Another topsy-turvy week in Washington around Republican efforts to, in order: repeal and replace the Affordable Care Act, then just repeal it, and then finally to open a vote on the Senate floor next week to see what happens.

“We’re going to vote on the motion to proceed to the bill next week,” Senate Majority Leader Mitch McConnell said on Wednesday. It is still unclear if McConnell has the 50 votes need to proceed as four Republican Senators voiced opposition to beginning debate on a repeal-only bill as of Thursday afternoon. However, if the if the order to proceed is passed, what would then happen is anyone’s guess; the most likely scenario is that a version of the GOP’s reform bill will be moved and then Republican senators with concerns about certain parts of it will offer a flurry of amendments to craft a national healthcare reform bill on the fly.  All Democrats are opposed to the Republican effort to pass a version of the GOP Better Care Reconciliation Act (BCRA).

On Monday enough GOP senators said they would oppose their party’s repeal-and-replace healthcare bill, causing McConnell to admit defeat and pull the measure. On Monday night, President Trump tweeted that “Republicans should just REPEAL failing ObamaCare” and start from a clean slate.  McConnell on Monday said he would call for a repeal-only vote.

On Tuesday, some GOP Senators objected to repeal only, with West Virginia Senator Shelley Moore Capito saying, “I did not come to Washington to hurt people.” On Tuesday, Trump tweeted that we should just let “ObamaCare fail” to force both parties to come together to create something new.

But on Wednesday, the president held a dinner for Republican Senators at the White House imploring them pass a repeal-and-replace bill.  The issue was further complicated on Wednesday when the GOP’s slim Senate majority was affected by the unfortunate news that Sen. John McCain (R-Arizona) was battling brain cancer, and that his return to Washington was uncertain.

Later on Wednesday, McConnell said there would be a vote to proceed next week.

Another important aspect of the Senate effort in D.C. to eradicate the Affordable Care Act involves what it would cost and what would it mean to people who have health insurance coverage.

The Congressional Budget Office (CBO) and the staff of the Joint Committee on Taxation (JCT) on Wednesday released their latest estimate of what would result from an ACA repeal.

CBO and JCT wrote that passing a repeal of the ACA would decrease deficits by $473 billion over the 2017 to 2026 period. As for coverage and premiums, CBO and JCT staff wrote this:

• “The number of people who are uninsured would increase by 17 million in 2018, compared with the number under current law. That number would increase to 27 million in 2020, after the elimination of the ACA’s expansion of eligibility for Medicaid and the elimination of subsidies for insurance purchased through the marketplaces established by the ACA, and then to 32 million in 2026.
• “Average premiums in the nongroup market (for individual policies purchased through the marketplaces or directly from insurers) would increase by roughly 25 percent—relative to projections under current law—in 2018. The increase would reach about 50 percent in 2020, and premiums would about double by 2026.

"In CBO and JCT’s estimation, under this legislation, about half of the nation’s population would live in areas having no insurer participating in the nongroup market in 2020 because of downward pressure on enrollment and upward pressure on premiums. That share would continue to increase, extending to about three-quarters of the population by 2026.”

Last week Governor Baker signed a $39.4 billion state budget, vetoing about $222 million in MassHealth line while sending back to the legislature proposed healthcare amendments to the budget that Baker wants action on within 60 days.

Legislative leaders said they’d give attention to the governor’s proposals to increase the per-employee health insurance assessment employers would have to pay, as well as to reforms of the MassHealth program. But the legislature made no promises about passing the governor’s plan. The governor initially had recommended his package of employer assessment and MassHealth reforms in June.

In that June package, Governor Baker sought an increase to the per-employee Employer Medical Assistance Contribution (EMAC) for all employers with six or more workers; employers whose workers receive coverage through MassHealth and subsidized insurance in the Health Connector exchange – even if their employer offers insurance – would pay a supplemental assessment. The legislature included this provision in its final budget, but did not couple it with the MassHealth reforms sought by the governor.

In returning the provision to the legislature, Baker wrote, “These [employer-assessment] sections …must not be considered in isolation of other measures needed to manage spending in the MassHealth program. Absent other reforms, this proposal imposes an unfair burden on Massachusetts’ employers without making the structural reforms essential to MassHealth’s long-term sustainability.”

Those proposed MassHealth changes include:
• Moving 140,000 non-disabled adults with incomes above 100% of the federal poverty level from MassHealth to subsidized insurance through the Health Connector exchange. (Pregnant women, those with HIV-AIDS, and those with breast or cervical cancer would be excluded from this MassHealth-to-Connector switch.)
• Disallowing MassHealth coverage for non-disabled adults who have access to employer health insurance.

On Thursday, the Executive Office of Health and Human Services (EOHHS) proposed an amendment to the state’s Medicaid waiver that including the aforementioned reforms and others, including changes to covered benefits for certain MassHealth enrollees, the MassHealth premium assistance program, and pharmacy formularies.  EOHHS is seeking comments by August 21.

The administration says such moves will “better align the MassHealth program with commercial insurance products and coverage,” but patient advocates say the moves will result in higher out-of-pocket costs for poor people and ultimately result in higher  uninsurance levels in the state.  The governor said if the legislature does not act within his 60-day deadline then he’ll be forced to make further budget cuts to cover what he called the “foregone revenues and savings associated” with his proposals.

On Tuesday, August 8, the Health Policy Commission (HPC) is holding a peer-to-peer session on strategies for implementing pharmacologic treatment of substance use disorder in primary care settings – a key strategy to address the opioid crisis.

Pharmacologic assisted treatment combines the use of medications with behavioral therapy to treat SUD. But initiating such treatment and prescribing for maintenance can be a challenge for providers. This event – by HPC in collaboration with Health Management Associates – aims to bring together providers from across Massachusetts to share knowledge on how to successfully implement treatment protocols in primary care settings.
 
An expert panel will be facilitated by Suzanne Mitchell, M.D. – a consultant to Health Management Associates. The session is open to any healthcare professionals interested in engaging in a discussion on practical strategies for implementing a pharmacologic treatment practice.
The session runs from 3 to 5 p.m. at HPC headquarters at 50 Milk Street, 8th Floor, Boston; or view the event by livestream. To register for the event in person, click here. To view the livestream of the event, click here at the time of the event. Virtual attendees may submit questions during the event by e-mailing HPC-Certification@MassMail.State.MA.US.

The following legislative and administration re-assignments this past week affect the healthcare community:

With the resignation of House Ways & Means Chairman Brian Dempsey (D-Haverhill) to take a job at ML Strategies (which has a vibrant healthcare division), House Speaker Robert DeLeo (D-Winthrop) picked the Chairman of the Joint Committee on Health Care Financing, Jeffrey Sanchez (D-Jamaica Plain), to fill the powerful House Ways & Means post.  Peter Kocot (D-Northampton) becomes Health Care Financing chairman in the House.

MHA President & CEO Lynn Nicholas said, “The hospital community is grateful for the many years of insightful and prudent leadership that Chairman Dempsey provided. While we’re sorry to see him leave, we were gratified to learn his responsibilities were placed in the capable hands of Chairman Sanchez, who brings a deep appreciation of the challenges facing the healthcare sector.”

On the administration side, Governor Baker announced that his chief of staff Steven Kadish was stepping down, and will be replaced by Kristen Lepore, the secretary of Administration and Finance. Michael J. Heffernan, Department of Revenue commissioner, will take over A & F, and Heffernan’s chief of staff, Chris Harding, will become Revenue commissioner.

Pediatric Case Management Conference
Care Across the Continuum: Managing the Patient, Plan, and Payer

Monday & Tuesday, Oct. 16-17; 9 a.m. to 4 p.m
MHA Conference Center, Burlington, Mass.

Working with pediatrics requires very strategic case management to ensure the best care. This comprehensive program is designed to turn pediatric case management challenges into strategies and real-time solutions. We’ll focus on managing pediatric care transitions while also teaching practitioners how to keep an eye on important aspects of the revenue cycle. This exciting 2-day program will take a deep dive with experts and leaders in the field and practitioners who are working on innovative solutions to ensure the best and most efficient care for these vulnerable populations. We encourage you to bring a team from your organization to learn the current best practices to take back and use with your pediatric cases.  Learn about full program details, costs, and registration information here.