February 6, 2017

By Mike Amery, Esq., Senior Legislative Counsel

The Repeal and Replacement of Obamacare

Republicans ran election campaigns focusing on the repeal of the Affordable Care Act (ACA), also known as “Obamacare” in 2010, 2012, 2014, and 2016. They eventually gained all three legislative legs of government with the House in 2010, the Senate in 2014, and then the presidency in 2016. Now they are working at fulfilling their pledge. 

The goal of this Capitol Hill Report is not to discuss the merits of potential changes, but rather, to examine the process that Republicans will try to use to repeal and replace and the defenses that Democrats might be able to employ in opposition. 

The main defense Democrats have is that controversial legislation almost always needs a 60-vote supermajority to pass through the Senate. Because Republicans only control 52 votes in the Senate, they cannot outright repeal and replace with an up or down vote. Last week, I had the opportunity to speak with both Speaker Paul Ryan (R-WI) and House Majority Leader Kevin McCarthy (R-CA) about their plans. Recognizing the inherent difficulty in getting to 60 votes in the Senate, Ryan and McCarthy plan to use three separate methods for repealing and replacing the ACA. They are calling the strategy “three buckets.” 

Bucket #1 - Reconciliation
Reconciliation is a legislative process that requires only a majority vote in the Senate, but it is restricted to proposals that change a budget deficit or surplus. Republicans passed a budget last month. This opened the door to make changes to the ACA, but only on those provisions that impact the budget. This includes sections such as the individual mandate, the medical device tax, and the Cadillac tax. This part should be easy. However, eliminating some of these provisions will likely be very expensive, which requires spending cuts in other areas or increased revenues, which would mean the unlikely prospect of raising taxes.

Bucket #2 - Department of Health and Human Services (HHS)
The legislation creating the ACA passed by Democrats in 2010 runs 2,700 pages. The word “secretary” appears in the ACA more than 3,000 times. This means that the secretary of HHS is given wide discretion on interpreting and implementing many of the ACA's provisions. A perfect example of this was the ACA's “Medicaid bump” which allowed the Center for Medicare & Medicaid Services (CMS), a division of HHS, to expand the bonus to all internal medicine subspecialties, but not neurology, psychiatry, or OB/GYNs.

President Trump's nominee for HHS secretary is Rep. Tom Price, MD, (R-GA) who is a former orthopaedic surgeon. Assuming he takes the reigns at HHS, his first priority is likely to begin unraveling Obamacare through the 3,000 times his office is mentioned in the ACA.

Bucket #3 - Legislation 
Anything that doesn't impact the budget and cannot be affected by the HHS secretary will have to pass both houses of Congress and will be subject to the Senate's 60-vote requirement. This includes popular programs like requiring insurance to cover pre-existing conditions and allowing children to remain on their parent's health insurance until age 26, as well as more controversial issues like insurance coverage mandates. This will require compromise and may be very difficult. 

The AAN has heard from many members concerned about how any repeal and replace plans might impact their patients and all Americans. In response, the AAN's Government Relations Committee has drafted principles for AAN positions. These principles include important AAN priorities such as ensuring appropriate health care coverage for all Americans, appropriately valuing the cognitive care that neurologists provide, and reducing regulatory burdens on all physicians. The AAN Board of Directors is considering the principles now and I hope to write about the specifics in the next issue of Capitol Hill Report.

Both Speaker Ryan and Majority Leader McCarthy stressed to me that they believe Obamacare has serious structural flaws and will collapse without changes. They say their goal is not to cause people to lose coverage, it is to create structural integrity. They are committed to “getting it right.” As they move forward, the AAN will be ready to weigh on the priorities of AAN members and the patients they serve.

Nominee Price Supports Telemedicine at Senate Finance Committee Hearing

HHS nominee Price cleared the first hurdle is his confirmation process last week by securing an 11-9 vote in favor of his nomination from the Senate Finance Committee. Of interest to the AAN was Price's response to a question about telemedicine from Sen. Tim Scott (R-SC), where he specifically mentioned the usefulness in cases of stroke.

“Telemedicine is one of those exciting innovations that I believe will allow for individuals, access to resources from a clinic standpoint to make decisions on patients that are before them without having to save resource and save patients in so many ways. We in the state of Georgia have a program that is a spoke and wheel program. There is a neurologist that works with telemedicine and has a network of clinics and hospitals around the state. If somebody comes in with symptoms of a stroke, that physician is able to see that patient in real-time and determine whether or not they are having stroke, if they can be treated in the community, or whether they have to be transferred to the academic center. In the past it was a call on the ground, no ability to talk with someone who has greater resources or knowledge. It was a huge waste of money and not having patients at the center of that decision. Telemedicine is absolutely vital. I think we need to accentuate the ability to use telemedicine. Telemedicine is not paid for, it is not compensated. The clinicians eat those costs. They help the patients, but make it so it's more difficult for them to provide the quality care necessary.”

Rep. Price is expected to receive a vote by the full Senate this week.

AAN Responds to Immigration Order

AAN advocacy usually focuses on health care policies, but President Trump's immigration order caught our notice last week for its potential to impact neurology in several ways including international collaboration and attendance at the AAN's Annual Meeting in Boston this year. 

AAN President Terrence L. Cascino, MD, FAAN, sent a message to all AAN members and the AAN signed on to two letters expressing concerns. Learn more and access the letters.