The two-year budget deal approved by the Senate Wednesday aims to prevent another government shutdown.
It also includes a familiar annual rider — language to avert a steep pay cut to doctors who treat Medicare patients. But this time might be different, with a fix that lasts. After more than a decade of temporary solutions, it appears Congress may be on the verge of permanently solving its persistent problem in the way it makes Medicare payments to doctors.
The problem was actually created by Congress itself, back in 1997, through a flawed formula called the Sustainable Growth Rate, or SGR. And every year since 2002, when the formula first began calling for cuts, the SGR has created political and fiscal fits for lawmakers.
"The SGR has threatened to make draconian cuts to physician payments — cuts that could cause seniors to lose access to their doctors," says Senate Finance Committee Chairman Max Baucus, D-Mont. "And every year Congress has had to spend more time and money to pass temporary fixes."
Indeed, the so-called Medicare doc fix, unlike the Affordable Care Act, is one of the few health issues that has enjoyed near unanimous bipartisan agreement. Neither Republicans nor Democrats have had the stomach to allow cuts in pay that, in recent years, would have topped 20 percent. Yet no matter which party has been in charge, the annual — and sometimes monthly — exercise to cancel the cuts has been painful.
"Since 2003, we've had to patch the SGR 15 times, at a total cost of $150 billion," said Sen. Orrin Hatch, R-Utah, the Finance Committee's ranking Republican.
The current patch cancels a scheduled 24 percent cut in doctor pay — at a cost of around $7 billion. And that's just for three months. But that's because this Congress that's now famous for doing almost nothing is poised to do something significant. It appears ready to repeal the flawed payment formula and replace it with a whole new system — one that pays doctors according to the quality of results they produce rather than the quantity of services they provide.
"I'm optimistic; we're optimistic," said Ardis Hoven. She's the president of the American Medical Association, which has led the charge to fix the formula almost since its inception.
"I think the prospects of repealing the SGR and replacing it with an appropriate payment mechanism are very good," she says. "And members of Congress understand this, and understand the need to move ahead."
Indeed, all three committees in the House and Senate that oversee the Medicare program have now approved such legislation. The House Energy and Commerce Committee approved a bill last summer; and the House Ways and Means and Senate Finance Committees followed suit just last week. In the normally more partisan House of Representatives, the votes on the bills were approved unanimously.
Still, it's not yet a done deal. For one thing, while physician groups are united in their opposition to the current payment system, they don't all agree on the details of the bills that are emerging. The bill approved by the Senate Finance Committee, for example, has drawn the opposition of the American College of Surgeons.
One big problem is that the bill would freeze physician pay at its current level for the next decade.
"To really ... send the message to physicians that things are going to be frozen for 10 years doesn't seem like an appropriate policy issue," says David Hoyt, the group's executive director.
But even more troubling, Hoyt says, is that the bonuses some doctors could earn under the proposal for performing well would come at the expense of other doctors — even if those doctors perform well, too.
It might reduce a physician's incentive to share best practices with others, and to work toward improving care together, Hoyt says. "And we don't think that's a good policy at a time when we're trying to get more consistency in care."
Even if those issues can be worked out — and most people think they can be — there's another thorny issue involving how to pay the estimated $116 billion to $136 billion cost of eliminating the SGR. The difference depends on whether fees are frozen over the next decade or not. Most of the previous doc fee fixes — including the one in the budget bill passed Wednesday — have been paid for by cutting payments to other Medicare providers, usually hospitals.
But Chip Kahn of the Federation of American Hospitals says that while hospitals strongly support a permanent repeal of the SGR, his industry is tired of being the piggy bank.
"If that has to come from other providers, where we see robbing Peter to pay Paul, they're just creating one problem trying to solve another," Kahn says.
Kahn says the glitch in the way doctors are paid for treating Medicare patients is not a health care problem, but a fiscal problem created by Congress when it devised the SGR and then refused to deal with the ongoing problem across a decade. And if Congress insists on offsetting the cost, they should do it without penalizing either health care providers or Medicare patients, he said.
"It's Congress' fault, so why should providers who are trying to serve beneficiaries pay a price for it?" he asks.
Lawmakers will now have three months to figure that out — or else they'll have to pass a 16th fix for doc fees.
Over the years, jazz musicians have produced a trove of recordings of carols and holiday music. Nick Spitzer, host of public radio's American Routes, called up NPR's David Greene to weigh in on some swinging, soulful and snarky jazz holiday favorites, some of which were created by the genre's most beloved and influential artists.
"Dear Father Christmas," the letter reads, "my name is Larissa. I know that you are very busy and that you live a long way away in the North Pole, but I'd like to ask you for a gift because my mother doesn't have enough money to buy what I want."
There are piles of similar letters — many decorated with stickers, drawings and hand prints — lying on makeshift tables in the main hall of the post office in downtown Sao Paulo.
Another letter, this one from a 10-year-old boy, reads: "My mother died when I was a young baby, I live with my brother and my father. But this Christmas he can't work because he's in the hospital."
A group of women sift through them, looking to choose one. Sonia Regina de Sa, a nurse's assistant, says she's been doing this every year for nine years.
"I really love it," she says.
The way it works, de Sa says, is that you come here, read the letters and look for something that really affects you. Then you buy the gift that the child asks for and bring it back to the post office, where staff wrap it up and deliver it to the child.
Most of kids ask for dolls, balls, bicycles — the usual array of toys. But some letters, she says, ask for heartbreaking things.
This year, de Sa says she chose an 8-year-old boy who was asking for food. He didn't want toys; he wanted food for his mother.
"It's something that just shocks you, and it makes me sad, too," she says.
Other letters have asked for help for crack-addicted parents or jobs for unemployed relatives.
Elizabeth Aragao says she always chooses gifts for small children.
"I cry reading the letters," she says. "We try and help a little. If everyone helped a little, the world would be a better place."
And that is the idea behind the program, which is sponsored by Brazil's post office and has been going on for more than 20 years.
Standing In For Santa
Wilson Abadio de Oliveira, the director of the post office for metropolitan Sao Paulo, says the campaign began through the initiative of postal service employees.
"They were receiving letters from children addressed to Santa Claus in the North Pole, and the workers started opening them and reading them," de Oliveira says. "They started buying some of the gifts the children asked for, and we thought what a great idea. It then was adopted officially by the post office."
De Oliveira says 1 million children across Brazil now write letters every year, and about half of them are adopted by someone. The post office ensures that the letters come only from children under 10 years old with verified addresses. And the letters must be handwritten; he says it's a way of also making sure kids improve their writing skills.
Every year the Father Christmas Project is a big operation nationwide. Tucked into the bowels of the Sao Paulo city post office, employees sift through letters, making sure all the information is there: name, age of the child and gift of choice. The letter then gets registered in the computer and a number is attached to it. At the end of the process the letters go down to the main floor to be "adopted."
"My name is Papa Noel," says the man dressed as Santa sitting on the main floor greeting children. His presence is part of the project. He acknowledges he is a post office employee, but refuses to go by anything other than Father Christmas to a visiting reporter.
While most of the gifts bought through the program are delivered by regular letter carriers, sometimes Papa Noel, in full regalia, makes a special visit to someone's door.
"The whole point of this is to keep alive the spirit of Christmas inside our children," he says. "But this isn't only for children. It's a way for people to help each other. That is what this season is really about."
We go with one of the deliveries to a favela, or shantytown, not far from the post office. We stop in front of a shack; it's made of cardboard siding and tin, crowded among other makeshift dwellings.
Maria Marisa Laureano answers the door. Her daughter has asked for three beds for her and her two sisters. When we go into the one-room home we see only one large bed where Laureano says she and her children all sleep. A pot of food is cooking in the corner and clothes are strewn on the floor. It's dark and crowded and the walls are so thin you can hear the neighbors talking.
The new beds barely fit in the house. Laureano says they are hoping to move.
"It's been three months since I moved here," she says, "but there are a lot of termites. Some nights we can't sleep. They fly and walk on the bed, on us, they bite. Life has been very hard."
She begins to cry.
"We wrote a letter but we didn't know if we would get anything. I don't even have words," she says. "I thank Father Christmas a lot."
North American fur is booming.
Not in North America, necessarily, but "you can't keep fur in stock in Russia," says furrier Greg Tinder. "The higher the price tag you put on it, the faster it sells."
Tinder, who left Saks Fifth Avenue to start his own label, says the East has always been a furrier's dream; think big plushy Soviet-era hats. But now, with Russia's economy on the rise, there's some new money on the block, and designers know that.
Russian designer Igor Gulyaev's recent Moscow exhibit was laden with fur, from hats and cuffs to shaggy handbags and fuzzy lapels. There were even whole dresses made of fur sheared short, like velvet.
And it's not just Russia: British Vogue estimates that 70 percent of fall collections for 2013 included at least some real fur.
Alan Herskovici with the Fur Council of Canada says upwardly mobile consumers in China and Korea, as well as Russia, are driving the market.
"The fur sales that are the strongest now are not necessarily your grandmother's old mink coat," says Herskovic. "Rather, it's the bunny cuffs and coyote fur ruffs that helped grow the retail fur industry to [$15.5 billion] last year — 45 percent more than sales 10 years ago."
And 10 years ago, it wasn't very lucrative at the other end of the business either, especially for trappers.
Maine trapper John Sewell says a coyote fur that would net $7 at auction a decade ago would sell for $50 today.
"That's what they want for the trim trade," he says.
What used to be a $2 muskrat is now a $12 muskrat. The marten that was worth $40 could bring almost $200 at an auction today.
With money like that, says Sewell, interest in trapping has gone up about five fold in the last few years.
Sewell traps on what he calls "a very small scale," and expects he'll make about $9,000 or $10,000 at the North American Fur Auction in February. Bigger trappers, he says will walk away with tens of thousands.
But the trappers' good fortune is not welcomed news for animal welfare advocates who've fought to keep fur off the catwalks.
Pierre Grzybowski from the Humane Society of the United States says trapped animals can be skinned alive, drowned in water traps and electrocuted. He doubts whether the new Eastern demand for fur will spill over into the United States, where he says many stores won't sell fur.
"More and more retailers realize that it's not worth the risk to their bottom line and the risks of angering their consumers," he says, noting that American consumers are buying a third less fur than they did a decade ago.
But for rural trappers like Sewell who have come to rely on the income they get from winter traplines, it doesn't really matter who's driving the market. They're just glad that the days of the $2 muskrat seem to be over.
Vince Gilligan created the groundbreaking TV show Breaking Bad, which recently finished its final season. The series was about a high-school chemistry teacher dying of cancer and his descent into drug-dealing and crime.
It earned critical raves and rabid fans — and made us wonder about the pop-culture influences on the man behind it. So, for the occasional Morning Edition series Watch This, NPR's Steve Inskeep talked to Gilligan about what he's watching on television when he's not too busy making it.
"Black Mirror is a show created by a writer named Charlie Brooker who I was not at all familiar with until I enjoyed being in the U.K. a few months back doing a press tour for Breaking Bad," Gilligan says. "And he has created this show that is an anthology series, inspired by The Twilight Zone, and it's very dark and very dystopic, and it is fascinating."
The show is so dark, in fact, that one episode's plot is not easily discussed on family-friendly radio. But Gilligan says he likes this kind of story when it's well done.
"The idea of it is so outrageous that you hear it, and you say to yourself, 'That sounds like a terrible TV show,' " he says. "Which, by the way, is what people said about Breaking Bad when it first went on the air. I can't tell you how many people said, 'Oh, a show about a guy who's dying of cancer so he decides to cook crystal meth? Ugh, that sounds terrible.' So I feel a kinship with Charlie in that respect."
Garth Marenghi's Darkplace
Gilligan's second pick is another British show, Garth Marenghi's Darkplace, which airs in the U.S. on Cartoon Network's Adult Swim.
"[In the show] there is a horror writer, sort of a British Dean Koontz or perhaps a Stephen King type — except very much a blowhard and very much an inept writer, not like those gentlemen," he says. "And the premise of the show is that years ago, in the early 1980s, he paid for his own television series, called Garth Marenghi's Darkplace, and he wrote it and starred in it. And it's just so ludicrous — the acting is so terrible and over the top, the editing is awful, the special effects are just laughable, and the whole thing is ridiculously bad on purpose. It is a laugh riot. I love that show."
These so-called "old episodes" are interspersed with interviews with the fictional horror writer and his co-star.
"It takes a great deal of talent to make something that bad, and that is what's so brilliant about it," Gilligan says.
From well back into television's archives, Gilligan's last choice is a '70s show produced by Jack Webb. It focuses on two Los Angeles paramedics played by Randolph Mantooth and Kevin Tighe.
"There's something about all the Jack Webb-produced shows — he's like a hand-puppet man operated by off-screen operators," he says. "There's a very stiff, formalized delivery to the speech patterns, and it's not like reality. And yet it fascinates me."
Beyond merely liking the show, Gilligan recently discovered a coincidental personal connection to it.
"I was watching an episode, and I jumped out of my chair at home because I'm watching the Squad 51, the ambulance ... in Emergency! driving along this very familiar stretch in Burbank," he says. "And I realize, they are pulling up to the scene to assist a guy with chest pains on the very spot that our writers room from Breaking Bad was located!"
Gilligan quickly emailed the clip to all of his writers.
"That was one of the biggest moments of 2013 for me," he says.