Day One: Trump Begins ACA Take Down

MedPage Today

Jan. 21, 2017

WASHINGTON — Just hours after his inauguration, President Donald Trump enabled a federal agency to pull back on critical provisions of the Affordable Care Act (ACA).

Trump signed an executive order on Friday pressing government departments to “change, delay or waive provisions of the law that they deemed overly costly for insurers, drug makers, doctors, patients or states, according to the New York Times. The move will essentially allow the U.S. Department of Health and Human Services (HHS) to begin unraveling the law before Congress can repeal it.

Rep. Ralph Abraham, MD, (R-La.) told MedPage Today in a phone interview on Friday that Trump was “going to work, right after he finishes lunch,” although he did not specify if orders related to the ACA would be enacted.

The order outlines its aim “to minimize the unwarranted economic and regulatory burdens of the [Affordable Care] Act, and prepare to afford the States more flexibility and control to create a more free and open healthcare market,” according to CNN. This includes the potential weakening of the “individual mandate,” which requires most Americans to have health insurance or pay a tax penalty.

Abraham noted that Rep. Tom Price, MD, (R-Ga.), currently Trump’s nominee for HHS secretary, would have the authority to change and undo many key regulations.

Asked whether such changes could hurt patients if a replacement plan has not been implemented, Abraham said he was optimistic. “[Price is] a very logical, measured man. He will make decision that are best for the patient,” he stated.

In a press release, Sen. Lamar Alexander (R-Tenn.), chair of the Senate Committee on Health, Education, Labor and Pensions, stated that “President Trump is right to make the urgent work of rescuing Americans trapped in a collapsing Obamacare system a top priority on his first day in office.”

Alexander noted that he was looking forward to repealing the law but also to “replacing it simultaneously with concrete, practical reforms that give Americans access to truly affordable health care.”

Med Students Assail Proposed ACA Repeal at D.C. Event

MedPage Today

Jan. 10, 2017
WASHINGTON — Medical students descended on the nation’s capital on Monday to protest the proposed repeal of the Affordable Care Act (ACA).

Hailing from all over the country, including as far away as Los Angeles, more than 50 medical trainees met with dozens of senators and legislative assistants, delivering petitions and hoping to dissuade Congress from doing away with the ACA. Medical students at over 30 other academic institutions in others states gathered to protest locally.

Also, around 25 members of #ProtectOurPatients participated in a FacebookLive Chat organized by Sen. Chuck Schumer (D-N.Y.) where they discussed the consequences of repeal with dozens of Senate Democrats in an online forum.

“Our main ask for today is for bipartisan work to be done on opposing repeal and working together to improve the existing ACA,” Sidra Bonner, a medical student at the University of San Francisco and lead organizer of the protest, told MedPage Today.

The grass-roots campaign #ProtectOurPatients, represents 4,000 medical students, including nursing students and other allied health professionals, Bonner explained.

While the group fundamentally opposes repeal, if it does happen, Bonner said, “there needs to be an immediate and better plan in place … [one that’s] better than the existing ACA in terms of access, quality, and cost,” she said.

The medical students may get their wishes granted to some extent — on Jan. 10, 2017, a group of Republican lawmakers introduced an amendment to extend the deadline for budget reconciliation, the promised “repeal bill,” from Jan. 27 to March 3, 2017.

“By providing more time to come up with legislative solutions, we have a better opportunity to produce a thoughtful, workable replacement that ensures Americans have access to affordable, diverse insurance plans that meet their needs,” Sen. Susan Collins (R-Maine) said in a press release.

The Senate is expected to vote on the preceding step in the repeal process, approving a budget resolution this week that would serve as a blueprint for repeal.

Lukewarm Republicans

Only two Republican senators met with protesters directly: Collins and Sen. Jeff Flake (R-Ariz.).

Protester Margaret Hayden, a second-year medical student at Harvard Medical School in Boston, grew up in Brunswick, Maine, and described her encounter with Collins, who is considered a more moderate Republican.

“I told her how I talked to the hospital CEO from Brunswick; talked to the chairman of the Maine Lobstermen’s [Community] Alliance and both said the same thing: That the Affordable Care Act isn’t perfect, but it’s providing essential services and protections for the people they care for and work on behalf of,” Hayden stated.

Hayden said she asked Collins to vote against repeal unless an immediate replacement offering “the same or better coverage” can be implemented.

Hayden described Collins as “responsive and understanding” especially regarding access to coverage for those with pre-existing conditions. “She’s committed to working on a replacement plan that will offer that for [Maine residents].”

As for the request to vote against repeal without a replacement, Collins said “she’s taking it under consideration,” Hayden reported.

A meeting between Flake and Kyle Ragins, MD, MBA, an emergency medicine resident at the University of California Los Angeles, had a less positive encounter.

Ragins wrote in a follow-up email on Tuesday that Flake was “evasive” and “noncommittal” regarding the request to vote “no” to a repeal without a simultaneous replacement.

Students also met with Republican staffers from the offices of Sen. Lamar Alexander (R-Tenn.), Sen. Roy Blunt (R-Mo.), Sen. Tom Cotton (R-Ark.), Sen. Rob Portman (R-Ohio), Sen. Marco Rubio (R-Fla.), and Sen. Pat Toomey (R-Pa.).

Democrats Engage

During the Facebook Live Chat, protester Maria Phillis, JD, a fourth-year medical student at Johns Hopkins University in Baltimore reported speaking with Sen. Elizabeth Warren (D-Mass.).

Phillis, who plans to specialize in obstetrics and gynecology, expressed concern to Warren that if the ACA is repealed, requirements to cover maternity care for women would disappear.

“[I]t’s really important to have that prenatal care,” Phillis said, noting that it’s not uncommon for life-threatening conditions to emerge during pregnancy. One example is pre-eclampsia, she said, noting that when it is caught early, clinicians can decide how to proceed to protect the mother and her baby.

“If we don’t have those people coming in and getting care, we may have them coming into deliver and having a seizure, and possibly even dying,” Phillis emphasized.

Following his Live Chat, MedPage Today asked Sen. Cory Booker (D-N.J.) if he was hopeful about saving Obamacare.

He said that he hoped warnings against repeal without replacement from groups such as the American Medical Association and the American Enterprise Institute (a conservative think tank) would prevail.

“Any action related to repeal is going to produce a lot of uncertainty that could destabilize markets and really cause a healthcare crisis in our country,” he said.

Sen. Ron Wyden (D-Ore.) and Sen. Amy Klobuchar (D-Minn.) were more cautious.

“Those who are saying they’re for repeal are saying ‘Nobody’s going to get hurt. Nobody’s going to lose any services.’ Tell that to the hundreds and thousands of women who depend on Planned Parenthood and depend on it for vital and preventive services,” Wyden told MedPage Today.

Klobuchar added that Republicans “just want to say ‘repeal.’ That sounds good on a bumper sticker, but you’re basically threatening the healthcare of millions of people.”

Sen. Kamala Harris (D-Calif.) made a pocketbook argument against repeal, saying that financially ACA repeal affects “all of us.” If “people are going to emergency rooms as the first place they seek medical care. It’s about all that we will benefit from in terms of having a healthy society and a productive society.”

Some medical students also participated in #ProtectOurPatients events at their own schools elsewhere in the country. Following are photos submitted to MedPage Today from Oregon Health & Science University, Yale University, Stanford University, and University of California branches in San Francisco, Los Angeles, Irvine, and Davis.

ACA Repeal: It Takes a Village of Congressional Committees

WASHINGTON — The takedown of Obamacare is at the top of the GOP-led Congress’ agenda, and health policy experts gave MedPage Today an account of how that process could play out.

In addition to dismantling the Affordable Care Act (ACA), legislators must also make key decision on bills that will impact healthcare programs for children and veterans, as well as the future of pharma regulation.

‘Process-Oriented’

When it comes to ACA “repeal and replace,” “procedurally it all starts with the budget committee,” said G. William “Bill” Hoagland, senior vice president of the Bipartisan Policy Center here.

But there’s no way to put forward the promised repeal bill until Congress passes a budget resolution, Hoagland told MedPage Today, and it has yet to pass a spending bill for the 2017 fiscal year.

So much of the action will be “process-oriented” rather than “substance-oriented,” and the House appears to be more aligned on that process than the Senate, he noted.

In addition, the House Ways and Means Committee will focus on the tax-related aspects of repeal, while the Energy and Commerce Committee will focus on Medicaid reform, potentially moving from expansion to a block grant or per capita system, said Tom Miller, JD, a resident fellow at the American Enterprise Institute here.

Both committees will play a part in budget reconciliation, Miller told MedPage Today. Meanwhile, in the Senate, much of the action will happen in the Finance Committee, he added.

In 2015, the Senate passed a partial repeal that reversed key pillars of the ACA, including the individual mandate, the employer mandate, and Medicaid expansion after a 2-year transition period, through that exact budgetary process. The bill was later vetoed by President Obama.

But given a similar bill, President-elect Trump is expected to sign.

If the ACA is repealed, it’s the private insurance market that really becomes important, Kavita Patel, MD, a nonresident fellow in economic studies at the Brookings Institution and a primary care internist at Johns Hopkins Medicine in Baltimore, told MedPage Today.

The Senate Health Education Labor and Pensions (HELP) Committee has jurisdiction there. That makes Sen. Lamar Alexander (R-Tenn.) and Sen. Patty Murray (D-Wash.), the chair and ranking member, respectively, of the HELP committee, the two “most important people everyone else has to work with,” she said.

Unlike the House, the Senate, which has only a slim Republican majority, needs bipartisan support in order to pass an ACA replacement. (On Tuesday, the American College of Physicians and the American Medical Association urged Congress to go slow with repeal.)

Hoagland noted some tension in the Senate — Alexander has spoken about “replace and repeal” rather than “repeal and replace” stressing that Congress should know what they are giving people before rolling back healthcare insurance coverage, he said.

Sen. Susan Collins (R-Maine) and Sen. Lisa Murkowski (R-Alaska) have expressed similar concerns, Hoagland added.

Key Positions

Congress is expected to name committee and subcommittee chairs in early to mid-January, and a few of these positions will have a major influence on important aspects of the anticipated repeal-replace agenda.

Currently, Rep. Tom Price (R-Ga.) chairs the House Budget Committee, but in December, President-elect Trump picked Price to serve as secretary of the Department of Health and Human Services (HHS). Price will likely continue in his current position until he’s confirmed as HHS secretary, Miller noted.

If Price is confirmed, Rep. Todd Rokita (R-Ind.), the current vice chair of the budget committee, would be the “logical person” to become chair, said Hoagland, adding that “He would reflect the same principals and position that chairman Price has had.”

Sen. Mike Enzi (R-Wyo.), who leads the Senate Budget Committee, is expected to continue in that role.

Recently, Rep. Greg Walden (R-Ore.) was chosen as chair of the House Energy and Commerce committee, which will help to draft a potential alternative to the ACA. The decision was made by the House Republican Steering Committee and due mainly to Walden’s efforts in helping Republican incumbents get re-elected, reported Politico.

Walden will play an important role in setting the political tone and presenting a unified front, Miller explained, but he doesn’t have a strong healthcare background, so he’s likely to delegate ACA-related issues to the chair of the subcommittee on health, said John O’Shea, MD, a senior fellow at the Heritage Foundation, a conservative think tank.

However, Rep. Joe Pitts (R-Pa.), chair of that healthcare subcommittee, is slated to retire. As a result, the post could fall to the current vice chair, Rep. Brett Guthrie (R-Ky.). Rep. Tim Murphy, PhD, (R-Pa.) and Rep. Mike Burgess, MD, (R-Texas), a psychologist and a physician, respectively, are also possible candidates, Miller said, and both are aligned with the GOP Doctor Caucus.

If Murphy takes the chair, it’s likely that the subcommittee could see more activity on mental health reform and substance use disorders — agenda items Murphy lobbied successfully to include in the 21st Century Cures Act.

Even if Burgess is not chosen for the spot, he will continue to be heavily engaged in repeal and replace activities, and physician payment rules, said Gail Wilensky, PhD, an economist and senior fellow at Project HOPE.

Regarding the House Committee on Ways and Means, both Rep. Kevin Brady (R-Texas) , the committee chairman, and the Rep. Pat Tiberi (R-Ohio), the current health subcommittee chairman, are expected to retain their positions, Miller noted.

While many key leadership positions are still “in flux,” Hoagland said ultimately those decisions are unlikely to alter Speaker Paul Ryan (R-Wis.) and Senate Majority Leader Mitch McConnell’s (R-Ky.) plans regarding the ACA.

Must-Do Legislation

In addition to changes to the ACA, Congress must also decide whether to preserve a handful of programs and bills before they expire including:

States start planning their budgets in the summer which means that the reauthorization of CHIP, a program managed by states and the federal government that provides healthcare for low-income children whose families aren’t eligible for Medicaid, must happen early in the session.

“Congress has to do something or those funds will not be available,” Patel cautioned.

The last time CHIP was reauthorized, the debate focused on whether the program was really needed because the ACA provided coverage to many of the same individuals. However, if the ACA is repealed and a replacement is not passed quickly, Congress will likely have to extend the program, Wilensky noted.

Meanwhile, two FDA reauthorizations — PDUFA and MDUFMA — are Congress’ “only shot” at curbing drug prices, Patel said.

However, Miller pointed out that a California ballot measure that required states pay no more for medication than the Department of Veterans Affairs failed to pass, possibly signaling a weaker resolve for taking on “Big Pharma.”

Hoagland noted that the passage of the 21st Century Cures Act was an example of bipartisan agreement on safety, efficacy, and innovation.

But the hard-line stance Sen. Chuck Schumer (D-N.Y.) has taken on repeal-replace could “stir the water early” and have ripple effects on other bills, he warned.

The Veterans Choice act allows veterans who live a certain distance from government health centers to seek care in private facilities, and this issue will be high on Congress’ radar as President-elect Trump made veterans’ healthcare a campaign issue, O’Shea said. Trump has spoken of at least partially privatizing veterans’ healthcare, although many veteran groups oppose the idea.

“They’re called vets; they’re not patients [at VA facilities] … they identify with the part of their life they’re most proud of,” he said.

Finally, Rep. Jeff Miller (R-Fla.), chair of the House Committee on Veterans’ Affairs, retired from Congress in 2016. He is one of several people being considered to run the Department of Veterans Affairs, which he’s criticized in the past.

RNC: And Now for a Different Take on Obamacare ACA

CLEVELAND — Could a Republican administration repeal Obamacare? That was the topic up for discussion at a briefing Tuesday, held outside the Republican National Convention.

“I do not believe … that my political party is going to be able to put together a complete repeal, and I don’t think it should,” said Tommy Thompson, JD, a fellow of the Council on Foreign Relations, who served as Secretary of Health and Human Services under President George W. Bush, and four terms as governor of Wisconsin.

Thompson was the keynote guest at the briefing hosted by RealClear Politics, and sponsored by Walgreens, the American Association of Nurse Anesthetists, the American Nurses Association, and the American Podiatric Medical Association.

He said attempting full repeal would create “real chaos. The Affordable Care Act has got lots of problems, but there’s some good parts of it, and most Republicans will recognize the good parts,” he told reporters after the briefing.

Republicans should focus on fixing Obamacare, by reducing its taxes, lowering premiums, and giving people an incentive to buy health insurance, he said.

“Why is it that you and I don’t get a tax deduction when we pay for health insurance, but the company that employs us does?” he said at the briefing.

Thompson argued for giving everyone a refundable tax credit to incentivize more people to buy into plans. He also said that the government should maintain parity laws, so that sick people aren’t charged more or kicked off their health plans — he called the latter move “un-American.”

When asked who the best person would be to navigate these “meaningful changes”, Thompson didn’t hesitate: “Without a doubt, Donald Trump.”

Policy analysts and journalists speaking on a separate panel were more skeptical, given Trump’s unpredictable nature and his changing opinions on healthcare reform.

“Donald Trump would be well-advised to outsource the making of policy to [Speaker] Paul Ryan (R-Wisc.),” said Lanhee Chen, PhD, JD, a research fellow at the conservative think tank, the Hoover Institution at Stanford University in Stanford, Calif. Chen was also the policy director for the Romney-Ryan 2012 campaign.

“Presumably, that’s what would happen,” he said, and then clarified “In an ideal world for conservatives, I think that’s what would happen.”

“I think we are in a phase of the conversation now, where we’re trying to do our best to imagine what a Trump administration would look like, when in reality, none of us really knows. This is like a freak wild card,” he stated.

Chen told MedPage Today, that full repeal would be “tough” but “a large amount of repeal” could happen through the budget reconciliations process, which requires fewer votes — a path that has already been tested.

If Trump wins the election, Chen anticipates a Republican administration would attempt repeal.

“It’s important for him to realize that just saying you’re going to repeal Obamacare alone is not enough, that there has to be a coherent plan to replace it,” he said, which is where turning to Ryan’s blueprint makes sense. “Otherwise, politically I think he’s in very dangerous water.”

If repeal weren’t achieved, Chen argued for developing more tailored plans to fit people’s needs that cost less, made possible by loosening some of the essential benefits requirements; paring back subsidies; developing a more “open architecture” to create a more competitive marketplace; and giving states more flexibility around Medicaid expansion on the front-end, instead of relying on the back-door 1115 waiver process.

If Secretary Hillary Clinton wins the presidency and Republicans maintain a majority in Congress, “they’ll want to try to work together,” Chen said. “It will be incumbent on [Senate Majority Leader] Mitch McConnell (R-Ky.) and Paul Ryan to lead that negotiation with her.”