August 2017
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Congress Moves on From ACA Repeal

By Chester A. Speed, J.D., LL.M., Vice President, Public Policy

To say it was a busy time in Washington, DC, last week is quite the understatement. Senate Majority Leader Mitch McConnell (R-KY) put three bills on the floor to repeal and replace the Affordable Care Act (ACA), only to see each one go down in defeat. The last vote was certainly the most dramatic, as Sen. John McCain (R-AZ) shocked his Republican colleagues and voted no on the so-called “skinny” repeal bill, essentially casting the final vote that killed Republican efforts targeting the ACA. Despite being diagnosed with brain cancer, Sen. McCain had traveled to Capitol Hill and was widely considered the final yes vote for some version of ACA repeal legislation.

After the vote, many prognosticators said the outcome was predictable. Republicans divided over ACA policy fixes could not overcome ideological differences, and faced uncertainty in the White House. Congressional Budget Office estimates predicted that any version of ACA repeal would result in millions of Americans losing their coverage, which was the most salient fact in my opinion.

So, where does that leave us now? Despite last week’s results, President Trump continues to push, in his own way, Senate Republicans to once again take up ACA repeal legislation. Calling Senators quitters if they move on and threatening to cut off healthcare subsidies to Members of Congress, the President made it clear he wants a legislative victory. However, in a town that still runs on relationships, it’s hard to see how these tweets from the White House gets President Trump any closer to legislative success.

There has been talk of bipartisan discussion to develop policies to help shore up ACA exchanges. For example, in the House, a group of 40 Republicans and Democrats has expressed interest in drafting legislation to improve the ACA. In addition, Sen. Lamar Alexander (R-TN) and Sen. Patty Murray (D-WA), the chair and ranking member of the Senate Health, Labor, Education, and Pensions Committee, have announced they will hold hearings in September on the ACA’s exchanges.

Speaking of the ACA, we’re very pleased to see Congressman Richard Neal (D-MA) share his thoughts on the ACA in this issue of AMGA Advocate and, just as importantly, his emphasis on delivery system reforms and how AMGA members’ efforts lead the way on value. Rep. Neal is the Ranking Minority Member on the House Ways and Means Committee and highly respected for his bipartisan efforts over the years on healthcare and tax issues.

As always, if you have any questions about policy, Congress, the White House, or HHS, please feel free to contact me at

Featured Column: We Must Build on Value-Based Care, Not Take Away Care

By Congressman Richard Neal (D-MA)

Washington, DC, has been singularly focused on Republican efforts to roll back health coverage and patient protections put in place under the Affordable Care Act (ACA).

The House-passed Republican plan would gut preexisting condition protections, cause millions to lose their healthcare coverage, and increase costs for middle-class Americans.

It would put health insurance companies back in control of health care. Nearly the entire medical community, including doctors, patients, seniors, hospitals, nurses, and rural healthcare providers, are opposed to both the House and Senate Republican bills. More than 23 million Americans would lose health coverage under the House-passed plan, older Americans would pay much higher costs, and those with preexisting conditions will see higher costs and fewer benefits.

Beyond the health consequences of taking away coverage and benefits from millions of Americans, the Republican approach is bad for business. In many communities, healthcare providers are one of the largest employers. Under the Republicans’ approach, which would shift billions in uncompensated care costs on to healthcare providers and states, estimates indicate that by 2026, 1.45 million fewer jobs would exist, compared to today. Employment in health care would be especially hard hit, with 919,000 fewer health jobs. Urban and rural safety net hospitals that treat large proportions of low-income patients could be hurt the most because of Republicans’ proposed cuts to Medicaid.

Higher deductible plans and plans that cover less are similarly bad for the business of health care. As any medical practice manager understands, when patients can’t pay their medical bills, they skip necessary care and many will not receive needed preventive care services. Forcing people to pay more for less health coverage and eliminating low or no-cost preventive services undermines the basic concept of promoting healthy living and rolls back the advances we have made in identifying and treating chronic conditions early.

In recent years, providers across the country have invested time and significant resources in changing the way business is done by reforming the delivery system to focus on value of care.
The ACA played an important role in getting the nation thinking on a broad scale about how we can work together with providers and patients to improve the quality of our healthcare system. Members of AMGA have led the charge in pushing delivery system reform from episodic fee-for-service programs toward value-based care, rewarding quality over quantity.

We know that each healthcare market is unique. Springfield, MA, is different than Miami, FL, with different challenges in population health and serving the community, which is why the Obama administration encouraged multiple models and activities to deliver better, smarter care.

This July, the Medicare Trustees announced that the life of the Medicare Trust Fund has been extended by another year, showing that delivery system reform is working. New ways of thinking and doing business help contain costs, improve access to needed services, and improve health outcomes through programs such as Accountable Care Organizations, which now provide care to more than 10 million Medicare beneficiaries in 500 different provider organizations in Medicare alone. Recent research published in JAMA Internal Medicine suggests that ACOs effectively reduce costs and improve healthcare quality for Medicare and Medicaid beneficiaries, building on what the scientific evidence shows works.

The Obama administration started the Partnership for Patients, a program that convened more than 4,000 hospitals to work with patient and clinical leaders in hospital safety. As a result, more than 87,000 lives were saved and the health system saved more than $20 billion. Will Department of Health and Human Services (HHS) Sec. Tom Price build on these efforts or curtail them? Other HHS initiatives launched under the ACA reduced the rate of hospital readmissions without harming patients; created value-based purchasing programs in all major provider categories; and built partnerships with more 30 states to drive local improvement efforts. Sec. Price has said virtually nothing about any of this work, and it’s fair to ask how he wants to see the health system evolve and whether he is going to continue to foster the delivery system reform efforts well underway.

I am proud of the efforts of providers across the country to engage in a new way of thinking, transforming medical care through continuous quality improvement processing and evidence- based practice. Unfortunately, the new administration, by all indications, is turning its back on the past eight years of delivery system reform efforts that were hand-in-glove-collaborations between the Centers for Medicare & Medicaid Services, providers, patients, and states to coordinate better care at lower costs.

We are six months into the new administration and, at best, we’ve seen no clear vision for continuing the progress the health system has made at improvements; at worse, it seems efforts to undermine progress are afoot. Healthcare delivery system reform is the track our nation needs to be on to reduce costs through improving quality—and focusing on value. We can reduce health costs without shifting the burden on to providers, patients, and families. It is rethinking care, both the process and the connections between providers and patients, but also looking at root causes of health and how to better manage keeping patients living at their best.

As we look forward, it is critical that public servants in Washington take their responsibilities seriously. We are all here to help improve the lives of our fellow Americans, and Republicans must end their ongoing efforts to sabotage current programs, which independent experts and the health community agree will harm patients and the healthcare community. We need a clear and renewed commitment from this administration that the positive trajectory of delivery system reform and focus on value, including strong partnerships between providers, CMS, and other stakeholders, will continue. Improving care is a patient-centered issue, not a partisan one.

AMGA’s efforts to help move us to a world of value-driven care will be even more important. Thank you for your ongoing commitment to this important work.

Legislative Update

The future of Affordable Care Act (ACA) repeal and replace efforts in Congress remain uncertain in the wake of the Senate’s repeated failure to agree on any legislative package. Despite President Donald Trump’s promise that one of his first actions as president would be to repeal the ACA, as well as years of congressional Republicans pledging to repeal the law if they controlled power in Washington, Republican leaders were unable to unify their members and pass a bill that repealed or replaced the ACA.

Although the future of ACA repeal and replace efforts in Congress is in flux, there is an effort in the House to address the ACA in a bipartisan manner. For example, the House Problem Solvers Caucus, which includes 40 Republicans and Democrats, has expressed an interest in drafting legislation to improve the ACA. In addition, some in Congress suggested maintaining the ACA’s cost-sharing reduction payments, which the Trump administration currently is considering whether to pay. In the Senate, the Senate Committee on Health, Education, Labor, and Pensions will hold hearings the week of September 4 to examine ways to “stabilize and strengthen” the individual health insurance markets, including ensuring the cost-reduction payments are made. Sen. Lamar Alexander (R-TN), the committee chair, said the hearings would be “bipartisan and … involve as many members of the committee as possible.”

Regardless of the debate surrounding the ACA, by the end of this this week, both chambers will be in recess until September 5. Policymakers will need to come to an agreement by September 31 to fund the government. If not, a government shutdown could occur. President Trump continues to express his desire to reform the U.S. tax code. Reforming transportation infrastructure of this country, another campaign promise, could be another legislative hurdle.

House Passes Replacement Bill
The effort to repeal and replace the ACA has been ongoing since March, when the House first attempted to repeal and replace the law with the American Health Care Act (AHCA). Despite expectations that the House would pass the bill, on the day of the vote, more than 30 House Republicans remained opposed, forcing Speaker Paul Ryan (R-WI) to withdraw the bill from House floor consideration.

In response to this opposition from more conservative the House Republicans, Rep. Tom MacArthur (R-NJ), co-chair of the moderate Tuesday Group, drafted an amendment to the AHCA to allow states to opt out of requiring plans to cover essential health benefits. The amendment also would have created a process for states to opt out of community rating standards, which under current law prohibit health plans from charging more to patients with preexisting conditions. While this plan garnered more conservative support, it forced more moderate Republicans to rethink their positions, as the amendment could cause higher healthcare costs for certain Americans. To alleviate these concerns, Rep. Fred Upton (R-MI) and Rep. Billy Long (R-MO) introduced an amendment that provided an additional $8 billion over five years to assist patients who may have higher premiums because they have preexisting conditions or failed to maintain continuous coverage.

These changes were sufficient to secure the Republican votes needed for passage, and on May 4, the House approved the AHCA by a vote of 217 to 213. At the time, the vote represented a significant victory for Speaker Ryan and his leadership team, which had been under tremendous pressure from the White House to repeal and replace the ACA. However, the House vote was held before the Congressional Budget Office (CBO) had an opportunity to update its estimate – or score – of the effect of the legislation. As introduced in the House, the CBO estimated the bill would produce $150 billion in savings and result in 24 million people losing their insurance. On May 25, the CBO revised its estimates and determined that as passed by the House, the AHCA would reduce the deficit by $119 billion and would leave at least 23 more million people uninsured who had previously received coverage under the ACA.

Senators Stymied by Procedural Restrictions
Throughout the summer, the Senate crafted its own version of ACA repeal and replace legislation that it could pass with only Republican votes. This would allow Senate Republicans to pass legislation with only 50 votes, as Vice President Mike Pence would be available to break a tie.

On June 22, the Senate unveiled the Better Care Reconciliation Act (BCRA) in an attempt to appeal to moderates and conservatives in the Republican Senate caucus. With only 52 members, Senate Majority Leader Mitch McConnell (R-KY) faced an uphill battle to appeal to 50 of his colleagues. Republican senators raised many concerns about the House-passed bill, including concerns about cuts to Planned Parenthood, changes to Medicaid, weakening market reforms, and less generous coverage. The day the BCRA was introduced, four Republican Senators came out in opposition, indicating that the framework needed to be altered. Initially, Senate leadership planned to pass the BCRA the week of June 26; however, Republican leadership continued to postpone the date, as there were not 50 Republican Senators willing to support this legislation.

On July 13, Sen. McConnell released an updated version of the BCRA with hopes of winning over enough of his Republican dissenters. During the month of July, debate and alterations to the legislation continued. Eventually, the CBO released an estimate for the BCRA that found it would cause 22 million people to lose access to health coverage. By July 25, Republicans reached a pivotal moment when they agreed to proceed on the ACA repeal and replace debate, which lasted a few days in the Senate. Even this procedural motion barely passed the Senate, with Vice President Mike Pence as the deciding vote.

First, the Senate defeated the BCRA by a vote of 43 to 57. Then, the Obamacare Repeal Reconciliation Act (ORRA), a bill to repeal the ACA without a replacement, failed by a vote of 45 to 55. The CBO estimated that the ORRA would have resulted in 32 million more people uninsured. The last effort by the Senate Republicans was a so-called “skinny bill” to repeal some provisions of the ACA. This “skinny bill”, known as the Health Care Freedom Act, would have repealed penalties associated with the individual mandate and the employer mandate. This legislation would have extended the moratorium on the medical device tax through 2020, increased the maximum contribution limit to health savings accounts, provided funding for state ACA waivers, defunded Planned Parenthood for one year, and increased funding for Community Health Centers. CBO estimated that this legislative proposal would result in 16 million more uninsured individuals. This “skinny bill” failed during the early morning hours of July 28, by a vote of 49 to 51, with Sen. John McCain (R-AZ) stunning his Republican colleagues by casting the deciding “no” vote.

AMGA will continue to advocate for you as the political landscape evolves.

Regulatory Update

AMGA Meets with Secretary Price
AMGA on June 28 attended a meeting with Department of Health and Human Services (DHHS) Secretary Tom Price in an attempt to identify federal regulations that compromise the physician-patient relationship. Fred McQueary, M.D., M.M.M., president of ambulatory care and chief clinical officer, Mercy, attended on behalf of AMGA. During the meeting, Sec. Price noted he wanted to better understand some of the challenges federal regulations pose for providers and how the department could work with stakeholders to simplify or streamline federal regulations. Dr. McQueary identified a number of areas where regulatory relief simplify may improve care delivery, including improvements in quality reporting, health information technology use, appropriate use criteria (AUC) relevant to imaging services, and simplified rules concerning the use of the skilled nursing facility benefit. Dr. McQueary also recommended the department reduce the regulatory burden for providers participating in value-based models of care, such as Accountable Care Organizations (ACOs) and other Alternative Payment Models (APMS).

Current CMS Regulatory Rulemaking Activity
The Centers for Medicare & Medicaid Services (CMS) has recently issued proposed rules for the Quality Payment Program (QPP), the CY 2018 Medicare Physician Fee Schedule update, the CY 2018 Hospital Outpatient Prospective Payment System (HOPPS) rule, and the rule for home health services. As part of these proposed rules, CMS also is requesting comment and feedback on ways to achieve “transparency, flexibility, program simplification, and innovation” about the broader healthcare delivery system. AMGA is reviewing these regulations carefully and will provide comments to CMS.

MACRA Rule Proposes Low-Volume Threshold Expanded
Concerning the QPP, which implements the Medicare Access and CHIP Reauthorization Act (MACRA), CMS is proposing several changes to the Merit-Based Incentive Payment System (MIPS) program. Among others, CMS is proposing to substantially increase the low-volume exclusion threshold from $30,000 to $90,000 in Part B charges and from 100 to 200 Part B beneficiaries. If finalized, CMS estimates only 36% of eligible clinicians will participate in the MIPS program in 2018. Excluding a substantial percentage of eligible clinicians from the program reduces the distribution of composite performance scores (CPS) that in turn will lower the average MIPS CPS to an estimated 2020 rate increase of 0.9%, which is substantially below the statutory maximum of 5%.

CMS also is proposing several changes to MIPS reporting. For 2018, CMS is proposing a 12-month performance period for quality and proposes to allow providers to report quality via more than one reporting mechanism. CMS is again proposing to exclude the cost component from the MIPS score; the cost category will have zero weight in 2018. Among other proposed changes, CMS outlines virtual group participation and a year-over-year improvement bonus, and will award small groups five CPS bonus points.

The rule proposes changes to APMS as well. Regarding the all-payer combination option, CMS is proposing to determine APM eligibility at the individual clinician level, rather than at the entity level. AMGA currently is drafting its formal response to CMS; our initial reaction is available on our website.

CMS Delays AUC in CY 2018 Physician Fee Schedule Proposal
Concerning the physician fee schedule proposed rule for CY 2018, CMS recognized several AMGA priorities. For example, the proposed rule will delay until 2019 the start of Appropriate Use Criteria (AUC) for advanced diagnostic imaging, a position AMGA has supported. CMS also is soliciting comments on whether the start date should be further postponed beyond the proposed January 1, 2019 start date.

Regarding telehealth, CMS is proposing to eliminate the required use of the GT modifier on professional claims.

Breaking Down Medicare’s Silos
In a June Health Affairs article, AMGA’s Senior Director for Regulatory and Public Policy David Introcaso, Ph.D., argued that Medicare has evolved into three separate and distinct programs: fee-for-service (FFS) or “traditional” Medicare; the Medicare Shared Savings (MSSP) or ACO program; and Medicare Advantage (MA,). This means that, as silos, these programs do not compete. This neither serves the provider community nor Medicare beneficiaries and taxpayers. Therefore, as the Medicare Payment Advisory Commission (MedPAC) has argued, the three programs’ financial benchmarking, risk adjustment, and quality measurement should be synchronized so that synergies could be developed and the Medicare program becomes greater than the sum of its parts.

Make Plans to Attend AMGA’s Capitol Hill Day – October 4 in Washington, DC
Congressman Michael C. Burgess, M.D. (R-TX) (Confirmed)
Senator Bill Cassidy, M.D. (R-LA) (Confirmed)
Senator Ron Wyden (D-OR)

Meeting with your elected representatives in person is the best way to influence change. Join your fellow executive and policy leaders in the nation’s capital on October 4 to advocate for the issues most important to organized systems of care and connect with your elected officials to ensure they understand the principles that guide our industry.

Haven’t participated in a fly-in before? AMGA’s skilled policy staff will brief all participants on relevant issues in advance and will assist in scheduling meetings with your members of Congress and staff. We will offer webinars in advance to help you learn how to maximize your time with your members of Congress.

This year, Capitol Hill Day will be held in conjunction with Chief Executive Officer/Chair/President, Chief Administrative Officer/Chief Operating Officer, and Government Relations Leadership Councils on October 5-6 in Washington, DC. The meetings will feature key legislators who play pivotal roles in influencing healthcare policy, including Rep. Michael Burgess (R-TX), Sen. Bill Cassidy (R-LA), and Sen. Ron Wyden (D-OR). Registration details are available at

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