Trump’s HHS nom­i­nees tee up Oba­macare re­peal ef­fort

Modern Healthcare - - NEWS - —Re­port­ing by Aurora Aguilar, Vir­gil Dick­son and El­iz­a­beth Whit­man. The story was writ­ten by Mer­rill Goozner.

On the cam­paign trail, can­di­date Don­ald Trump pledged to re­peal and re­place Oba­macare and shift Med­i­caid to state block grants. But he also vowed not to cut Medi­care— the bedrock se­nior cit­i­zen health­care pro­gram that Democrats and con­ser­va­tives in Congress have sparred over for years.

Last week, the pres­i­dent-elect moved ag­gres­sively to fol­low through on those pledges on Oba­macare and Med­i­caid by choos­ing Ge­or­gia Rep. Tom Price, an or­tho­pe­dic sur­geon and ac­tive op­po­nent of the Af­ford­able Care Act, to run HHS and its $1 tril­lion bud­get. He also chose health­care con­sul­tant Seema Verma, who en­gi­neered the “per­sonal re­spon­si­bil­ity” ap­proach in In­di­ana’s Med­i­caid expansion plan, to run the CMS.

With Demo­cratic sen­a­tors—led by new Se­nate Mi­nor­ity Leader Sen. Chuck Schumer of New York—pledg­ing an all-out fight against any at­tempt to force fu­ture se­niors to ac­cept pre­mium sup­port or vouch­ers to pur­chase their Medi­care plans, Repub­li­can lead­ers on Capi­tol Hill are al­ready mov­ing to take the is­sue off the ta­ble. Sen. La­mar Alexan­der (R-Tenn.), chair­man of the up­per cham­ber’s Health, Ed­u­ca­tion, Labor and Pen­sions Com­mit­tee, told the news web­site TPM that tak­ing on Medi­care in the first year of the 115th Congress that gets un­der­way in Jan­uary “would fall in the cat­e­gory of bit­ing off more than we can chew.”

In­stead, Price and Verma (See story, p. 9) will get max­i­mum sup­port from the Repub­li­can-con­trolled Congress and the White House to move quickly to re­peal the ACA and give states more con­trol over Med­i­caid. “To­gether, Chair­man Price and Seema Verma are the dream team that will trans­form our health­care sys­tem for the ben­e­fit of all Amer­i­cans,” Trump said in a state­ment.

Re­peal­ing Oba­macare is likely to oc­cur within the first 100 days of the new ad­min­is­tra­tion. But while the ex­act shape of the re­peal leg­is­la­tion re­mains an open ques­tion, im­ple­men­ta­tion will prob­a­bly be post­poned for two or three years to give the Repub­li­can ma­jor­ity time to craft a re­place­ment.

How­ever, that will leave the new ad­min­is­tra­tion and the Repub­li­can-led Congress with the prob­lem of deal­ing with the flaws in the cur­rent ex­change mar­ket­places—at least if they expect in­sur­ers to con­tinue sell­ing plans un­til a re­place­ment plan is crafted.

Price, a strong ad­vo­cate for pri­vate physi­cians and their spe­cialty so­ci­eties, is well-po­si­tioned to re­cruit and de­ploy the small army of ex­perts at HHS needed to help Congress craft re­place­ment leg­is­la­tion. He has in­ti­mate knowl­edge of the nuts and bolts of health­care leg­is­la­tion since he chaired the House Bud­get Com­mit­tee and served on the Health Sub­com­mit­tee of the House Ways and Means Com­mit­tee.

In 2014, he au­thored the Em­pow­er­ing Pa­tients First Act, which would give Amer­i­cans with­out em­ployer­based health in­sur­ance age-ad­justed tax cred­its to buy pri­vate in­sur­ance plans. The bill also set up ex­panded health sav­ings ac­counts and high­risk pools in the states and would al­low peo­ple to opt out of Medi­care, Med­i­caid or Veter­ans Af­fairs ben­e­fits and in­stead give them a tax credit to buy in­di­vid­ual plans.

While the leg­is­la­tion re­ceived wide­spread sup­port from Repub­li­cans, it was roundly crit­i­cized by Democrats, who say it would turn the health in­sur­ance sys­tem into one based largely on cat­a­strophic plans. How­ever, such an ap­proach could draw a few Demo­cratic votes from con­ser­va­tive states—un­like the ACA, which passed with­out a single Repub­li­can vote. That could give Repub­li­cans bi­par­ti­san cover and in­su­late them from charges they rammed the ap­proach through Congress.

Health­care ex­perts on the center and left of the po­lit­i­cal spec­trum say such a plan, un­less gen­er­ously funded, would fail to keep pace with in­fla­tion and ul­ti­mately ratchet up out-of-pocket costs through higher co-pays and de­ductibles. High-risk pools, which were used widely be­fore pas­sage of the ACA and gen­er­ally con­sid­ered a fail­ure, would also re­quire mas­sive sub­si­dies to work. The leg­is­la­tion was never scored by the Con­gres­sional Bud­get Of­fice.

Ge­or­gia Rep. Tom Price is well-po­si­tioned to re­cruit and de­ploy the small army of ex­perts at HHS needed to help Congress craft re­place­ment leg­is­la­tion.

Democrats lack the power to block Price’s nom­i­na­tion be­cause of changes to the fil­i­buster rules they or­ches­trated when con­trol­ling the Se­nate. But they will be able to turn his con­fir­ma­tion hear­ing into a fo­rum for high­light­ing the suc­cesses of Oba­macare, the pos­si­ble roll­backs in women’s re­pro­duc­tive health rights and to con­tinue rais­ing pos­si­ble

changes in Medi­care.

“Con­gress­man Price has proven to be far out of the main­stream of what Amer­i­cans want when it comes to Medi­care, the Af­ford­able Care Act and Planned Par­ent­hood,” Schumer said. “Thanks to those three pro­grams, mil­lions of Amer­i­can se­niors, fam­i­lies, peo­ple with dis­abil­i­ties and women have ac­cess to qual­ity, af­ford­able health­care. Nom­i­nat­ing Con­gress­man Price to be the HHS sec­re­tary is akin to ask­ing the fox to guard the hen house.”

Health­care in­ter­ests, mean­while, quickly voiced sup­port for Price and Verma. The Amer­i­can Hospi­tal As­so­ci­a­tion, Amer­i­can Med­i­cal As­so­ci­a­tion, Amer­ica’s Es­sen­tial Hos­pi­tals, As­so­ci­a­tion of Aca­demic Med­i­cal Col­leges and Amer­ica’s Health In­sur­ance Plans were among the many groups is­su­ing state­ments promis­ing to work with the new ad­min­is­tra­tion.

In part that’s be­cause Price has shown sup­port for the move­ment to­ward value-based re­im­burse­ment, which health­care in­ter­ests gen­er­ally sup­port. He voted in fa­vor of the Medi­care Ac­cess and CHIP Reau­tho­riza­tion Act, which puts physi­cians on that path.

But he re­cently has crit­i­cized the re­port­ing re­quire­ments in MACRA as bur­den­some. He’s also op­posed to manda­tory demon­stra­tion projects from the Center for Medi­care & Med­i­caid In­no­va­tion, which de­vel­ops and pi­lots value-based pay­ment mod­els.

The In­no­va­tion Center’s first manda­tory bun­dled-pay­ment pro­gram, which went into ef­fect in April, in­volved or­tho­pe­dic surg­eries—his spe­cialty. His Septem­ber let­ter call­ing for the CMS to “cease all cur­rent and fu­ture planned manda­tory ini­tia­tives” was co-signed by 178 other mem­bers of Congress.

The CMS has also pro­posed re­duc­ing physi­cian markups on Medi­care Part B drugs and adding car­diac op­er­a­tions to the manda­tory bun­dled-pay­ment pro­gram. Both will now likely be on Price’s chop­ping block.

But some are hope­ful that Price, a fis­cal con­ser­va­tive who rec­og­nizes the need to keep Medi­care costs un­der con­trol, could work to ex­pand those pro­grams vol­un­tar­ily or be­come an ad­vo­cate for a re­vamped MACRA im­ple­men­ta­tion scheme. “The Repub­li­cans want MACRA to suc­ceed. It’s their baby,” said Blair Childs, se­nior vice pres­i­dent at Premier, a com­pany that of­fers per­for­mance-im­prove­ment ser­vices for hos­pi­tals and health sys­tems.

What de­fines suc­cess could shift dra- mat­i­cally un­der Price. His Oba­macare re­place­ment bill con­tained sec­tions that would give physi­cian spe­cialty so­ci­eties a pow­er­ful say in what qual­ity and out­comes in­di­ca­tors are used in value-based re­im­burse­ment.

That trou­bles some con­flict-ofin­ter­est ex­perts. “Th­ese physi­cian groups are ad­vo­cacy or­ga­ni­za­tions that ex­ist to serve the in­ter­ests of their mem­bers, which are physi­cians, and those in­ter­ests are of­ten fi­nan­cial in na­ture,” said Eric Camp­bell, a so­ci­ol­o­gist and pro­fes­sor of medicine at Har­vard Med­i­cal School.

Price joined Congress in 2004 after four terms in the Ge­or­gia state Se­nate. He worked in pri­vate prac­tice for nearly 20 years and has taught res­i­dents at Emory School of Medicine and Grady Me­mo­rial Hospi­tal in At­lanta.

Health pro­fes­sion­als have been a ma­jor source of dona­tions to Price through­out his po­lit­i­cal ca­reer. In­di­vid­ual and po­lit­i­cal ac­tion com­mit­tees in the health­care sec­tor have do­nated more than $4.8 mil­lion to him. The Amer­i­can As­so­ci­a­tion of Or­thopaedic Sur­geons is a top donor group.

AP PHOTO

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