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If the ACA is repealed, it’s the private insurance market that really becomes important, Kavita Patel, MD, a nonresident fellow in economic studies at the Brookings Institution and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

CLEVELAND — Ted Cruz enraged an arena full of Trump fans by failing to endorse the confirmed billionaire nominee, instead seeming to take the opportunity to relaunch his own brand.

And GOP nominee Donald Trump returned the favor by disrupting Cruz’s speech by entering the back of the hall giving his blessing to the jeering crowd.

Cruz started his prime time remarks with a conciliatory note by formally congratulating Trump on his nomination. He then paid homage to a slain Dallas police officer, criticized the “corrupt” Democratic establishment, slammed Obamacare, and then — at the point where most convention speakers would endorse the nominee — he went in a different direction.

“And to those listening, please don’t stay home in November. If you love your country and love your children as much as I know that you do, stand and speak and vote your conscience, vote for candidates up and down the ticket, who you trust to defend our party.”

The audience responded by booing Cruz off stage.

The jumbo screens above fizzed and crackled and eventually sputtered out for a period, but not before playing another family-focused video. Donald Trump’s son, Eric, spoke next, but it was former House Speaker Newt Gingrich who managed to restore order at least temporarily.

“I think you misunderstood one paragraph that Ted Cruz, who’s a superb orator, said,” Gingrich told the crowd.

“In this election there is only one candidate who will uphold the constitution,” he said, and that is Trump-Pence.

Later in the night, House Speaker Paul Ryan (R-Wis.) introduced Indiana Gov. Mike Pence as a”Reagan conservative.”

“He’s a man of faith, a man of conviction, a man you can trust,” he said.

And while Ryan reserved his praises for the vice presidential nominee, he spoke of sending “him and Donald Trump straight to the White House.”

Pence, billed as the headline attraction for the evening, then introduced himself.

“I’m a Christian, a conservative and a Republican, in that order.”

Pence introduced his mother in the audience, who blew him a kiss, and then the rest of his family.

Trump tapped Pence, a social conservative and born-again evangelical Christian, as his running mate last week.

He negotiated a compromise to expand Medicaid in Indiana, an action which even some liberal policy experts say they were gratified to see, but as recently as this past Saturday has promised to repeal Obamacare. In his remarks Wednesday, he took a poke at Hillary Clinton’s role in health reform during her husband Bill’s administration, saying, “She planted the seeds of the disaster we now know as Obamacare.”

The core of Thursday’s speeches centered around law and order and defeating terrorism, but the speakers spent considerable time bashing Clinton, the former Secretary of State and presumptive Democratic nominee.

And Pence fell in line with that theme calling her “America’s secretary of the status quo”

“It’s change versus the status quo … and when Donald Trump is elected president of the United States of America the change will be huuuuuge,” he said, playing to the audience. While the crowd interrupted Pence several times with chants of “Trump” and “USA” he waited them out.

During the day, there were a number of protests in the public square outside the Quicken Loans Arena, site of the convention — including a flag-burning protest that involved 17 arrests. Leah Wolfe, who was working as a volunteer”street medic” treating injured protesters, said she had mostly been taking care of minor injuries such as blisters, sunburns, and dehydration.

The street medics haven’t had much contact with regular emergency medical services (EMS) staff as of yet, she noted. “We’re trained to identify real emergencies, so if a real emergency happens behind police lines, EMS is not allowed to go back there because they have to wait for police to clear the scene, whereas a lot of street medics are willing to be back there so they can help people, and get them out to the ambulance if it’s necessary.

“We’re a collective effort of volunteers from all over the country,” added Wolfe, who was interviewed prior to the flag-burning protest. “For me it’s practice in disaster preparedness … [although] so far it seems like it’s been pretty calm.”

When GOP presidential nominee Donald Trump takes the stage tomorrow night, physicians, nurses, and other health professionals will be joining the ranks of protesters outside the arena.

Protesters will convene Thursday afternoon for a march and later that evening for a rally in Public Square.

RNC Day One: A Dust-up, But No Derailments

CLEVELAND — The Republican National Convention here kicked off calmly Monday, but then descended into chaos, if only temporarily.

Business began as usual with the Pledge of Allegiance and the other standard opening procedures. Delegates even danced to the music, some wearing cowboy hats as many two-stepped in the aisles to the tune of “Happy Together,” “Come Join the Party,” and “How Sweet it is to be Loved by You.”

Despite that amicable beginning, things got rowdy inside the Quicken Loans Arena when the chair of the Republican National Committee’s rules committee moved that the convention rules be adopted.

A voice vote was taken but because both sides were shouting very loudly it was unclear whether the Aye or Nay votes had prevailed. A lot of chanting followed, including voices saying “USA!” and others yelling “We want Trump!”

The convention chair then asked for another voice vote. He declared that the rules committee report had been adopted. A delegate from Utah requested a voice vote but his request was denied, with the chair saying there was not enough support for one. The convention business resumed shortly thereafter, although shouts of “Roll call vote!” erupted periodically.

That dissension was emblematic of disagreements about Donald Trump, the party’s presumed nominee, that were going on behind the scenes, even though Paul Manafort, Trump’s acting campaign manager, had presented unity as one of the convention’s core themes during a press briefing Monday morning.

As one example of some prominent party members’ dissatisfaction with Trump, John Kasich, Ohio’s own Republican governor, will not be speaking at the convention and has thus far failed to endorse the candidate.

“He’s embarrassing his party,” Manafort said of Kasich at a media breakfast.

The theme for the opening day was “Make America Safe Again,” with a focus on national security, but a few speakers did make comments about healthcare issues.

Rep. Greg Walden (R- Ore.) slammed the Affordable Care Act (ACA). “Under this flawed law, healthcare has become anything but affordable,” he said. “Insurance premiums and healthcare costs, they’ve skyrocketed. Another round of double-digit rate hikes are set to hit consumers this November. Obamacare is what happens when a president cares more about securing a political win than setting good policy for our country.”

Walden drew comparisons between Obamacare and the “patient-centered” replacement plan touted by House Republicans, including House Speaker Paul Ryan (R-Wisc.). “We’re offering a real alternative and showing voters that Republicans are the party of new and good ideas, while Democrats are clearly the party of the failed status quo, especially on healthcare … Donald Trump will be our partner in this effort and together we will replace Obamacare with healthcare that works for all Americans.”

The orthopedic surgeon who chairs the party’s platform committee,Sen. John Barrasso, MD, (R-Wyo.), also criticized the ACA.”The president … dismantled the American system of healthcare and replaced it with a costly, complicated scheme that takes away our freedom,” he said.

Outside the “Q” second tier activities included a forum on the future of health information technology, sponsored by the Health Information and Management Systems Society (HIMSS).

Martin Harris, MD, chief information officer at the Cleveland Clinic, discussed his facility’s use of a patient portal that gives patients most test results at the same time as their physicians receive them.

“It creates a continuous relationship with physician that’s sustainable over time,” he said of the portal, which patients can access on their smartphones. “Now patients have access to exact same information that their provider has.” Certain test results, such as pathology results for suspected cancers, are delayed before being posted in the patient portal until the physician has time to discuss them with the patient, he added.

Warren Selman, MD, neurosurgeon-in-chief at University Hospitals of Cleveland, discussed the benefits of using a 3-D virtual reality system to analyze neurosurgery patients. One advantage is that it makes consultation with far-away colleagues easier.

“It’s not enough for me to make a decision by myself [in some cases] … Wouldn’t it be great to get a couple of colleagues on the same surgical theater and say, ‘Would you take a look at this? Take a look in 3D and tell me what you think,” he said. “Virtual reality has a very strong place in improving healthcare.”

In addition, Selman said, being able to see, for example, what their own brain aneurysm looks like and how the neurosurgeon is planning to approach the surgery “gives patients a greater sense of trust.”