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.
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If the ACA is repealed, it’s the private insurance market that really becomes important, Kavita Patel, MD, a nonresident fellow in economic studies at the Brookings Institution and a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.
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.
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.