109/s1418

[18] Hatch, Alexander Introduce Legislation Repealing Health Law's Individual Insurance Mandate (2013, January 22). In US Senate Committee on Health, Education, Labor & Pensions. Retrieved February 22, 2013, from http://www.help.senate.gov/newsroom/press/release/?id=4292ec36-511f-471c-8af2-67316d258454&groups=Ranking

[19] Bill Summary & Status: 113th Congress (2013 - 2014) S.40 (2013, January 22). In The Library of Congress: THOMAS. Retrieved February 22, 2013, from http://thomas.loc.gov/cgi-bin/bdquery/D?d113:1:./temp/~bdxicb:@@@L&summ2=m&|/home/LegislativeData.php?n=BSS;c=113|

[20] Patel, K., & Rushefsky, M. (2006). Health Care Politics and Policy in America. (3 ed., p. 272). Armonk, New York: M.E. Sharpe

[21] H.R. 5540 (99th): Health Care Quality Improvement Act of 1986 (1986, September). In govtrack.us. Retrieved February 23, 2013, from http://www.govtrack.us/congress/bills/99/hr5540

[22] Hefferman, M. (1996, April). Bulletin of Medical Library Association, 84(2), p.263.

[23] Health Care Quality Improvement Act of 1986 Hearings (1986, October). Retrieved February 23, 2013, from http://congressional.proquest.com.proxy.lib.fsu.edu/congressional/result/pqpresultpage.gispdfhitspanel.pdflink/http%3A$2f$2fprod.cosmos.dc4.bowker-dmz.com$2fapp-bin$2fgis-hearing$2f0$2f6$2f3$2f7$2fhrg

[24] Health Care Quality Improvement Act of 1986 (1986). In ProQuest: Hearings Published. Retrieved February 23, 2013, from http://congressional.proquest.com.proxy.lib.fsu.edu/congressional/result/congressional/pqpdocumentview?accountid=4840&groupid=127019&pgId=175d5b35-539b-48b8-8237-366f2ad185f6&rsId=13C6E39C601#

[25] Rodwin, M. A., Chang, H. J., & Clausen, J. (2006, June). Malpractice Premiums And Physicians’ Income: Perceptions Of A Crisis Conflict With Empirical Evidence. Health Affairs, 25(3), p.750.

[26] Bill Summary & Status: 108th Congress (2003 - 2004) H.R.1219 (2003, March). In The Library of Congress: THOMAS. Retrieved February 22, 2013, from http://thomas.loc.gov/cgi-bin/bdquery/D?d108:5:./temp/~bddKtQ:@@@L&summ2=m&|/home/LegislativeData.php?n=BSS;c=108|

[27] H.R. 3359 (109th): Medical Malpractice and Insurance Reform Act of 2005 (2005, July). In govtrack.us. Retrieved February 22, 2013, from http://www.govtrack.us/congress/bills/109/hr3359

[28] Bill Summary & Status: 108th Congress (2003 - 2004) H.R.5 (2003). In The Library Congress: THOMAS. Retrieved February 23, 2013, from http://thomas.loc.gov/cgi-bin/bdquery/D?d108:2:./temp/~bdF1PC:@@@L&summ2=m&|/home/LegislativeData.php?n=BSS;c=108|

[29] H.R. 5 (108th): Help Efficient, Accessible, Low-cost, Timely Healthcare (HEALTH) Act of 2003 (2003, February). In govtrack.us. Retrieved February 23, 2013, from http://www.govtrack.us/congress/bills/108/hr5

[30] Congress.gov: US Legislative Information. Retrieved February 24, 2013, from http://beta.congress.gov/search?pageSize=25&Congress=99th+Congress+(1985-1986)

[31] Weissert, W. G., & Weissert, C. S. (2012). Governing Health: The Politics of Health Policy (4th ed., p. 21). Baltimore, MD: The Johns Hopkins University Press

[32] McDuffee, A. (2013, January 3). The 113th Congress: Is diversity the answer to gridlock?. In The Washington Post. Retrieved February 24, 2013, from http://www.washingtonpost.com/blogs/thinktanked/wp/2013/01/03/the-113th-congress-is-diversity-the-answer-to-gridlock

[33] House Gavels In First Session of 113th Congress (2013, January 3). In C-Span. Retrieved February 24, 2013, from http://www.c-span.org/Events/House-Gavels-In-First-Session-of-113th-Congress/10737436964/

[34] Senate Convenes First Session of the 113th Congress (2013, January 3). In C-Span. Retrieved February 24, 2013, from http://www.c-span.org/Events/Senate-Convenes-First-Session-of-the-113th-Congress/10737436963-1/

[35] Weissert, W. Congress 1-28-13, Slide 7

[36] Weissert, W. G., & Weissert, C. S. (2012). Governing Health: The Politics of Health Policy (4th ed., p. 24). Baltimore, MD: The Johns Hopkins University Press

[37] Beth, R. S., & Heitshusen, V. (2012, November). Filibusters and Cloture in the Senate. In Congressional Research Service. Retrieved February 25, 2013

[38] S. 2061 (108th): Healthy Mothers and Healthy Babies Access to Care Act of 2003 (2003, February). In govtrack.us. Retrieved February 25, 2013, from http://www.govtrack.us/congress/bills/108/s2061

[39] Cloture Motions-108th Congress. In The United States Senate. Retrieved February 25, 2013, from http://www.senate.gov/pagelayout/reference/cloture_motions/108.htm

[40] Cloture Motions-109th Congress. In The United States Senate. Retrieved February 25, 2013, from http://www.senate.gov/pagelayout/reference/cloture_motions/109.htm

[41] Bill Summary & Status: 109th Congress (2005 - 2006) S.22 (2006, May). In The Library of Congress: THOMAS. Retrieved February 25, 2013, from http://thomas.loc.gov/cgi-bin/bdquery/z?d109:SN00022:@@@L&summ2=m&

[42] Weissert, W. G., & Weissert, C. S. (2012). Governing Health: The Politics of Health Policy (4th ed., p. 47). Baltimore, MD: The Johns Hopkins University Press

[43] H.R. 5835 (101st): Omnibus Budget Reconciliation Act of 1990 (1990, October). In govtrack.us. Retrieved February 23, 2013, from http://www.govtrack.us/congress/bills/101/hr5835

[44] Bill Summary & Status: 101st Congress (1989 - 1990) H.R.5835 In The Library of Congress: THOMAS. Retrieved February 23, 2013, from http://thomas.loc.gov/cgi-bin/bdquery/z?d101:HR05835:@@@L&summ2=m&

[45] Frequently Asked Questions: Hospital Value-Based Purchasing Program (2012, February). In CMS. Retrieved February 26, 2013, from http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/downloads/HVBPFAQ022812.pdf

[46] VanLare, J., & Conway, P. (2012, July). Value-Based Purchasing — National Programs to Move fomr Volume to Value. The New England Journal of Medicine, 367(4), p.294. Retrieved February 26, 2013

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