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If the ACA is repealed, it’s the private insurance market that really becomes important, Kavita Patel, MD, a nonresident fellow in economic studies at the Brookings Institution and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

Obamacare and Planned Parenthood Get Axed by Senate

WASHINGTON, D.C. — The Senate took a first step toward dismantling the Affordable Care Act, aka Obamacare, and defunding Planned Parenthood, and now the ball is in President Obama’s court.

But the president has already stated his intention: he will veto the bill.

The “Restoring America’s Healthcare Freedom Reconciliation Act” or less formally the “Obamacare repeal bill,” passed 52-47, with Sen. Susan Collins (R- Maine) and Sen. Mark Kirk (R- Ill.) joining the Democrat opposition.

Sen. Bernie Sanders (D- Vermont) was absent for the vote.

The new bill would dismantle the individual mandate, as well as the employer mandate — an unpopular provision that requires mid-size businesses to provide health insurance for workers.

Other major provisions of the bill include:

  • Reversing Medicaid expansion after a 2-year transition period.
  • Repealing certain tax increases including taxes on medical devices and prescription drugs
  • Preventing federal funds from reaching Planned Parenthood for 1 year.
  • Take new monies from repeal and invest them in Medicare Trust Fund.

An amendment sponsored by Sen. Dean Heller (R-Nevada) to repeal the “Cadillac tax”, a levy on expensive insurance plans slated to begin in 2018, also passed in a vote of 90-10.

But an amendment from Sen. Collins and Kirk and Sen. Barbara Murkowski (R- Alaska) to remove language targeting investments in Planned Parenthood failed.

President Obama will undoubtedly veto any bill that would hurt his signature law or restrict women’s reproductive rights. Nonetheless, Republican Senators are basking in the victory of the moment because it is the first time a repeal measure on Obamacare has passed the Senate.

And, the gesture, veto or no, is still meaningful for anti-Obamacare conservatives because it gives them a chance to flex their political muscle, put their aversion for the President’s health reform bill in writing and fulfill a promise to their constituents on the eve of an election year.

Before the vote began, Sen. Mitch McConnell (R-Kentucky), the majority leader, seemed to be suppressing a grin. “A new Senate that’s back on the side of the American people will vote to move beyond all of the broken promises, all the higher costs and all the failures,” he said.

“We will vote to build a bridge away from Obamacare and toward better care.”

Then Sen. Patty Murray (D-Washington) spoke, citing the millions of Americans who now have health insurance.

“I am ready, and I know our colleagues on this side are, to work with anyone who has good ideas about how we can continue making healthcare more affordable, and expanding coverage and improving quality of care, but the legislation we have spent the last few days debating, which has no chance of becoming law, will do the exact opposite.”

She continued, “I hope, once this bill reaches the dead-end it has always been headed for, Republicans will drop the politics and work with us to deliver results for the families and communities we serve.”

Under budget reconciliation, a special process that pertains only to revenue-related programs, and can’t be filibustered — it requires only 51 votes, instead of 61 to pass. It also allows unlimited amendments and 20 hours of negotiation.

Sen. Elizabeth Warren (D- Mass.) , responded to the conservative attack on Planned Parenthood, which was exacerbated in recent months by reports that centers used fetal tissue for research. She stressed that no federal funds are currently being spent on abortion, under the Hyde Amendment, calling the bill “a reckless scheme.”

“This isn’t a game for the millions of women who depend on Planned Parenthood for basic medical care every year and have nowhere else to go.”

Sen. Harry Reid (D- Nevada) who defended the Affordable Care Act earlier on Thursday, also argued against repeal, and against the conservative view that constituents are hammering to see Obamacare killed. He listed states whose Republican governors “displayed courage” by expanding Medicaid despite criticism from their own Republican senators .

“If Obamacare is so awful why are Republicans in Kentucky, Wyoming, Montana, North Dakota, New Hampshire eager to use it? Simple. The Affordable Care Act expands coverage and cuts costs. It’s good for the states.” It should be noted that Kentucky expanded Medicaid when Steve Beshear,a Democrat, was governor. The current governor, Republican Matt Bevin, is planning to roll back that expansion.

Sen. Dan Sullivan (R- Alaska) disagreed.

“Probably no other state in the country has been more negatively damaged by Obamacare than Alaska,” he said. Of the five insurers who initially offered healthcare plans on the exchanges only two are left, he said and both will raise premiums by about 40% this year.

Sullivan said many Alaskans chose to stomach the penalty for not complying with the individual mandate, rather than paying for health insurance “that’ s been forced on them by the federal government and that they cant afford.”

He also found it “a bit ironic” that Democrats were complaining about a predictably partisan vote on the repeal, noting that Obamacare originally passed through the House and Senate on party lines 6 years ago. “To hear their concerns now rings a little hollow.”

Sen. Lamar Alexander (R-Tenn.) decried the “unfunded mandate on Medicaid” in a press statement Thursday, he wrote, “When I was governor, Medicaid only made up about 8 percent of Tennessee’s state budget. By last year, it was 30.6 percent. States paying more and more to expand Medicaid means less to spend on other priorities like higher education, roads, and law enforcement.”

Sen. Barbara Boxer (D- Calif.) said on Wednesday she thinks that Republicans secretly want the bill to fail. “They have nothing, nothing, to replace it with. It’s kind of a joke.”

Sen. Johnny Isakson (R-Georgia), who also spoke on the floor Wednesday said, “The promise of lower cost healthcare and better benefits was exactly wrong. What the American people were promised is wrong… It’s time the American people got the truth, better coverage, lower costs and do it the old fashioned way with a private competitive system.”

McConnell said Thursday, the House would have a chance to vote again on the amended bill, and then, he continued, “President Obama will have a choice. He can defend the status quo that’s failed the middle class by vetoing the bill or he can work toward a new beginning and better care by signing it.”

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

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.

Doctors, Nurses Still Divided on Tom Price

WASHINGTON — When President-elect Trump chose Rep. Tom Price (R-Ga.) to be Secretary of Health and Human Services, he poked an already buzzing hornet’s nest.

Like the rest of the country, doctors, nurses, and medical students have very divided opinions about the government’s role in healthcare. Price’s nomination amplifies that division.

The American Medical Association (AMA) voiced immediate support for Price, while the American Medical Students Association (AMSA), Physicians for a National Health Program (PNHP), and National Nurses United (NNU) roundly condemned the nominee. Most other physician and nurse organizations voiced something between concern and resignation.

MedPage Today spoke with the leadership of several physician and nursing groups to understand their concerns and in some cases highlight areas of agreement.

Line In the Sand

On Nov. 29, the AMA backed Price, a member of the association’s House of Delegates, in a press statement: “Dr. Price has been a leader in the development of health policies to advance patient choice and market-based solutions as well as reduce excessive regulatory burdens that diminish time devoted to patient care and increase costs,” wrote Patrice Harris, MD, a psychiatrist from Atlanta and chair of the AMA Board of Trustees.

That statement infuriated many physicians, including AMA members and nonmembers alike.

For example, the Clinician Action Network, led by Manik Chhabra, MD, Navin Vij, MD, and Jane Zhu, MD, MPP, posted a letter that has since gathered 5,000 signatures from clinicians across the country: “We believe that in issuing this statement of support for Dr. Price, the AMA has reneged on a fundamental pledge that we as physicians have taken — to protect and advance care for our patients.”

The letter criticized Price’s record and presumed agenda, such as “the dismantling of Medicaid” and “proposals to reduce funding” for the Children’s Health Insurance Program. The group also worried that essential benefits such as opioid use disorder treatment, prenatal care, and access to contraception would be threatened.

Harris explained that the AMA’s support should not be viewed as a blanket endorsement for every one of Price’s positions. She also recalled the “flurry of objections” that targeted another physician nominee, C. Everett Koop, MD, who served as surgeon general under President Ronald Reagan. Koop is now remembered for his efforts to prevent tobacco use and to promote safe sex for AIDS prevention.

Initially, many physicians were alarmed by Koop’s anti-abortion stance, Harris noted. But “Dr. Koop’s one-time opponents later cited him as a role model for how the U.S. surgeon general can help the nation face serious health care challenges.”

Some Docs Enthusiastic

Others, like Jane Orient, MD, executive director of the Association of American Physicians and Surgeons, who practices in Tucson, Ariz., offered unqualified support for Price’s nomination.

Orient said she shares Price’s views on reproductive rights and does not believe taxpayers should pay for another person’s abortion or birth control, which she said “is quite reasonably priced.”

She said she considers Price’s critics’ concerns for health equity “laughable.”

“Instead of trying to have the optimal medical care for everybody and [giving] people the right to choose their own medical care and the right to control of their own money, they want to take these resources out of the hands of people making decisions for themselves and put it in the hands of bureaucrats who have this whole formula to decide what they think is equitable. And they don’t think it’s equitable for people to spend their own money for their own medical care,” Orient said.

“Tom Price has been in favor of allowing people to do this, even if they’re on Medicare,” she said, referring to Price’s support for Medicare privatization.

Red Flags for Others

While PNHP has been critical of the Affordable Care Act, wholesale repeal is not the solution the group has in mind — that is, unless the ACA were replaced with a single-payer system, Robert Zarr, MD, a pediatrician based here and a past PNHP president, said in a phone interview with MedPage Today.

Instead, Zarr anticipates an acceleration of healthcare privatization: “We’ll see it go a lot faster now that we have a House and a Senate and a White House presumably agreeing on this one premise — which is ‘private is good, public is bad.'”

“People who have HIV, who have advanced kidney disease … people who are living in devastated communities economically … If access to healthcare is made harder and harder, then they’re going to have a shorter lifespan, and they’re going to suffer more before they die.”

Many nurses also oppose Price’s nomination, Deborah Burger, RN, of Santa Rosa, Calif., and co-president of National Nurses United, the largest nurses union in the country, told MedPage Today in a phone interview.

If the ACA is repealed, one of the first steps in that repeal will likely involve a reversal of the tax increases that fund subsidies that help people afford their premiums.

And the revenue for Republicans’ proposed block grants for Medicaid won’t be there, she continued.

Seeking Common Ground

Other nurses like Pamela Cipriano, PhD, RN, president of the American Nurses Association, also criticized Price’s record on diversity and inclusion, as well as his opposition to gay marriage.

As more people declare their gender identity and sexual identity, they have been ostracized and stigmatized by clinicians, said Cipriano: “The healthcare community really needs to step up to make sure that these [LGBTQ] individuals … are being adequately cared for, and if there’s an inherent bias in the leaders of our Health and Human Services [Department], that doesn’t bode well for the healthcare community really embracing their needs.”

Price will very likely be confirmed, said Cipriano. She hopes that he will listen to nursing groups. In addition to supporting continued federal funding for nursing education, Cipriano hopes Price will set partisanship aside and embrace the “triple aim” — improving access, quality, and affordability of healthcare — and continue to advance value-based payment.

The American Congress of Obstetricians and Gynecologists (ACOG), in a letter to Price concerning his opposition to federal funding for abortion and for Planned Parenthood, sounded a warning: “Planned Parenthood clinics provide critical preventative healthcare services to women and men. Abortion is healthcare. ACOG remains committed to protecting each of these critical aspects of women’s health.”

The group also acknowledged areas where Price’s views aligned with its own: Medicare physician payment reform, repeal of the Independent Payment Advisory Board, and medical liability reform.

“Your consistent efforts to find common ground and work together on shared goals are laudable, and your commitment to accomplishments, rather than talking points, is unfortunately all too rare in Washington. We hope that you will use your new role as an opportunity to expand on these collaborative practices,” ACOG wrote.

Laura Wooster, MPH, executive vice president of public policy for the American Osteopathic Association, also sounded a cautious tone in a phone call with MedPage Today. “Other than stating our priorities, it seems premature to really start getting vocal,” she said, explaining that the group doesn’t normally endorse or oppose nominees.

She noted, though, that many of the group’s members have echoed one of Price’s talking points, the “administrative burden” that government involvement in healthcare can sometimes bring.

Senate Opposition Brewing?

Even though confirmation seems assured, Price still must face grilling and probable opposition from Senate Democrats.

On Thursday, Democrats in Congress called for an ethics probe into Price’s financial holdings and investments. Price traded $300,000 worth of shares in health-related companies while in the House, according to The Wall Street Journal.

“There’s enough evidence here that cries out for an investigation. Whether the law was actually broken, whether there [were] quid pro quos or inside information is the better way to put it — we don’t know,” said Senate Minority Leader Chuck Schumer (D-N.Y.) at a news conference, as reported by CNN.

Senators Grill Price, but He Stands His Ground

WASHINGTON — Repeal of the Affordable Care Act and its consequences were on the hot seat as senators questioned Rep. Tom Price, MD (R-Ga.) Wednesday about his fitness to serve as Secretary of Health and Human Services.

“I have serious concerns about your qualifications for the department you hope to lead,” said Sen. Patty Murray (D-Wash.), ranking member of the Health, Education, Labor, & Pensions (HELP) Committee, at a hearing on the nomination. “Just last week you voted to begin the process of ripping apart our healthcare system without any plan to replace it, even though [it’s estimated that] 30 million people will lose their coverage.”

Wednesday’s hearing was a “courtesy” hearing before the committee, which is not tasked with sending Price’s nomination to the Senate floor for a vote. That responsibility falls to the Senate Finance Committee, which is scheduled to hold a formal confirmation hearing and vote on the Price nomination next Tuesday.

Healthcare for All

Price maintained that if he is confirmed, he will fulfill president-elect Donald Trump’s promise of healthcare for everyone. “The principles that I think are absolutely imperative for the healthcare system is one that’s affordable for everybody, one that provides access to health coverage and care for everybody, one that’s of highest quality, that’s responsive to patients … one that incentivizes innovation, and that insures choices are made and preserved by patients,” he said.

Access was a word that Price returned to frequently when he was asked if he would guarantee that certain groups would not lose healthcare coverage under a replacement for the ACA. “It’s incredibly important that we have a system for every single American to have access to the kind of coverage they need and desire,” he said in answer to another question.

Access to health insurance is not an exact match for President-elect Donald J. Trump’s promise of health insurance for all, a point hammered home by Vermont Sen. Bernie Sanders, the independent who challenged Hillary Clinton for the Democratic nomination. “I have access to buying a $10 million home. I don’t have the money to do that,” Sanders said.

Democratic senators also pressed Price on potential conflicts of interest, specifically his healthcare stock trades, several of which been the subject of media coverage. Price maintained that many of his stock trades are done through a broker so he is not always aware of them, and that he has disclosed any relevant trades as required by the House Office of Government Ethics.

In response to questions about his purchase of stock in six pharmaceutical companies shortly before introducing a bill blocking a regulation that would likely have hurt those same companies, he noted that “My opposition to having the federal government dictate what drugs are available to patients is longstanding.”

Contraception Coverage

Murray also asked Price about his views on paying for contraceptive coverage. “You have said you don’t think cost is an issue for women in buying birth control and stated, ‘Bring me one woman who has been left behind … there is not one,’ correct?” she said.

“I think what I said and what I meant was that when I had patients in my office who were unable to afford medication, we did everything we could to make certain they got that medication. What I meant to capture in that conversation was that if there are individuals who are unable to afford that med, or any med, that there are avenues within the healthcare system physicians and others take to make sure individuals receive medication that they need.”

Murray related the example of a constituent diagnosed with endometriosis who takes contraceptives for chronic pain and who told Murray that “No copay birth control is an essential tool for helping women like me with endometriosis who otherwise would have to live with chronic pain.”

“Women are deeply concerned about the impact this election could have on access to healthcare they need; I’ve heard from many of them,” said Murray. “Will you commit to ensuring all 18 FDA-approved methods of contraception continue to be covered so women don’t have to go back to paying extra costs for birth control?”

“What I will commit to … is that we believe strongly that every single American ought to have access to the kind of coverage and care they desire and want,” said Price. “That’s our commitment and it runs across the board.”

“Birth control is an essential part of women’s healthcare and if you are confirmed I will be holding you accountable for that,” Murray responded.

As was expected, Price received friendlier queries from Republicans on the HELP Committee. “You are clearly one of premier people in all of Congress to understand the problems of healthcare, and have the background … to solve the problems we have,” Sen. Orrin Hatch (R-Utah) said to Price, an orthopedic surgeon.

Sen. Rand Paul, MD (R-Ky.), also spoke favorably of Price. “I think what I regret about this kind of hearing is sort of the vitriol, the rancor and partisanship that should go into something; we want the same things. To question your motives is insulting; To question whether you’re honest is insulting … I think we all want the most amount of insurance for people, and the least amount of cost.”

Paul and Price discussed ideas that might be included in a Republican replacement for the ACA, including health savings accounts and high-deductible catastrophic coverage. “I think health savings accounts and high-deductible catastrophic coverage make a whole lot of sense for many individuals; they ought to have the choice,” said Price.

He also said a replacement plan could include high-risk pools to insure people who might otherwise have trouble getting coverage. Sen. Al Franken (D-Minn.) who was called on next to question Price had his own comment on the risk pool idea: “I’ll tell you how to get a really big risk pool — it’s called Medicare for everyone,” he said.

Price also discussed the Meaningful Use regulations for physicians’ use of electronic health records. “Electronic medical records and electronic health records (EHRs) are so important because … they allow the patient the opportunity to have their health history with them at all times, and allow the provider access to that,” he said. “We in the federal government have a role [in EHRs], but that role ought to be interoperability, to make certain that different systems can talk to each other so it inures to the benefit of the patient.”

But the Meaningful Use rules have really been burdensome for doctors, Price added. “I have had more than one physician tell me that the final regulations and rules related to Meaningful Use were the final straw for them … and they quit.”

“I think the thing that’s absolutely imperative, is to find out what things ought to be determined and checked … that the metrics used actually correlate with what’s being provided … so if we truly worked with those providing the care, saying, ‘What is it that we could ask you to measure that would really correlate with the outcome and quality of care provided,’ I suspect there’s some really specific things we could use.”

“Hope those watching are reassured by what they heard from you,” committee chairman Sen. Lamar Alexander (R-Tenn.) said as the hearing concluded. “While we intend to repair damage from Obamacare and that would mean repealing major parts of it, that won’t become effective until alternatives are in place … we don’t want to pull the rug out from everybody.”

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Volunteers deliver petitions to the Senate HELP Committee with more than 510,000 signatures from people opposing the nomination of Rep. Tom Price, MD, as Health and Human Services secretary. (Photo by Shannon Firth)

Voices Opposed

Just before the hearing began Wednesday morning, representatives of Planned Parenthood, the National Physicians Alliance, Physicians for a National Health Program, and Public Citizen, hand-delivered stacks of boxes containing various anti-Price petitions that they report include 500,000 signatures.

“As a physician, it just doesn’t look like he puts the interests of patients first,” said Susan Molchan, MD, a psychiatrist, nuclear medicine physician, and member of the board of directors for the National Physicians Alliance, told MedPage Today.

Molchan cited his stock buys in tobacco companies as evidence that Price has put corporate interests ahead of patients. Price opposed regulating nicotine as a drug, but Molchan said “nicotine has clearly been accepted as a drug, a very addictive drug for years.”

Price’s support for privatizing Medicare, by transitioning to a voucher-like program for future beneficiaries, also worried Molchan.

“To throw Medicare, which has much lower overhead than private insurance … into the grinder of private health would be terrible.” While she acknowledged that Medicare has its flaws, “it works better than the private health industry, which is out for big corporate entities,” she said.

If his nomination is confirmed, Price’s leadership, “will further erode standards for the approval of medical devices and the approval of drugs,” said Sammy Almashat, MD, MPH a research associate for Public Citizen’s Health Research Group based here.

“We’re very concerned that his presence [at HHS] will send a message to the FDA that the standards should be lowered even further than they already have been.”

His support for repealing the Affordable Care makes him “very dangerous” particularly for Americans with life-threatening diseases such as cancer and HIV and other chronic diseases, he said.

“[G]utting the minimal safety nets that still exist in the form of Medicare, in the form of the Affordable Care Act, would be disastrous for those patients. As a physician, I don’t see how another physician could support such policies.”

Day One: Trump Begins ACA Take Down

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.”

Healthcare Proponents Rally at Women’s March

WASHINGTON — Among the masses that descended on the nation’s capital Saturday for the Women’s March was Katie MacMillan, a fourth-year medical student.

“This isn’t all about ‘Not-Trump,'” said MacMillan, referring to Donald Trump, who was sworn in as the 45th president on Friday. An aspiring pediatrician at Quillen College of Medicine in Johnson City, Tenn., MacMillan wants to ensure that women’s reproductive rights are respected, as are vaccination criteria for U.S. children.

“We want women to have access to anything they need to to make the right choices for their bodies,” she said.

As for vaccines, MacMillan said people mistakenly associate them with autism because symptoms of the condition often surface around the time when their children get their shots, but the two events are unrelated. “A lot of people are afraid, and I think fear motivates people in a bad way to make uninformed choices,” she emphasized.

 

Many marchers were in step with MacMillan, armed with signs and banners that promoted reproductive rights and “Medicare for All,” among other hot button issues.

Annie Kolarik, a fellow fourth-year medical student, agreed that Trump wasn’t the only reason for the protest, stating that “the need to fight for women’s rights’ existed before Trump and will exist long after he’s gone.”

MacMillan and Kolarik were joined by other healthcare professionals on the day after Trump’s inauguration. “Sister protests” were held all around the world, including in Boston, Chicago, Miami, New York, Denver, and London.

Saving the ACA

Some healthcare advocates were there to stump for the beleaguered Affordable Care Act (ACA). Late on Friday, Trump signed an executive order 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.

Elizabeth Collins, MD, a resident at Thomas Jefferson Hospital in Philadelphia who drove to Washington with friends, told MedPage Today “Our whole goal is ultimately single-payer healthcare but [the ACA] is about as close as we’ve gotten.”

Another ACA advocate, Kyle Ragins, MD, MBA, an organizer for Doctors for America and a resident at the University of California Los Angeles, said he was pleased at the physician turnout on Saturday.

“I think people appreciated seeing a doctor’s presence … to offer perspective that healthcare providers are on the side of the American people,” Ragins said in a phone interview.

Since the ACA was implemented, Ragins said he has been able to help patients, who have presented in the emergency department, gain healthcare coverage. “To be able to say [to a patient], ‘It sounds like you have a chronic condition that’s going to require specialist care … and you need to get health insurance, so that you can do that’ … to be able to do that from the emergency department is huge.”

Single-Payer Advocates

Carol Paris, MD, the new president of Physicians for a National Health Program, a single-payer advocacy group stood with fellow doctors at the march, holding “Medicare for All” posters.

Paris, a retired psychiatrist from Nashville, Tenn., told MedPage Today, that while she was pleased to see 20 million people get insurance through the ACA, she believes the law is flawed.

On the other hand, repealing the ACA will result in a “leaner and meaner” ACA under a different name, she said.

Paris said she does agree with conservatives that the ACA triggered “needless expense and bureaucracy,” but those same conservatives have told her a single payer system is not “politically feasible.”

Still, she is undeterred: “I will not tolerate another administration and another 4 years of incrementalism.”

Reproductive Rights

A call for maintaining reproductive rights was a dominant theme, with chants of “Women’s rights are human rights.” The main march was co-sponsored by Planned Parenthood, with NARAL Pro-Choice America and Emily’s List named as “social justice partners.”

Ilyse Hogue, president of NARAL, said that she was proud her organization was taking part in the event.

“The diversity driving these marches and the progressive values they represent demonstrate the strength of the grassroots political power at the core of this movement. It also sends a strong message to the anti-choice politicians trying to roll-back our right to access basic reproductive health-care, including abortion,” she said in a press release.

A representative for the American Congress of Obstetricians and Gynecologists (ACOG) said in an email that it was not participating in the march “in any kind of official capacity.” ACOG did not issue any statements regarding the march, although last week, it did officially stand against a House bill (HR 490) that bans abortion after the detection of the fetal heartbeat, which occurs as early as 6 weeks gestation, measured from the woman’s last menstrual period.

“This bill is both unconstitutional and unnecessary political interference in the practice of medicine,” according to an ACOG news release.

Donna Harrison, MD, executive director of the American Association of Pro-life Ob.gyns called the march a “pro-abortion march disguised with a more palatable spin.”

“It is interesting to us that with all the talk about focus on women, none of the participants will cover the documented association between abortion and preterm birth, abortion and breast cancer, and abortion and psychological suffering,” Harrison stated in an email, adding that the organization will take part in the March for Life on January 27.

Optimism, Excitement, and Protest: An Inauguration Day Snapshot

WASHINGTON — Before and during Friday’s inauguration of Donald J. Trump as the 45th president, MedPage Today reporters were on the phone and on the scene to talk to healthcare providers — those taking care of the inauguration crowd as well as physician members of the audience — and members of Congress who are health professionals and had their own take on the day. We also were present for one of the more offbeat protest actions at the inauguration.

Rep. Eddie Bernice Johnson (D-Texas), a former psychiatric nurse, was at the inauguration. “I really don’t know Trump, but I’m going to do my best to make the best use of my working with him for the betterment of my constituents,” she said in an interview Thursday. “I just can’t sit back and say, ‘Mine didn’t win and there’s nothing I can do.’ … I just believe that if I work hard there’ll be something I can do that will represent the people of [my] district.”

At the inauguration, Lou Provost, a member of a two-person roving medical team from the U.S. Public Health Service that was on the lookout for inauguration-goers who experienced health problems, said that things had been slow so far, “which is just the way we like it.” Any minor injuries the two had seen came from people who had tripped or fallen on the soft ground near the Capitol.

Bijender Kumar, MD, medical director of Hancock Regional Hospital in Indianapolis, Ind., said in a phone interview from the inauguration that he was excited about Trump’s presidency because “we definitely need some changes in the Affordable Care Act (ACA).” Kumar said he was “proud” of Rep. Tom Price, MD (R-Ga.), President Trump’s nominee for Secretary of Health and Human Services, and that Price and Seema Verma, Trump’s pick to run the Medicare and Medicaid programs, “might make great changes” by working together.

However, Kumar said he was not in favor of completely repealing the ACA. “Twenty million people are already on it, so completely repealing it is not a good idea,” he said.

Good Ideas for Replacement

Another supporter, Anne Galante, MD, an ob.gyn who volunteers at the Open Door Clinic of Middlebury, Vt., also did not support full repeal; however, she’s still critical of the law.

“The spirit of covering everybody is good, but in reality it wasn’t good for everybody … People technically have insurance, but they can’t use it.”

Trump has good ideas for replacing the ACA, she said — i.e., including health savings accounts and allowing health insurance companies to sell plans across state lines — and she believes that he won’t let people “die in the streets,” as he’s promised.

She admits, she is “nervous” — “I really hope the new administration doesn’t drop the ball.”

Meanwhile, a few hundred people gathered downtown Friday morning to call for President Trump to end federal cannabis prohibition. Congregating on the sidewalk just to the west of Dupont Circle in Northwest Washington, a group of event organizers with the group DCMJ handed out small joints to anyone who could show proof of being at least 21.

About 11:30 a.m., the protesters marched down 19th Street towards the National Mall. They played music as they walked, arriving peacefully in between the Washington Monument and World War II Memorial.

Several protesters headed for a nearby security checkpoint to get into the Mall, while others stayed outside and listened to the inauguration festivities via a portable speaker organizers brought. Four minutes, 20 seconds into Trump’s speech, most among that crowd of about 100 sparked their lighters and indulged.

Helping the Uninsured

Sen. Bill Cassidy (R-La.) sounded positive about Trump’s inauguration speech, in which he talked about solving the problems of the poor.

Cassidy said he wasn’t disappointed that new president hadn’t mentioned healthcare.

“If you combine his previous statements regarding the need to cover all and take care of those with pre-existing conditions with [today’s speech] about those who have not done well over the past 8 years and you put them together … it shows that I think he’s going to be where most physicians are,” he said in a phone interview. “We want patients to have coverage, and we want it to be meaningful.”

Rep. Andy Harris, MD, (R- Md.) said Trump’s speech was non-partisan. “It was an America-first speech. He was unabashedly America-first on the campaign and I think it struck a chord in the Midwest.”

Harris was also unfazed by the absence of healthcare in Trump’s speech.

“I think he’s going to to roll up his sleeves and begin to take the steps to make sure that American healthcare and health insurance becomes affordable … He’s sent clear signals in the last week that this is one of his top priorities.”

Harris characterized healthcare changes as “reform and replace” rather than repeal-and-replace, noting that Republicans can’t do everything they’d like through the budget reconciliation process.

“Without 60 votes in the Senate you really can’t repeal it… I’m just being a little more technically correct.. The end goal is to put in something that works, so I don’t think that the semantics of it matter.”

‘Repair’ Rather Than ‘Replace’

Harris’s colleague, Rep. Ralph Abraham, MD, (R- La.) took a similar view.

“I would prefer to use the word ‘repair’ rather than ‘replace,’ because we’re going to keep some things. It’s not going to be a complete replacement, but it’s going to be a pretty good overhaul,” he told MedPage Today in a phone interview, noting that preserving access for those with pre-existing conditions and allowing people under 26 to stay on their parents’ insurance plans were two of the “good things.”

Anish Koka, MD, a Philadelphia cardiologist who supported Obama prior to voting for Donald Trump, said he was optimistic about Trump’s healthcare plans. “My general feeling was we were headed on a path that’s going to make it more and more challenging for physicians — especially independent physicians — to survive, since [things like] bundled payment and large integrated care networks have a lot of [requirements] that a lot of solo or small practices don’t have,” he said in a phone interview.

“It is somewhat of a relief to feel that, based on some of the early comments Tom Price has made — certainly at his hearing — there may be relief coming for independent physicians in terms of onerous regulations that are tough to manage.”

As for the ACA, “Whether you call it repeal, or fixing it, something that allows us as physicians to take on patients in a way that’s not untenable; that’s what I’d like,” Koka said. “The vast majority of us want expanded access for patients … the question is, how do we get that? It became increasingly obvious that the ACA and the way they were going about it is not necessarily the best way to go about it.”