CHIP extension, more ACA reform among the possibilities
This article first appeared January 3, 2018 on Medpage Today.
By Joyce Frieden
WASHINGTON -- Capitol Hill is slowly coming back to life after the holiday recess -- the Senate is back this week and the House comes back next week -- and Congress has a full plate of healthcare items to deal with.
One big question is whether Republicans in the House and Senate will try again to repeal the entire Affordable Care Act (ACA), now that they have repealed the law's individual mandate as part of the newly passed tax reform bill.
"We don't have a clear picture there yet," Elizabeth Carpenter, senior vice president of Avalere, a consulting firm here, said in a phone interview. She noted that proposals to stabilize the ACA's health insurance markets "have less support now that the mandate has been repealed, and on the flip side, folks like Sen. [Lindsey] Graham (R-S.C.) are saying that now that the mandate has been repealed, Congress needs to take additional action."
Graham and Sen. Bill Cassidy, MD (R-La.), got pretty close to passing their bill to repeal and replace the ACA, "and they've been pretty clear they'd like to engage on that topic ... I suspect we'll get a better sense of that ... later this month," said Carpenter.
But Gail Wilensky, PhD, senior fellow at Project HOPE in Bethesda, Maryland, disagreed.
"There may be noise about repeal and replace ... but if it didn't happen [in the Senate] at 52 [Republicans] 48 [Democrats], it's hardly likely to happen at 51-49," she said, referring to the fact that the Senate is up by one Democrat now that Sen. Doug Jones (D-Ala.) has replaced Luther Strange, a Republican.
"It wasn't going to happen even if it stayed at 52-48 -- there was too much difference in the Senate to get something through that repeals the Medicaid expansion," Wilensky added.
Experts did agree, however, that Congress is likely to pass a more permanent extension of funding for the Children's Health Insurance Program (CHIP), whose funding expired at the end of September. As part of the tax reform bill, Congress passed an extension of CHIP funding designed to last for the first few months of 2018.
Michael Sparer, PhD, JD, chair of the department of health policy and management at Columbia University in New York, did admit to a little bit of hesitation: "I'm fairly confident CHIP funding will be extended, but my confidence is a bit shaken given the long delays and the ongoing partisan bickering over how to pay the bill," he said in an email.
CHIP funding "takes on special urgency with the announcement of Sen. [Orrin] Hatch's retirement," Kenneth Thorpe, PhD, chair of health policy and management at Emory University in Atlanta, said in an email. "As an original sponsor of the program, this would seem to be a key priority."
Getting the CHRONIC Care Act passed will also be on the agenda, he added. This bill, known as the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017, would increase access to telehealth for Medicare beneficiaries with chronic illnesses -- including those in Medicare Advantage plans -- as well as provide more incentives for enrollees to receive care through accountable care organizations. It also would extend the Independence at Home demonstration program to keep people in their homes rather than hospitals.
The CHRONIC Care Act "passed without opposition in the Senate but is taking a more fragmented direction in the House," said Thorpe. "There is lots of bipartisan Senate interest to get this passed."
Reforming the Medicare and Medicaid programs also has been mentioned by some Republican leaders. "There will be renewed efforts to cut Medicaid funding (via some sort of block grant) and also to cut Medicare spending," predicted Sparer. "My guess, however, is that both of those programs will survive these challenges; the political cost to cuts in these programs is increasingly high."
"Indeed," he continued, "as the Democrats develop their own healthcare agenda going into 2018 (and 2020), part of that agenda will be efforts to expand eligibility for both of those programs. I think it is also more likely than not that one (or more) states will enact a version of a Medicaid buy-in program."
Wilensky was more skeptical on the idea. "Don't hold your breath [on entitlement reform]," she said. "At some point we're going have to do it, but we don't have to do it in 2018 and we're not going to. Sometimes after the next presidential election, we will have to get serious because of the effects of the Baby Boomers, and especially because Medicare spending is going up again."
There is also a laundry list of other items, Robert Laszewski, president of Health Policy and Strategy Associates, a consulting firm in Alexandria, Virginia, said in an email. These include:
- Permanent extension for community healthcare centers, whose funding -- like CHIP's -- ran out at the end of September.
- Further extension of the health insurance tax and the medical device tax moratoria -- "they will reappear in 2018 if the Republicans don't keep their promise to extend the 2017 moratoria," he said.
- Further extension of the "Cadillac" tax moratorium slated to restart in 2020. "Employers want to know now if they should plan for it."
- The long list of Medicare extenders that have to be funded each year.
The big question will be whether Republicans and Democrats will be willing to work in a bipartisan fashion, Laszewski said.
"We are already hearing the White House is intent on seeing the Alexander-Murray and Collins-Nelson bills [to stabilize the ACA's health insurance markets] passed early in the new year," he said. "Conservative Republicans are dead set against these. And, it would take 60 votes to pass them in the Senate. I will suggest that these two bills jointly might well be one of the first tests for any willingness to put Democratic and Republican coalitions together to get things done."