House votes to repeal ObamaCare’s Medicare cost-cutting board

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The House on Thursday voted to repeal a controversial Medicare cost-cutting board that has drawn the ire of both parties.

Lawmakers voted 307-111 to abolish what is known as the Independent Payment Advisory Board (IPAB). The board is tasked with coming up with Medicare cuts if spending rises above a certain threshold but has been criticized as outsourcing the work of Congress.

It has also been the target of the false attacks from ObamaCare opponents that the board enables unelected bureaucrats to helm “death panels.”

The bill now moves to the Senate, but it’s not likely the upper chamber will act before the end of the year. Even then, Republicans may not get the 60 votes needed to pass it as a stand-alone bill.

Nobody has been appointed to the panel and budget experts have estimated they don’t expect IPAB to be triggered until 2021 or 2022. Democrats say Congress has the authority to overrule any recommendations the panel could make.

This was not the first time the House has tried to get rid of the panel; they’ve been trying since 2012, but it is the first attempt with a Republican in the White House. It’s also the first vote since congressional Republicans failed to abolish IPAB as part of a larger ObamaCare repeal earlier this year.

The White House on Wednesday signaled support for the bill, noting in a statement that IPAB repeal was part of President Trump’s budget request.

The bill has bipartisan co-sponsors, but Democrats said during the bill’s committee markup that they wished Republicans were focusing on other priorities.

Democrats are also angry that Republicans are not seeking to offset the repeal, which is estimated to cost $17 billion but are requiring offsets to fund the Children’s Health Insurance Program.

Still, 76 Democrats backed abolishing the board despite the objections of leadership.

The panel’s proponents say the board is necessary to address Medicare’s runaway spending and keep the program fiscally solvent for future enrollees.


MIPS Takes a Beating at MedPAC

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MedPAC has been set on defeating the Merit-based Incentive Payment System for a long time; but whether the program should be simply “repealed” or “repealed and replaced” wasn’t clear at Thursday’s meeting.

Health policy experts sometimes battle for consensus over payment issues, but when it comes to the new way of paying most doctors under Medicare, one group reached near-unanimous agreement: Scrap it.

The Merit-based Incentive Payment System (MIPS) should be spiked, virtually all members of the Medicare Payment Advisory Commission (MedPAC) said during a meeting on Thursday morning.

MedPAC, whose members include physicians, healthcare executives, and other policy experts charged with advising the Department of Health and Human Services on Medicare policy issues, has been set on defeating MIPS for a long time; but whether the program should be simply “repealed” or “repealed and replaced” wasn’t clear at Thursday’s meeting.

At the start of the meeting, MedPAC’s analysts addressed the challenges with the MIPS program and proposed a potential alternative.

The Problem with MIPS

The MIPS program is one of two payment vehicles created as a result of the the Medicare Access and CHIP Reauthorization Act (MACRA) — which replaced the almost universally despised Sustainable Growth Rate (SGR) formula. The other payment pathway consists of an array of advanced Alternative Payment Models (APMs), which weren’t discussed in any detail at the meeting.

The main problem with the MIPS program, as MedPAC’s analysts see it, is that MIPS won’t achieve the policy goals that it’s designed to achieve.

The flexibility of the program — the various options for how physicians can report measures and the broad exemptions for certain types of clinicians — has made it overly complex. There are also statistical challenges that stem from trying to develop individual-level performance scores, due to the relatively small case sizes for some providers.

“Everyone will seem to have high performance when in fact many of the measures are topped out or appear to be topped out … and that will limit Medicare’s ability to detect meaningful differences in clinician performance,” said David Glass, a principal policy analyst for MedPAC.

In the end, Medicare gives clinicians a score based on their performance and either raises or reduces their Medicare payment based on that score, but for all the reasons Glass mentioned, he believes it is “extremely unlikely that physicians will understand their score or what they need to do to improve it.”

“Our most basic concern is that the measures in MIPS have not been proven to be associated with high-value care,” he said.

Alternative Proposed

Glass and MedPAC senior analyst Kate Bloniarz suggested an alternative policy approach that leverages population-based measures.

The Voluntary Value Program, as they’ve dubbed the alternative, would get rid of the MIPS program and all three types of reporting requirements — Advancing Care Information (ACI), Clinical Practice Improvement Activities (CPIA), and quality measures — and scrap CMS support for Electronic Health Records reporting.

In the new model, all clinicians would see a portion of their fee schedule dollars withheld, which would be lumped into a pool — for example 2%, though analysts stressed the percent amount had not been decided.

Clinicians would then have three options:

  • Choose to be measured with a “sufficiently large entity” of clinicians and be eligible for value payments
  • Choose to participate in an advanced APM model
  • Lose the withheld fee schedule dollars

In the first option, the “sufficiently large entity” could be those physicians affiliated with a single hospital or one geographic area, she said.

“An entity’s performance would then be collectively measured using a set of population-based measures,” Bloniarz added.

A limitation of the model is that entities must be “sufficiently large” in order to have “statistically detectable performance on the population based measures.”

In the Voluntary Value Program, measures could potentially fall under three categories: clinical quality, patient experience, and value. For example, a clinical quality measure might include mortality or avoidable admissions.

Unlike the MIPS program, all of the measures could be pulled from Medicare claims data or “centrally conducted surveys” avoiding the clinician reporting burden, Bloniarz explained.

Repeal and Replace?

Most members of the commission expressed support for the new model or at least felt it was a good start.

One new commissioner, David Grabowski, PhD, of Harvard Medical School in Boston, said he favored having a replacement, but he worried that some physicians, particularly those in rural areas, or those treating dual eligible patients (enrollees in both Medicare and Medicaid) might be left out. He stressed that incorporating proper risk adjustment mechanisms into the measurement process would be critical.

Paul Ginsburg, PhD, of the Brookings Institution, also supported a repeal-and-replace strategy.

“My sense is that the politicians don’t want to do nothing. They want to do something,” he said.

However, several commissioners were more hesitant, asking whether replacing the MIPS program was necessary.

“Are we creating something that is so close to the advanced APM structure that it’s almost not worth it?” asked Dana Gelb Safran, ScD, of Blue Cross Blue Shield of Massachusetts.

Gelb Safran suggested that if the commission does choose to recommend an alternative, distinctions between it and the APMs would need to be clear. She also wondered aloud whether with these new entities would revive some of the challenges of the old SGR formula.

The challenge with the SGR was that individuals weren’t truly accountable to each other even though they were lumped together, she explained.

“That really undercuts the desire to behave in the way that the incentives should make them behave because somebody else could kill their incentive, so why bother.”

Craig Samitt, MD, MBA of Anthem in Indianapolis, said he would favor a repeal-only approach, based on the replacement model he’d seen that day.

“If a replacement is a voluntary model that would allow us to keep practicing healthcare the way we’ve been practicing, then that replacement is not a good replacement,” Samitt said.

MedPAC member Kathy Buto, MPA, of Arlington, Virginia, suggested another idea: repeal the MIPS program, but continue to withhold the funds from the clinicians who aren’t participating in the advanced APMs. Then use those dollars to reward APM performance.

“I would actually increase the penalty and make it less attractive to stay in MIPS regardless,” she said.

Commission Chairman Francis J. Crosson, MD, joked that he would be happy to escort Buto from the meeting after it adjourned — implying her idea might be dangerously unpopular with physicians.

In the end, Crosson determined that MedPAC’s technical team would return to the group with draft recommendations for repealing the MIPS program and offer two options: a voluntary replacement program similar to the one discussed at Thursday’s meeting with some revisions, and suggestions on how to make the advanced Alternative Payment Models more accessible for physicians.

The commission could then decide whether to recommend one or both options to HHS.

This Week’s Other Looming Health Care Crisis

The Republicans’ latest Obamacare repeal attempt may fail, but two vital programs that serve 18 million Americans are set to expire.

This week, 18 million of the most vulnerable people in America will wait nervously to see if Republicans in Washington will axe their health coverage. I’m not talking about the repeal of Obamacare. Two other programs expire at the end of this week, and without their reauthorization, millions of impoverished children and the desperately poor will be cut off from the only source of health care coverage they could ever hope to obtain. It’s an example of how Obamacare has overwhelmed every other health care public policy issue, and the results could be catastrophic.

As of Monday morning, we’re still not sure that there will even be a Senate vote on the latest repeal effort, Cassidy-Graham. With two Republicans (Rand Paul and John McCain) firmly opposed and one more, Susan Collins, all but against it, there seems to be no path to the necessary 50 votes. Even Ted Cruz begged off on Sunday. But Republicans have backed themselves into such a corner with their base, promising repeal for seven years, that the leadership keeps plugging away. That’s likely to continue until the September 30 deadline under current reconciliation rules.

This uncertainty is toxic for other important measures that face the same deadline. As of last year, 8.9 million children, mostly those whose families earn less than 200 percent of the poverty line, get covered through the Children’s Health Insurance Program (CHIP), which also pays for thousands of births and postpartum care services for low-income pregnant women. CHIP operates like Medicaid, as a state-federal partnership, and federal funding must be reauthorized by the end of the month.

Children wouldn’t be cut off right away; it depends on how states manage their programs. But at least ten, including California and its two million enrollees, would see fairly immediate impacts, including enrollment freezes and a shortfall in paying for care. The Senate Finance Committee announced an agreement on a five-year extension last week, but with the Cassidy-Graham mess, it’s unclear if they’ll get the floor time to pass it. And the House hasn’t acted at all.

But that’s not all. Enhanced funding for thousands of community health centers, which have provided care for underserved communities since being established during Lyndon Johnson’s War on Poverty, also faces a Saturday expiration date. Community health centers are the dirty little secret of the U.S. system—a safety net that looks as much like Britain’s National Health Service as anything. In most cases, anyone can enter a center for care, regardless of ability to pay or even immigration status. More than single payer, this is actually socialized medicine.

It’s also astonishingly popular. If no action is taken this week, 70 percent of current funding levels for community health centers would be lost, likely forcing the closure of 2,800 facilities nationwide and the loss of 50,000 provider and staff jobs. Twenty-five million Americans use these centers each year, nearly three-quarters of them below the poverty line. An estimated nine million would be left with no medical home if funding expires.

These clinics serve a diverse set of communities—downtrodden urban areas and low-density rural regions with no other health care providers. One in ten Montanans get some health care from a community health center. Four hundred thousand Tennesseans use them, and almost that many South Carolinians. With that deep a funding cut, all of these facilities, in red states and blue states, are at some level of risk, forced to bar new patients, scale back services like dental care or drug treatment, or shut down. And local papers from California to North Carolina are raising the alarm.

Maybe no other major issue could get 70 senators from both parties on a letter of support, but Democrat Debbie Stabenow and Republican Roy Blunt did it for community health center funding last week. For all the ideological hot air, Democrats and Republicans are perfectly thrilled to support something as centrally planned and disruptive to the marketplace than any single payer system. Independent Bernie Sanders and Republican Bill Cassidy will be debating health care on CNN on Monday night, but both of them signed this letter to expand a government-funded health care provider network. (Sanders was actually instrumental in getting five years of enhanced community health center funding into the Affordable Care Act. Congress extended the funding in 2015, but only through September.)

Despite this rare bipartisan support, nothing has been done to extend the funding. A five-year extension has been introduced in the House, but no floor time has been scheduled. Consumed with the war over Obamacare, Congress has let this enormously successful program get lost in the shuffle.

Put together the patients at risk from expiring CHIP funding and community health center funding, and you get 18 million. And this population of Americans, which includes the homelesspoor pregnant women, the uninsured, the addicted, and the undocumented, is by and large more vulnerable to loss of health care access as those at risk in Obamacare repeal.

Obamacare has taken on a meaning that goes far beyond its actual function. It has helped to dramatically lower the uninsured rate, no doubt. But it’s still just part of a series of programs that assist people with coverage. Allow any one of those to falter and the whole system buckles. Obamacare could be working spectacularly, but without CHIP or community health center funding, the nation’s health care system would sink into absolute crisis.

Maybe you believe, as I do, that such a Rube Goldberg delivery system for health care makes no logical sense. In fact, the looming CHIP/community health center deadline serves as a good argument for a single-payer system where no one part of the program can fall through the cracks so easily. But that’s not where we are this week. We’re staring down the barrel of a health care catastrophe, and congressional leaders are busy trying to salvage campaign promises and play to their most ideological of supporters.

Medicaid Has A Bull’s-Eye On Its Back, Which Means No One Is Entirely Safe

Medicaid Has A Bull’s-Eye On Its Back, Which Means No One Is Entirely Safe

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When high levels of lead were discovered in the public water system in Flint, Mich., in 2015, Medicaid stepped in to help thousands of children get tested for poisoning and receive care.

When disabled children need to get to doctors’ appointments — either across town or hundreds of miles away — Medicaid pays for their transportation.

When middle-class older Americans deplete their savings to pay for costly nursing home care, Medicaid offers coverage.

The United States has become a Medicaid nation.

Although it started as a plan to cover only the poor, Medicaid now touches tens of millions of Americans who live above the poverty line. The program serves as a backstop for America’s scattershot health care system, and as Republicans learned this year in their relentless battle to replace the Affordable Care Act, efforts to drastically change that can spur a backlash.

The latest Republican proposal — by Sens. Lindsey Graham (S.C.) and Bill Cassidy (La.) — is being pummeled by doctors, insurers, hospitals and patient advocates because it would scrap the health law’s Medicaid expansion and reduce federal funding for Medicaid. Senate leaders are trying to get a vote before Sept. 30, when special budget rules would allow the package to pass with only 50 votes.

Today, Medicaid is the nation’s largest health insurance program, covering 74 million, or more than 1 in 5 Americans. Over the next weeks, Kaiser Health News will explore the vast reach of the program. Twenty-five percent of Americans will be on Medicaid at some point in their lives — many are just a pink slip away from being eligible.

Medicaid funding protects families from having to sell a home or declare bankruptcy to pay for the care of a disabled child or elderly parent. It responds to cover disaster relief, public health emergencies and programs in schools that lack other sources of funding.

Millions of women who don’t qualify for full Medicaid benefits each year obtain family planning services paid for by Medicaid. These women have incomes as high as triple the federal poverty rate, or over $36,000 for an individual. And thousands of women, who otherwise don’t qualify for the program, get treated each year for breast and cervical cancers through Medicaid.

“Instead of cutting Medicaid, [lawmakers] increased public awareness of its value and made it even harder to cut in the future,” said Jonathan Oberlander, professor of health policy and management at the University of North Carolina-Chapel Hill and a supporter of the federal health law. The Medicaid cuts passed the House, but the ACA overhaul legislation fell short in the Senate in July.

Medicaid is the workhorse of the health system, covering:

  • 39 percent of all children.
  • Nearly half of all births in the country.
  • 60 percent of nursing home and other long-term care expenses.
  • More than one-quarter of all spending on mental health services and over a fifth of all spending on substance abuse treatment.

Unlike Medicare beneficiaries, who keep that insurance for life, most Medicaid enrollees churn in and out of the program every few years, depending on their circumstances.

Such numbers underline the importance of Medicaid, but also provoke alarm among conservatives and some economists who say the U.S. cannot afford the costs over the long run.

Bill Hammond, director of health policy of the fiscally conservative Empire Center for Public Policy in Albany, N.Y., said Medicaid has been a big help for those it was designed to cover — children and the disabled. But it has grown so big that the cost hurts state efforts to pay for other necessary public services, such as education and roads. “I can’t think of any other anti-poverty program that reaches so many people. … It’s too expensive a benefit.”

“We need to transition people to get coverage in the private sector,” he said, noting how millions on the program have incomes above the federal poverty level.

It May Be The Person Down The Block

Joana Weaver, 49, of Salisbury, Md., who has cerebral palsy, has been on and off Medicaid since birth. For the past few years, it’s paid for home nursing services for six hours a day to help her get dressed, bathed and fed. That’s kept her out of a nursing home and enabled her to teach English part time at a local community college.

“For me, Medicaid has meant having my independence,” Weaver said.

Like Weaver, many people getting Medicaid today are not easily typecast. They include grandmothers — one-quarter of Medicaid enrollees are elderly people or disabled adults.

Or the kid next door. About half of Medicaid enrollees are children, many with physical or mental disabilities.

Many of the rest — about 24 million enrollees — are adults under 65 without disabilities who earn too little to afford health insurance otherwise. About 60 percent of non-disabled adult enrollees have a job. Many of those who don’t work are caregivers.

“It’s the mechanic down the street, the woman waiting tables where you go for breakfast and people working at the grocery store,” said Sara Rosenbaum, a health policy expert at George Washington University in Washington, D.C.

While all states rely on Medicaid, it’s used more in some places than others because of varying state eligibility rules and poverty rates. As of August, about 44 percent of New Mexico residents are insured by Medicaid. In West Virginia and California, the rate is nearly 1 in 3.

peak or walk. It also covers costs for his wheelchair, walker and home health care. (Nick Krug/Lawrence Journal-World)

Jane and Fred Fergus, in Lawrence, Kan., said Medicaid has been a cornerstone in their lives since their son, Franklin, was born eight years ago with a severe genetic disability that left him unable to speak or walk. He is blind and deaf on one side of his body.

Although the family has insurance through Fred’s job as a high school history teacher, Franklin was eligible for Medicaid through an optional program that states use to help families let their children be cared for at home, rather than moving to a hospital or nursing home. Medicaid pays all his medical bills, including monthly transportation costs to Cincinnati Children’s Hospital, where for the past 18 months he has been receiving an experimental chemotherapy drug to help shrink tumors blocking his airway, Jane Fergus said. It also covers his wheelchair, walker and daily nursing care at home.

“We have such great health care for him because of Medicaid,” his mother said.

Jane Fergus was never politically active until this year, when she feared that the GOP plans to cut Medicaid funding would reduce services for her son.

“If there is a silver lining in all this debate, it’s that we have been given a voice, and people in power are being educated on the role of Medicaid,” she said.

Moving Beyond Its Roots

Medicaid was born in a 1965 political deal to help bring more support for President Lyndon Johnson’s dream of Medicare, the national health insurance program for the elderly.

Over the past 40 years and in particular since the 1980s, Medicaid expanded beyond its roots as a welfare program. In 1987, Congress added coverage for pregnant women and children living in families with incomes nearly twice the federal poverty level (about $49,200 today for a family of four).

In 1997, Congress added the Children’s Health Insurance Program to help cover kids from families with incomes too high for Medicaid.

And since September 2013, Obamacare allowed states to expand the program to anyone earning under 138 percent of poverty (or $16,394 for an individual in 2016), adding 17 million people.

In addition, more than 11 million Medicare beneficiaries also receive Medicaid coverage, which helps them get long-term care and pay for Medicare premiums.

“Medicaid is plugging the holes in our health system,” said Joan Alker, executive director of the Georgetown University Center for Children and Families, “and our health system has a lot of holes.”

But that comes at a steep price. 

A Blessing And A Curse

With increasing enrollments and health costs steadily rising, the cost of Medicaid has soared. Federal and state governments spent about $575 billion combined last year, nearly triple the level of 2000.

Those dollars have become both a blessing and a curse for states.

The federal government matches state Medicaid spending, with Washington paying from half to 74 percent of a state’s costs in 2016. Poorer states get the higher shares.

The funding is provided on an open-ended basis, so the more states spend the more they receive from Washington. That guarantee protects states when they have sudden enrollment spikes because of downturns in the economy, health emergencies such as the opioid crisis or natural disasters such as Hurricane Katrina.

The program is the largest source of federal funding to states. And Medicaid is often the biggest program in state budgets, after public education.

“Medicaid is the elephant in the room for health care,” said Jameson Taylor, vice president for policy for the Mississippi Center for Public Policy, a free-market think tank. He said states have become dependent on the federal funding to help fill their state budget coffers. While the poorest states, such as Mississippi, get a higher percentage of federal Medicaid dollars, that still often isn’t enough to keep up with health care costs, he said.

Extensive Benefits

Medicaid provides significant financing for hospitals, community health centers, physicians, nursing homes and jobs in the health care sector.

But the revenue stream flows further. Billions in annual Medicaid spending goes to U.S. schools to pay for nurses; physical, occupational and speech therapists; and school-based screenings and treatment for children from low-income families, as well as wheelchairs and buses to transport kids with special needs.

Medicaid also often covers services that private health insurers and Medicare do not — such as non-emergency transportation to medical appointments, vision care and dental care. To help people with disabilities stay out of expensive nursing homes, Medicaid pays for renovations to their homes, such as wheelchair ramps, and personal care aides.

Rena Schrager, 42, of Jupiter, Fla., who has severe vision problems, has relied on Medicaid  for more than 20 years. Although she often has difficulty finding doctors who will accept Medicaid’s reimbursements — which are often lower than private insurance and Medicare — she is grateful for the coverage. “When you do not have anything else, you are glad to have anything,” Schraeger said.

As it’s grown, Medicaid has become more popular, another reason why politicians are cautious to curtail benefits or spending.

A recent survey by the Kaiser Family Foundation showed three-fourths of the public, including majorities of Democrats (84 percent) and Republicans (61 percent), hold a favorable view of Medicaid. That’s nearly as high as Americans’ views on Medicare. (Kaiser Health News is an editorially independent program of the foundation.)

But it may still have a bull’s-eye on its back.

“The fact that the House passed a bill to cut $800 billion from Medicaid and it came one vote short to passing the Senate shows Medicaid is stronger than maybe many Republican leaders anticipated,” said Oberlander. “But politically it is still in a precarious position.”

Senate bargainers say deal reached on children’s health

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Senate Republican and Democratic bargainers reached agreement late Tuesday to extend financing for the children’s health insurance program for five years, a pact that if approved would avert an end-of-month cash crunch for the popular program.

In a concession to Republicans, the agreement would phase out extra federal funds that have gone to states for the program since the additional money was mandated as part of President Barack Obama’s 2010 health care law.

Money for the federal-state program is due to expire at the end of September. The program provides health coverage to around 8 million low-income children and pregnant women.

It was initially unclear how the agreement would fare in the Senate and the House.

But the two negotiators — Senate Finance Committee Chairman Orrin Hatch, R-Utah, and that panel’s top Democrat, Ron Wyden of Oregon — work closely with party leaders. In addition, having embarrassingly failed in this year’s attempt to repeal Obama’s health care statute, Republicans and President Donald Trump are eager for an accomplishment and would be unlikely to stymie the continuation of such a widely supported initiative.

It was also unclear if the pact would move quickly and by itself through Congress, or become a vehicle for other, less widely backed legislation.

In a written statement, Hatch said “Congress needs to act quickly” to extend the program.

Without providing detail, Hatch said the agreement would give states “increased flexibility” to run the program. He also said lawmakers will “continue to advance this agreement in a way that does not add to the deficit,” suggesting that a compromise on how to pay for the extra funds may have not yet been found.

Wyden called the agreement “a great deal for America’s kids.”

The federal government pays around $7 billion annually for the program. States by law pay a small share — until recently, an amount ranging from 15 percent to 35 percent of costs.

But under Obama’s law, states each received an additional 23 percent share from Washington. Many Republicans, particularly conservatives, have chafed at that added amount.

Under the agreement, the full 23 percent share would continue for two more years. It would phase down to 11.5 percent in 2020 and the extra money would disappear completely the following year. The details were provided by a Senate aide who spoke on condition of anonymity because full details weren’t released.

A Glimmer of Bipartisanship on the ACA

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With the eclipse of Republican efforts to repeal and replace the Affordable Care Act (ACA), bipartisan approaches to improving the law are having a moment in the sun. This week, Senators Lamar Alexander (R-Tenn.) and Patti Murray (D-Wash.) are cosponsoring hearings before the Senate Health, Education, Labor and Pensions (HELP) committee on bipartisan solutions to stabilizing private health insurance markets. The Problem-Solvers — a new caucus of House Democrats and Republicans — are similarly at work on a cross-party package of reforms. Eight governors have released a bipartisan plan, as has a group of health policy experts with mixed party affiliations.

The value of bipartisanship is indisputable. The alternative — on excruciating display over the last seven months — is ongoing partisan warfare that destabilizes our health care system. Health care providers and insurers cannot function effectively when changes in party control at the federal level threaten to upend the health care system every two to four years. And the fear of health coverage loss is unquestionably stressful for the millions of Americans who depend upon the ACA.

But the growing apparent consensus on key elements for a short-term, cross-party package is encouraging. These proposals focus on strengthening individual insurance marketplaces by legislating cost-sharing reduction payments; helping private insurers manage the risk of very high-cost patients using reinsurance and other means; creating a source of backup coverage for “bare markets” that lack private insurers; and offering states greater flexibility in implementing federal regulations governing private insurance markets.

Different groups propose additional bells and whistles, and there is much room for disagreement on how to design and implement specific provisions. But at least both parties are at the table. Where there’s a will, there may be a way.

Still, important practical questions remain. One is whether the will really exists. Republican supporters of repeal and replace continue to divide the Senate Republican caucus. Conservatives in the House — including the Freedom Caucus — will likely oppose anything that threatens their hope that the ACA will collapse of its own weight. And it is possible that President Trump, still grumbling about the failure of repeal and replace, will veto any narrow package that he believes pours salt in his health care wound.

Ironically, the failure of ACA markets to self-destruct may also sap the will for bipartisan reforms. Deadlines and crisis drive congressional action and, until recently, the threat that some individual markets — admittedly, small in number and population — would lack any insurer was an important spur for Congress to act. Now, that threat has receded as the last of the bare markets has found a carrier.  Bipartisanship is the legislative equivalent of nuclear fusion; it needs major external pressure to push those mutually repelling atoms together.

Even if there were a will, there might not be a way to get an ACA package into the queue. The fall congressional calendar is packed with other high-profile, high-stakes, deadline- and crisis- driven legislation. By September 30, Congress must reauthorize the Children’s Health Insurance Program (CHIP), which has traditionally enjoyed bipartisan support and is vital to the health care of more than 9 million American children. To respond to Hurricane Harvey, Congress also needs to rapidly enact emergency aid for Texas and Louisiana, which will require the extension of previously controversial flood relief legislation.

And these measures are just the beginning. Congress has to fund the federal government by September 30 — with or without support for the border wall — or face a government shutdown. There is the need to pass a controversial increase in the federal debt ceiling by the same date. And to have any hope of enacting major tax reform before the 2018 election, work must accelerate right after Labor Day. Putting the tax project off until after January is dangerous for proponents, because passing controversial tax legislation is infinitely more difficult in an election year.

Bipartisanship on health care action could lay vital groundwork in the short term for bolstering the individual health insurance market. Longer term, bipartisanship is essential for the kind of fundamental change that is necessary to increase coverage and contain costs in our health care system. We should not, however, underestimate the huge political and procedural obstacles that lie in the way of current admirable efforts to bring the two parties together on health care. It will take all the skill of committed Senate and House leaders from both parties to make progress on health care this year — or thereafter.

Obstacles await as Congress resumes health care fight

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Republican hopes for repealing and replacing former President Barack Obama’s health care law are still twitching in Congress, though barely.

Leaders lack the votes to pass something and face a fresh obstacle — the Senate parliamentarian ruled Friday that Republicans only have the ability to dismantle the law with 51 votes until the end of the month.

It’s among several health issues lawmakers face when they return from summer recess, even as fights over the budget and helping Texas recover from Hurricane Harvey grab center stage.


Senate Majority Leader Mitch McConnell, R-Ky., tried to push three plans through his chamber erasing the 2010 law called Obamacare. Republican defections denied him the 50 votes needed, with Vice President Mike Pence ready to seal victory with a tie-breaking vote.

The excruciating last roll call failed 51-49. Three Republicans voted “no,” one more than McConnell could afford to lose. President Donald Trump used August to insult McConnell for that flop, even suggesting he might need to relinquish his leadership post, inflaming tensions between the White House and congressional Republicans and lacerating party unity.



Republicans have used a procedure that’s prevented Democrats from killing the health bill by filibuster. It takes 60 votes to defeat a filibuster. Without that special step, Republicans controlling the Senate 52-48 would need support from eight Democrats to repeal Obamacare, impossible given unanimous Democratic opposition.

The safeguard against filibusters was included in a budget for the government’s 2017 fiscal year that Republicans pushed through Congress in January.

That protection expires at the end of September, the Senate’s nonpartisan parliamentarian, Elizabeth MacDonough, has ruled. That’s when the fiscal year ends.

Sen. Bernie Sanders, I-Vt., the ranking member of the Budget Committee, said in light of the ruling, “we need to work together to expand, not cut, health care for millions of Americans who desperately need it.”

That leaves Republicans with only September to nurture their slim repeal hopes unless the GOP-run chamber votes to overrule her.



This repeal push comes from GOP Sens. Lindsey Graham of South Carolina, Louisiana’s Bill Cassidy and Nevada’s Dean Heller.

They’ve proposed funneling Obamacare’s federal dollars directly to states and erasing its requirements that people buy coverage and companies offer it to employees. They’d cut and reshape Medicaid, halt Obama subsidies that reduce consumers’ out-of-pocket costs and repeal the tax on some medical devices.

GOP aides say the proposal is evolving.

There’s no sign sponsors have enough Republicans to prevail and McConnell hasn’t been publicly encouraging. Further reducing its chances, lawmakers need September to prevent a damaging federal default and a government shutdown, help Texas recover from Harvey and craft a GOP tax overhaul.

“If people can show me 50 votes for anything that would make progress on that, I’ll turn back to it,” McConnell said in early August of repealing Obamacare.



The brightest hope comes from Senate health committee chairman Lamar Alexander, R-Tenn., and Washington state Sen. Patty Murray, that panel’s top Democrat. They’re seeking a deal on continuing federal payments to insurance companies who reduce costs for lower-earning customers.

Even this will be uphill.

Obama’s law requires the cost reductions and government subsidies to insurers, but a court has ruled Congress hasn’t legally authorized the payments. Obama and Trump have continued them, but Trump keeps threatening to stop, calling them an insurance company bailout. Many conservatives agree.

Yet those payments are a priority for Democrats and many Republicans. They and the nonpartisan Congressional Budget Office say halting the subsidies will force insurers to boost premiums for millions.

In exchange, Republicans want to revise parts of Obama’s law. They’ve suggested making it easier for insurers to avoid some Obama coverage requirements or steps like curbing lawsuits against health care providers.

Alexander wants to extend the insurers’ subsidies for one year while Democrats want two years or more. Another hurdle: Democrats have little interest in relaxing Obama’s law.

“Nobody is going to put their fingerprints on sustaining Obamacare without some sort of reform element,” Rep. Tom Cole, R-Okla., said of Republicans.



Funding for the popular Children’s Health Insurance Program expires Sept. 30. It provided health care to more than 8 million low-income children in 2015.

Democrats and most Republicans want to extend the program and success seems likely. First they must compromise on details like how many years to finance it and at what levels.

Washington pays for most of the federal-state program, and in recent years the federal share was bumped up by 23 percent for each state. Many Republicans want to phase out that boost, but Democrats are resisting.

Some Republicans say Congress needn’t act by Sept. 30 because states have enough money to continue coverage. Democrats and program advocates say without fresh funds by September’s end, some states would be forced to make cuts to wind down services.

110 ACOs to know | 2017

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In its sixth edition, Becker’s Healthcare is pleased to highlight a variety of Medicare and commercial payer accountable care organizations led by hospitals, health systems, physician groups and other organizations.

Leavitt Partners, a Salt Lake City-based healthcare consulting firm, reports 934 active public and private ACOs in the United States during the first quarter of 2017 covering 2.2 million lives. Over the past year, 138 new ACOs began operation and 46 dropped their accountable care contracts, leading to an 11 percent growth year-over-year, according to Health Affairs.

Several ACOs represented on this list participate in the Medicare Shared Savings Program. Tracks 1 and 2 have limited provider risk; participants can benefit from shared savings but aren’t at risk for loss. MSSP Track 3, added in 2016, creates shared savings opportunities with greater risk. Track 3 ACO providers can share up to 25 percent of savings, but are at risk for loss. The most recently reported data for MSSP ACOs is the 2015 performance year.

CMS launched the Next Generation ACO Model in 2016, requiring providers to shoulder greater financial risk with the potential of earning more shared savings. The Next Generation ACOs qualify as advanced alternative payment models under the Medicare Access and CHIP Reauthorization Act’s Quality Payment Program in the 2017 reporting year. There are currently 45 participants in the Next Generation ACO Model.

These governmental contracts are in addition to commercial ACO arrangements, which at 715 in number, represent the plurality of all contracts, according to Health Affairs. Commercial ACOs tend to cover more lives than their Medicare counterparts.

Becker’s included ACOs on this list based on several factors, such as cost performance, participation in CMS ACO models and participation in innovative commercial agreements. ACOs are presented in alphabetical order. ACOs with multiple contracts are listed by the health system or provider group name.

Five tough decisions for the GOP on healthcare

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Republicans have left Washington for the August recess with healthcare decisions hanging overhead, many of which must be addressed by the end of September.

Here are five decisions looming for the GOP.

  1. Should there be one more effort at ObamaCare repeal?

While the GOP attempt at repealing ObamaCare has stalled for now, some in the party are not giving up.

“This ain’t over by a long shot … we won’t rest until we end the ObamaCare nightmare once and for all,” Vice President Pence said at the Tennessee GOP 2017 Statesmen’s Dinner Thursday, according to a pool report.

Yet Republicans are running out of time to take action, as the legislative vehicle they were using to gut the health law and avoid a Democratic filibuster expires at the end of September.

Sens. Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.) are pushing a new plan to redirect money currently spent on providing coverage through ObamaCare and instead give it to states to spend as they choose.

They have been meeting with White House officials, who are also pushing Congress not to give up on repeal.

“I hope that our leadership will pay attention to this effort because the idea of leaving ObamaCare without a replacement is pretty naive,” Graham said this week.

Still, Senate GOP leadership has largely signaled they are moving on from repeal for now, with the legislative session in September likely to be dominated by work on funding the government and raising the debt ceiling.

And there are so far no signs that any of the three GOP “no” votes who sunk repeal, Sens. Lisa Murkowski (Alaska), Susan Collins (Maine), or John McCain (Ariz.), are changing their minds.

However, Graham said he is working with conservative Sens. Mike Lee (R-Utah) and Ted Cruz (R-Texas) to try to incorporate their ideas on repealing ObamaCare regulations into the plan.

And Majority Leader Mitch McConnell (R-Ky.) left the door open to bringing repeal back in some form, noting the fast-track procedure being used to avoid a filibuster had not expired.

“There’s still an opportunity to do that,” he said.

  1. Should we work with Democrats?

Lawmakers are ramping up bipartisan talks on the next steps for healthcare legislation, some more enthusiastically than others.

Sen. Mike Rounds (R-S.D.) said that following the failure of the Senate GOP’s ObamaCare repeal vote, Democrats have been more willing to talk with Republicans about ways to fix the law.

“Both sides are moving a little bit more to the middle,” Rounds said. “The discussions I’m having have been positive with Democrats, saying ‘look we are open to these changes, we will listen, we will work with you.’”

Sen. Roy Blunt (R-Mo.), a member of the GOP leadership, told The Hill he still wants to repeal ObamaCare “and start over, but that doesn’t mean an effort to hold up the collapsing structure in the short term isn’t the right thing to do.”

Both the Senate’s Health and Finance committees plan to hold bipartisan hearings in September when lawmakers return from recess.

Sen. Lamar Alexander (R-Tenn.) — the chairman of the Health, Education, Labor and Pensions Committee — said the goal is for the panel to craft a bipartisan, short-term proposal by mid-September, as insurers must sign contracts saying they’ll sell plans on the federal exchange by the end of that month.

Finance Committee Chairman Orrin Hatch (R-Utah) did not suggest the panel would produce legislation, but said there was bipartisan interest in a hearing.

“We’ve also heard a lot of demands from members of the committee for a healthcare hearing. I intend to do that as well shortly after the recess,” Hatch said Thursday.

But it’s not clear that the renewed interest in bipartisanship will yield legislation.

Alexander’s committee runs the ideological gamut from conservative Sen. Rand Paul (R-Ky) to progressive Sens. Elizabeth Warren (D-Mass.) and Bernie Sanders (I-Vt.).

Getting everyone behind a bill could prove a tall order, especially as some Republicans like Paul are committed to repealing ObamaCare, not repairing it.

  1. Should we back legislation to make key payments to insurers?

Insurers are desperate to know whether they’re going to continue to receive critical ObamaCare payments from the federal government.

President Trump has threatened to halt the payments, which compensate insurers for subsidizing out-of-pockets costs for certain healthcare consumers.

But Congress could take the matter out of his hands by authorizing the payments the administration has been making on a monthly basis, which total about $7 billion for fiscal 2017.

Even if Trump doesn’t halt the cost-sharing reduction payments, a yearlong appropriation from Congress would give insurers certainty that they’ll continue to receive the funds.

Republicans are divided on what to do.

Many say the ObamaCare marketplaces need to be stabilized and are open to funding the payments. Alexander took the first concrete step forward to do so, saying that any stabilization package his committee produces should fund the payments.

But conservatives are vehemently opposed.

“I think it is a mistake to simply go forward with bailouts for big insurance companies,” Cruz said. “For whatever reason, the Democrats’ central priority seems to be providing billions of dollars in subsidies and bailouts to giant insurance companies.”

  1. What’s to be done with CHIP?

Time is of the essence for Congress to reauthorize the Children’s Health Insurance Program (CHIP). Funding is set to expire Sept. 30.

CHIP has historically had bipartisan support, and the Senate Finance Committee announced on Thursday it would hold a post-recess hearing on CHIP.

Congress last reauthorized the CHIP program in 2015 as part of a broader health package.

However, for Republicans still searching for a way to pass provisions of their failed ObamaCare repeal legislation, the authorizing legislation may be a tempting vehicle.

If CHIP funding expires, states will be forced to make difficult decisions about coverage. Millions of families would have to find other sources of insurance for their children at a time of uncertainty around the stability, availability and affordability of other types of coverage.

  1. What’s to be done with ‘bare’ counties?

Insurance commissioners have a big fear: That the ObamaCare health marketplaces will open for business, but people in some areas won’t have any plans to choose from.

This scenario has never happened before, but as of Friday, 17 counties have zero insurers committed to their exchange, according to Kaiser Family Foundation.

The deadline to participate is looming. Insurers sign contracts with the federal government at the end of September, saying they’ll offer plans on the ObamaCare exchanges.

If the Senate Health Committee is able to meet its goal — hammering out a bipartisan short-term stabilization bill by mid-September — then that could help prevent more insurers from fleeing the marketplaces.

And behind the scenes, insurance commissioners have been offeringinsurers previously unheard of flexibilities to keep or entice them into the marketplaces.

Congress is aware of the situation, and has proposed several other solutions.

One bill from Tennessee’s Republican senators, Bob Corker and Alexander, would let people use their ObamaCare subsidies to purchase plans off the exchange — that is, if they live in a “bare county” without any ObamaCare plans to buy.

A counter bill from Sen. Claire McCaskill (D-Mo.) would allow those in bare counties to buy coverage on Washington, D.C.’s exchange, where Congress members and their staff purchase insurance.

The BCRA is dead, but don’t take your eye off Capitol Hill

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The healthcare industry may have dodged a bullet, but this week’s legislative stumbles for the GOP don’t mean healthcare is off the table for Congress. Here’s what to watch.

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