The failure to pass funding for reinsurance and cost-sharing reduction subsidies for the Affordable Care Act (ACA) exchanges and the potential for pharmaceutical-backed changes to the 340B drug discount program are just some of the major issues on the American Hospital Association’s radar this year, according to executive vice president of government affairs Tom Nickels.
Besides playing the role of pundit in predicting how the 2018 midterm elections may turn out, Nickels gave the crowd at the American College of Healthcare Executives (ACHE) Congress in Chicago a lay of the land in D.C. on what may—and may not—get done on Capitol Hill and at HHS and CMS over the rest of 2018 and into next year. It helps, Nickels said, that some priorities like delaying cuts to Medicare Disproportionate Share Hospital (DSH) payments were included in a short-term budget bill passed in February.
Other issues, Nickels said, have been left unresolved, including:
1. ACA stabilization
Despite months of work between Sens. Lamar Alexander, R-Tennessee, and Patty Murray, D-Washington, on a package aimed at preventing another double-digit premium hike on the ACA exchanges, a fight over abortion language kept ACA-related funding out of the March budget.
Nickels said Congress missed its best chance the stabilization measures had of passing this year. Coupled with the elimination of the individual mandate for 2019 in last year’s tax cut legislation, premiums for 2019 coverage are likely to go up “dramatically.”
“Everybody’s worried because those rates will come out right before the 2018 election,” Nickels said, which he guessed might lead to more talk of ACA stabilization being included in the budget for the 2019 fiscal year.
2. Opioid money is coming
An exception to the hyper-partisan atmosphere in D.C. has been moves to address the opioid epidemic. Unlike other healthcare-related policies, Nickels said actions on opioids has enough support from both parties to move through Congress without being attached to a bigger bill—like the budget—and he expects legislation to begin moving in April using the additional $3 billion appropriated to opioid efforts in the March budget.
“This one I think has legs and could get done prior to the Memorial Day recess at the end of May,” Nickels said. “What could be the impediment? Same thing that it was for the Children’s Health Insurance Program, same thing as for CSRs and stabilization—will partisanship, will the inability of the parties to work together, get in the way of something where there is already a consensus that things need to be done?”
3. Fighting 340B cuts
One of the most pressing legislative and regulatory battles for the AHA, the 340B drug discount program is being hit on both fronts. CMS cut Medicare payments made under the program by $1.6 billion through last year’s outpatient payments rule, a change the AHA has gone to court to reverse. On the legislative side, there have at least three bills proposed to impose new reporting requirements in the program, all of which the AHA opposes.
Nickels said the effort is being led by the pharmaceutical companies which don’t like having to offer discounts on their products to hospitals. He dismissed what he called a “bad” Republican-authored report that 340B has encouraged hospital consolidation and decreased charity care—though nonpartisan studies have reached some of the same conclusions.
Additional transparency in 340B is negotiable, Nickels said, but the AHA isn’t willing to shrink the program and “take money away from our members.”
“This program is not about taxpayer dollars," he said. "I think Congress should be very vigilant in watching out for my tax dollars. They should be on that all the time. These are drug company dollars that go to hospitals."
Nickels expects more legislation to be proposed and discussed regarding 340B, but predicted nothing will actually be signed into law.
4. “Aggressive” regulatory relief
In an area where Nickels said the AHA is in “lock step” with HHS, CMS and the Trump administration, pruning back regulations will likely be a high priority in the annual Medicare rules released later this year on inpatient, outpatient and physician payments now that their attention isn’t on repealing the ACA.
Nickels said judging by the AHA’s meetings with CMS Administrator Seema Verma, MPH, hospitals should expect to see action on rolling back regulations on physician self-referral laws, health IT requirements like Meaningful Use and conditions of participation.
“You may see as much activity the rest of this calendar year on the regulatory side as you do on the legislative side,” Nickels said. “There may be more interesting stuff going on there as there is on Capitol Hill.”
5. Watching for Medicare, Medicaid and other cuts in 2019
The 2017 tax cut law may lead to additional talk about “entitlement reform” in 2019, Nickels said, considering how the cuts are expected to increase the federal deficit by more than $1 trillion by 2027. That means cuts to Medicare and Medicaid will be discussed because as Nickels said, “That’s where the money is.”
For more specific cuts which may be proposed in the future, Nickels pointed to the budget proposed by President Donald Trump. While budget blueprints from the White House often aren’t acted upon, what’s included does illustrate priorities for the administration which may be brought back in later years. For hospitals, this could mean the administration resurrects proposals like $138.4 billion in cuts over 10 years by removing uncompensated care from Medicare inpatient payments and ending any exemptions to the site-neutral payment policy.
John joined TriMed in 2016, focusing on healthcare policy and regulation. After graduating from Columbia College Chicago, he worked at FM News Chicago and Rivet News Radio, and worked on the state government and politics beat for the Illinois Radio Network. Outside of work, you may find him adding to his never-ending graphic novel collection.