Republicans and the incoming Trump administration seem to be coalescing around a strategy of "repeal and delay."

This article first appeared December 14, 2016 on Kaiser Health News.

By Julie Rovner

Republicans in Congress are so eager to repeal the federal health law that some have vowed to get a bill to President-elect Donald Trump's desk on the day he takes the oath of office.

"We will move right after the first of the year on an Obamacare repeal resolution," Senate Majority Leader Mitch McConnell, R-Ky., told reporters at a news conference Monday.

But could lawmakers introduce, pass and get a repeal measure to the new president in the 17 days between Jan. 3, when they convene, and Inauguration Day, Jan. 20?

Not likely, say budget experts.

"No way. I just don't think it's possible," said G. William Hoagland, senior vice president at the Bipartisan Policy Center, a Washington-based think tank, and a 20-year Republican staff veteran of the Senate Budget Committee.

Others think it could be done, but probably won't be. "Mechanically they can get it done," said Ed Lorenzen, senior adviser to the nonpartisan Committee for a Responsible Federal Budget. "The bigger question is can they decide what should be in the package."

Republicans and the incoming Trump administration have been careful not to talk about exactly what they plan to do to the Affordable Care Act beyond repealing virtually all of its coverage expansions and the taxes that help fund them. But they seem to be coalescing around a strategy of "repeal and delay," in which they would pass a bill to kill many of the major provisions of law by a certain date, then set to work on crafting and passing a replacement before that date arrives.

It would be quicker for Congress to simply repeal the health law outright. But Republicans can't do that, because they would need 60 votes in the Senate to fend off Democrats' delaying tactics, and they will only have 52 GOP members. So instead they will be limited to using a special budget strategy that will let them pass their bill with 51 votes.

That so-called "budget reconciliation" measure does not let lawmakers repeal the entire law — only the parts that directly impact federal spending. That has been widely discussed. There has been less focus on how long the process takes.

No one in Congress can simply introduce a budget reconciliation bill. The word "reconciliation" refers to the process by which congressional committees that control permanent spending programs such as Medicare and Medicaid, as well as tax policy, take action to "reconcile" that spending with the terms of the annual budget resolution.

That means the first action must be to pass a budget resolution, which Congress failed to do last year. That is the "resolution" McConnell was referring to.

The budget resolution, which is essentially a planning document for spending and taxes for the coming fiscal year, does not go to the president for a signature. But, like a regular bill, it does have to be passed by both the House and Senate in the same form. And while the budget resolution also may not be filibustered in the Senate, lawmakers have up to 50 hours to debate it, and unlimited time to vote on proposed amendments, which in practice can take up to another full day.

Once that measure is agreed to by the full House and Senate, the action moves back to congressional committees. The budget resolution often includes "reconciliation instructions" to committees. Those instructions order proposed legislative changes to the programs the committees oversee to meet the terms of the budget. That triggers the reconciliation bill that goes to the president.

In the normal course of events, those changes take from several weeks to several months to accomplish. Legislative changes need to be written, voted on by the committee and reported back to the House or Senate budget committees, which then forward them to the House or Senate floor for votes. Again, Senate debate is limited to 20 hours with unlimited additional voting on amendments. House and Senate negotiators then hammer out a compromise, pass it again in the full House and Senate and then send it to the president.

The last budget reconciliation bill, considered a dry-run by Republicans for the coming year, was launched by the budget resolution at the end of April 2015. The resulting reconciliation bill was sent to President Barack Obama (who vetoed it) on Jan. 26, 2016.

Clearly, if Republicans were to simply recycle their 2015 bill, the process could be dramatically shortened. That bill called for repeal of funding for the Medicaid expansion, as well as for jettisoning premium and other subsidies that help individuals afford private coverage, along with the taxes to pay for those benefits, as of Dec. 31, 2017.

Budget expert Stan Collender, executive vice president of the communications firm Qorvis MSLGROUP, a Washington communications and consulting firm, said predictions of getting the reconciliation bill to the president by Inauguration Day are ambitious. "It would be unprecedented to do it that quickly," said Collender, who has worked for the both the House and Senate budget committees. "But just because it hasn't worked that expeditiously before, doesn't mean they can't do it."

While Jan. 20 might not be feasible, "I think they could do it by the end of January," said Lorenzen. He noted that while some Republicans in the Senate have been expressing doubts about repealing the law without having a replacement in hand and others in the House object to leaving current policies in place for as long as three years, "no one want to be the skunk that stops repeal."

But others think that even with a model bill in hand, the process will be harder — and take longer — than many Republicans are saying.

With last year's bill, "that repeal legislation, they knew they weren't shooting with real bullets," said Hoagland of the Bipartisan Policy Center. "They knew it was going to be vetoed."

Already health analysts and health provider groups are warning that repealing major pieces of the law without immediately replacing them could cause a virtual collapse of the individual insurance market that currently covers around 20 million people.

That could — and should — slow things down, said Chris Jennings, a health consultant who worked in both the Bill Clinton and Obama White Houses.

"Few people have ever been wrong projecting that Congress takes a little bit longer" than some predictions, he said. "I think this health debate is of such consequence that will likely be the case for this as well."

Tom Price has tried to block efforts by Medicare to scale back payments for expensive chemotherapy and to limit large payments for hip and knee replacements. There isn't consensus in the medical community about his appointment.

This article first appeared December 12, 2016 on Kaiser Health News.

By Christina Jewett and Marisa Taylor

In picking Tom Price to be secretary of Health and Human Services, Donald Trump has chosen an orthopedic surgeon who in his congressional career, has loyally promoted the interests of the medical profession —its freedom and importantly, its financial interests.

A conservative representing Georgia's 6th District, Price sponsored a 2015 bill that would restrict efforts to reduce doctor payments for medical services. He cosponsored another 2011 bill that would have limited reports used by hospitals and regulators to perform background checks used to screen doctors before hiring them.

A fierce critic of Obamacare, Price has tried to block efforts by Medicare to scale back payments for expensive chemotherapy and to limit large payments for hip and knee replacements. He also has taken the lead in trying to impose federal controls on medical malpractice suits.

Most of Price's proposals stalled in Congress, but he now stands a better chance of implementing his ideas with a powerful cabinet position and a Republican-controlled White House and Congress.

"Instead of having a secretary for the people, you have a secretary for the medical profession," said Max Mehlman, a law professor at Case Western University, who specializes in medical malpractice and reviewed Price's proposal.

The American Medical Association, the doctors' professional group whose members are among Price's top campaign supporters, says he brings a unique perspective to the job of HHS secretary, a role traditionally filled by foundation executives, career politicians, social scientists, lawyers and public health experts.

The most recent physician to hold the position was Dr. Louis Sullivan who served under George H.W. Bush and was the founding president of Morehouse School of Medicine, as well as an expert on health care in minority populations.

"As a lawmaker, Dr. Price has had the valuable ability to see how legislation and regulation would affect patients and their physicians," Dr. Patrice Harris, chair of the AMA board of trustees, said in a statement to Kaiser Health News.

Price, who founded a large orthopedic practice in suburban Atlanta, did not respond to interview requests. He came to Congress with strong backing from medical interests, including the AMA and trade groups representing orthopedic doctors, dentists and anesthesiologists, according to campaign finance data compiled by the nonprofit, nonpartisan Center for Responsive Politics.

But there isn't consensus in the medical community about his appointment. Within days, more than 4,800 physicians from a wide array of backgrounds signed a petition protesting his appointment.

"Dr. Price's proposed policies threaten to harm our most vulnerable patients and limit their access to health care," wrote the group, citing his stance on Medicaid. "Dr. Price purports to care about efficiency, while opposing innovations by the Centers for Medicare & Medicaid to improve value and eliminate waste in health care."

Price describes himself as the "go-to Republican on quality health care policy," according to his website. He mobilized GOP opposition to the Affordable Care Act and proposed alternate plans, the most recent in May 2015, called the Empowering Patients First Act.

In a recent interview with Radio America, Price said increases in insurance premiums and deductibles show the failures of Obamacare.

"We opposed the plan because it doesn't work for people, it doesn't work for patients," Price said.

Price's alternative includes health care saving accounts to help individuals pay for health insurance, a concept now embraced by the Trump team.

But the bill also includes fine print calling for "lawsuit abuse reforms" that would allow the HHS secretary to give states money to create tribunals to review malpractice claims. The process would make it more difficult for patients to prove medical error, setting the standard at "gross negligence."

Chip Wagar, a New Orleans malpractice lawyer who advises a patient advocacy group, said Price's proposal, if implemented, would mean that "checks and balances that have been in place, which are already friendly to the medical profession, would be even further tilted away from patient and victims' rights."

The AMA did not support Price's 2015 bill, although it has supported specialized health courts.

In 2011, Price cosponsored a bill that would limit reports to the National Practitioner Data Bank, a confidential repository of information, such as malpractice judgments and hospital discipline, about doctors and other health professionals. The information is used by health licensing boards and hospitals making hiring decisions.

The bill, which died in committee with 15 GOP co-sponsors, would have allowed physicians to contest reports to the data bank by hospitals that deny doctors' access to their facilities due to questionable performance.

Dr. Michael Carome, director of Public Citizen's Health Research Group, a consumer advocacy group, said the proposal would have made it more difficult for hospitals to adequately oversee physicians.

"Dr. Price is a physician who is just obviously responding to pressure from colleagues in the medical field who'd like to be exempt from being held accountable," said Carome, who also reviewed Price's malpractice proposal.

Price has also criticized some Obama administration efforts to cut health costs, citing too much government interference. His Obamacare replacement bill would bar states from limiting doctors' charges for medical services.

Price opposed a Medicare proposal intended to rein in spending for medications doctors administer to patients, such as intravenous chemotherapy drugs. Medicare officials have said spending on such drugs went from $3 billion in 2007 to $8 billion in 2015.

The change, which has not been approved, would have eliminated incentives for doctors and hospitals that earn higher payments by prescribing more expensive drugs.

Price cosponsored a bill in March to block final implementation of the proposal, saying it would harm vulnerable patients by limiting their access to care.

Price had the first signature on a letter backed by more than 200 Congress members, saying the proposal would force some doctors — particularly those in small practices — to lose money. "The impact on patients will be sweeping and affect seniors across the country," the letter says.

The nonpartisan Congressional Budget Office estimated that Price's proposal to ax drug pricing limits would cost taxpayers $395 million from 2016 to 2026.

Price sought to delay implementation of another plan to pay doctors a flat rate for joint replacement surgery, eliminating situations where Medicare covers the added costs of patient infections or prolonged physical therapy.

Tom Miller, a resident fellow with the American Enterprise Institute, a conservative think tank, said Price's opposition to cost-cutting proposals arises from a free market philosophy that less government intervention is better.

"Many of those objections are to how the cost cutting are being done — a brute-force, top-down bureaucratic approach," he said. "His opposition is to government control of more aspects of health care — that's the driving force. It's a shared point of view if you're a Republican conservative doctor."

Even some critics of Price's proposals are hopeful his experience will prompt him to tackle cost-cutting and improve patient-care quality as HHS secretary.

"He has been a loyal Republican and a champion of conservative causes that I don't support," said William Sage, a University of Texas at Austin law professor who has studied medical malpractice and health care costs. "Far more important is that as someone with deep inside knowledge of health care he understands how overpriced health care delivery is and how disorganized and often ineffective it is."

Prompted by a state law that took effect this year, a coalition of emergency and social service providers is working to create an electronic registry that will be accessible to first responders and medical providers.

This article first appeared December 7, 2016 on Kaiser Health News.

By Anna Gorman

CONCORD, Calif. — Mary De Freze, who has heart problems, chronic lung disease and a history of falling, knows she may not have too many years left. And she's clear about what she wants — and doesn't want — at the end of her life.

"I don't want to be in a lot of pain and I don't want to be kept alive by machines," said De Freze, 81.

After a recent fall landed De Freze in Stonebrook Healthcare Center with cracked ribs and a bruised spleen, the staff there helped her put those wishes on paper.

The document they used, Physician Orders for Life-Sustaining Treatment, or POLST, gives patients a choice of how much medical care they want in an emergency.

Prompted by a state law that took effect this year, a coalition of emergency and social service providers is working to create an electronic registry for POLST forms so they will be available to first responders and medical providers when they are needed. The group is starting with a three-year pilot project in San Diego and Contra Costa counties that could serve as a model for a single, statewide registry. Paper-based POLST forms are used across the nation, but electronic registries exist only in a few states, including Oregon, New York and West Virginia.

Many adults have advance directives, which are legal documents that designate a surrogate decision-maker and list patients' health care preferences. POLST forms go further, creating a set of medical orders that are signed by the provider and the patient or a legally recognized decision-maker. Unlike advance directives, they are specifically designed for people who are already seriously ill or near the end of life.

Research shows that POLST forms help ensure patients' end-of-life wishes are followed. But that only happens if doctors and other emergency providers can get them quickly. In California, the POLST form is a paper document and might not be at hand when patients need it. In many situations — a heart attack, a stroke or severe dementia — patients may not be able to communicate. And doctors may not be able to reach their families right away.

Without information on what patients want, there is an increased chance their wishes won't be followed.

"If you take the time to fill out a POLST form, you want your health care wishes to be known and respected," said Kate O'Malley, a senior program officer at the California Health Care Foundation, which is funding the pilot project in California. (California Healthline is an editorially independent service of the California Health Care Foundation.)

A POLST registry "would be a big plus for being able to give people the care they want and not give them the care they don't want," said Jeffrey Klingman, a neurologist at Kaiser Permanente in the East Bay.

"I don't want to do things to people they don't want done," he said. "On the other hand, I don't want to delay treatment while I wait to figure out what they want done."

Oregon was the first state to use POLST forms in 1991. California has been using them for nearly 20 years. Filling out the forms is voluntary, but once they are completed and signed, they must be followed, and providers have immunity from criminal prosecution or civil liability when they do so in good faith. The forms are printed on bright pink paper and include decisions such as whether a patient should be resuscitated, admitted to the intensive care unit or have a feeding tube inserted.

Tony Chicotel, a staff attorney at California Advocates for Nursing Home Reform in San Francisco, said patients should document their wishes in advance but that there are some downsides to doing so only with POLST forms. They are not nearly as thorough as advance directives and don't allow you to designate a decision-maker, he noted. "The most comprehensive health care planning you can do is to name an agent."

In addition, Chicotel said many nursing home residents are being urged to complete POLST forms even if they aren't seriously ill or at the end of life. He said if an electronic registry is created, it should also include advance health care directives.

California's electronic registry would be a secure, cloud-based portal for medical providers to submit and view POLST forms, regardless of whether the patient was at home, in the hospital or at a nursing home.

An electronic registry is a "no-brainer," said Judy Thomas, CEO of the Coalition for Compassionate Care of California, which coordinates the state's POLST program. But implementation will be much harder because it will require the cooperation of state agencies, doctors, emergency personnel, and private and public health systems. Success will also depend in part on hospitals' willingness to share records.

"We are not asking all health systems to share all information," said Allen Namath, co-founder of Vynca, the technology vendor for the project. "But the value in these forms is being able to share them."

Patients who go through the trouble of documenting their medical preferences shouldn't have to worry about getting the wrong care, he said. "It is not a cardiology problem. It is not a cancer problem. Helping improve our end-of-life care … applies to everybody."

San Diego County already has a health information exchange that allows hospitals and health systems to share some data. But Contra Costa County is further behind.

"It's going to be challenging," said Donald Waters, executive director of the Alameda-Contra Costa Medical Association, which is helping lead the pilot project.

But Waters said it's worth the effort to overcome the hurdles because having documents uploaded means paramedics and others will know in an instant if patients want to be resuscitated or just kept comfortable.

Situations arise every day in which being able to access POLST forms electronically could improve end-of-life care, said Tom Sugarman, an emergency physician at Sutter Delta Medical Center in Antioch, Calif.

"If you come [to the hospital] in full cardiac arrest … we only have one or two minutes to make a decision," said Sugarman, who educates doctors about POLST. "All physicians are going to err on the side of preserving life."

Sometimes, however, a patient may prefer comfort care, Sugarman said. A POLST form — if it is available — means families don't have to make decisions during an emergency, he said. "The worst time to have that conversation is during a crisis."

At Chaparral House, a nursing home in Berkeley, the POLST forms are in the residents' folders at the nursing station. The forms go with patients to the hospital, but sometimes there is still a disconnect. Administrator KJ Page recalls one resident getting a feeding tube when he didn't want one and another who almost underwent bypass surgery against his wishes.

Audrey de Jesus, 83, arrived at Chaparral House just a few months ago. She uses a wheelchair and an oxygen tank. Beside her bed sits a Bible and a book of Psalms.

De Jesus has seven children and said the form tells them exactly what she wants — comfort-focused treatment — so there aren't any questions in an emergency. "I want pain control and the least suffering for my family," she said.

Stonebrook Healthcare Center Social Services Director Shirley Jackson said filling out POLST forms is part of the admission process. "It's almost like a driver's license for the end of your life," she said. "It's important."

Having the form available electronically would make it much easier for everyone. "If, God forbid, you have to send somebody out in an emergency, especially if they are unresponsive, it's right there in the chart," she said.

De Freze, a former certified nursing assistant, said she plans to put her pink form on her refrigerator when she leaves Stonebrook. She knows she could have an emergency and may not be able to tell doctors or paramedics what she wants.

"You can't communicate if you are in excruciating pain," she said.

Among other things, the bill pushes federal agencies and health providers to use EHR systems and to collect data to enhance research and treatment.

This article first appeared December 2, 2016 on Kaiser Health News.

By Sydney Lupkin and Steven Findlay

A sprawling health bill expected to pass the Senate and become law before the end of the year is a grab bag for industries that spent plenty of money lobbying to make sure it happened that way.

Here are some of the winners and losers in the 21st Century Cures Act:

Winners

Pharmaceutical and Medical Device Companies. The bill will likely save drug and device companies billions of dollars bringing products to market by giving the Food and Drug Administration new authority and tools to demand fewer studies from those companies and speed up approvals.

The changes represent a massive lobbying effort by 58 pharmaceutical companies, 24 device companies and 26 "biotech products and research" companies, according to a Kaiser Health News analysis of lobbying data compiled by the Center for Responsive Politics. The groups reported more than $192 million in lobbying expenses on the Cures Act and other legislative priorities, the analysis shows.

Medical schools, hospitals and physicians. The bill provides $4.8 billion over 10 years in additional funding to National Institutes of Health, the federal government's main biomedical research organization. (The funds are not guaranteed, however, and will be subject to annual appropriations.)

The money could help researchers at universities and medical centers get hundreds of millions more dollars in research grants, most of it toward research on cancer, neurobiology and genetic medicine.

The bill attracted lobbying activity from more than 60 schools, 36 hospitals and several dozen groups representing physician organizations. They reported spending more than $120 million in disclosures that included Cures Act lobbying.

Mental health and substance abuse advocates. The bill provides $1 billion in state grants over two years to address opioid abuse and addiction. While most of that money goes to treatment facilities, some will fund research.

The bill also boosts funding for mental health research and treatment, with hundreds of millions of dollars authorized for dozens of existing and new programs.

Mental health, psychology and psychiatry groups spent $1.8 million on lobbying disclosures that included the Cures bill as an issue.

Patient groups. Specialty disease and patient advocacy groups supported the legislation and lobbied vigorously. Many of these groups get a portion of their funding from drug and device companies. The bill includes more patient input in the drug development and approval process, and the bill is a boost to the clout of such groups.

More than two dozen patient groups lobbied the bill, and reported spending $6.4 million in disclosures that named the bill as one of their issues.

Health information technology and software companies. The bill pushes federal agencies and health providers nationwide to use electronic health records systems and to collect data to enhance research and treatment. Although it doesn't specifically fund the effort, IT and data management companies could gain millions of dollars in new business.

More than a dozen computer, software and telecom companies reported Cures Act lobbying. The groups' total lobbying spending was $35 million on Cures as well as other legislation.

Losers

Preventive medicine. The bill cuts $3.5 billion — about 30 percent — from the Prevention and Public Health Fund established under Obamacare to promote prevention of Alzheimer's disease, hospital acquired infections, chronic illnesses and other ailments.

Consumer and patient safety groups. Groups like Public Citizen and the National Center for Health Research either fought the law outright or sought substantial changes. Although they won on some points, these groups still say Cures opens the door for unsafe drug and device approvals and doesn't address rising drug costs.

Hair growth patients. The bill says federal Medicaid will no longer help pay for drugs that help patients restore hair. The National Alopecia Areata Foundation spent $40,000 on lobbying disclosures this cycle that included Cures.

The FDA. The bill gives the FDA an additional $500 million through 2026 and more hiring power, but critics say it isn't enough to cover the additional workload under the bill. The agency also got something it opposed: renewal of a controversial voucher program that awards companies that approve drugs for rare pediatric diseases.