November 21, 2016

By Mike Amery, Esq., Senior Legislative Counsel

The ACA and MACRA: Two Very Different Laws, Two Very Different Futures 

With the election of Donald Trump to the presidency and his call for repeal and replacement of the ACA a distinct possibility, AAN members have been asking how this change, if successful, will impact the new physician payment system under MACRA.

The ACA and MACRA, defined:

Affordable Care Act (ACA):
 Also known as “Obamacare.” Law passed in 2010. Intended to increase health insurance quality and affordability, lower the uninsured rate by expanding insurance coverage, and reduce the costs of health care. 

Medicare Access and CHIP Reauthorization Act (MACRA)
: Law passed in 2015. Commonly called the “Permanent Doc Fix,” eliminates the Sustainable Growth Rate formula by establishing a new way to pay doctors who treat Medicare patients. 

The first thing to know is that although both laws deal with health care, they are very different in substance and each passed Congress under very different circumstances.

In early 2010, the ACA passed with exactly zero Republican votes. Since taking over the majority in the House in 2011 and the Senate 2015, Republicans have voted dozens of times to repeal all or part of the law. With President-elect Trump's campaign promises, any legislation repealing the ACA that hits his desk is sure to be enacted rather than facing the certain veto of President Obama.

MACRA is completely different. This was bipartisan legislation passed in March of 2015 on a vote of 392-37 in the House and 92-8 in the Senate. With broad support, there isn't anyone in Congress calling for the repeal of MACRA. The Centers for Medicare and Medicaid Services (CMS) just published the first rules on MACRA and many, including the AAN, are looking for some changes, but not a repeal.

President-elect Trump is laying out plans for his first 100 days and repeal of some or all of the ACA is on the table, but he still has to deal with the Senate minority. Democrats picked up two seats with victories over Republican incumbents in New Hampshire and Illinois. Senate rules require legislation to move forward with unanimous consent or reach a 60-vote majority. Republicans are likely to have just 52 votes making a total repeal of the ACA very difficult.

MACRA's new payment system has broad congressional support, and the AAN is committed to doing everything possible to ensure our members can successfully participate. MACRA is not Obamacare. Although some parts of these laws are intertwined, the impact of a repeal of the ACA will not eliminate MACRA.

Election Notes

  • In addition to picking up two Senate seats, it looks like House Democrats will gain six seats bringing the Republican majority down to 241-194.
  • At least three new House Republicans have medical backgrounds: Representatives-elect Roger Marshall is an OB/GYN from Kansas, Drew Ferguson is a dentist from Georgia, and Neal Dunn is a urologist from Florida.
  • Rep. Ami Bera, MD, (D-CA) is making it interesting again as his race is still uncalled, just as it was at this time in 2014. The two-term Sacramento family physician holds a lead of 4,800 votes (51%-49%) as provisional ballots are being counted in California's 7th District.
  • Three physicians looking for promotions from the House to the Senate failed to win on election day. Reps. Charles Boustany (R-LA), John Fleming (R-LA), and Joe Heck (R-NV) each came up short.
  • Incumbent Senator Mark Kirk (R) was defeated in Illinois by Rep. Tammy Duckworth (D). Sen. Kirk, a stroke survivor, is the author of S. 1465, the Furthering Access to Stroke Telemedicine Act (FAST Act) that has been a top priority of the AAN for the last two years. We are hopeful of passing the FAST Act before the 114th Congress expires, but if it doesn't, we will be looking for a new Senate sponsor in 2017.
  • It is the first time in 100 years of senators being popularly elected that every state with a Senate seat race voted for the same party for both President and Senate.  

Lame Duck Session Prospects

Congress returned to Washington last week for leadership elections. House Republicans reelected Speaker Paul Ryan (WI); meanwhile Democrats suddenly postponed their elections after several dozen caucus members asked for more time to digest their disappointment about the recent election. No one has set up yet to formally challenge current Minority Leader Nancy Pelosi (CA), who has served as the Democratic leader for the past 12 years. Congress is on break this week for Thanksgiving but will be back in session again next week to complete some essential business, including electing the next Democratic leader in the House.

The most pressing “must pass" issue is the need for an agreement to fund government beyond December 9 when the latest deal expires. Also on the table are some health-related items, including the 21st Century Cures legislation that includes a big boost to NIH funding, and a less ambitious effort in the Senate on chronic care.

We are watching these closely, especially the Senate's chronic care plan because it includes the FAST Act. However, with Republicans holding the presidency and the Congress beginning in January, they are less likely to pass sweeping reforms prior to the end of 2016.

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