Why so many uncertainties still surround the fate of ACA
As the transition of administrations moves into the final week, there’s still much we don’t know about the fate of healthcare policy direction.
The 115th United States Congress convened last week, and President-elect Donald Trump will be inaugurated on January 20. In the two months since the election, there has been much coverage of Republicans' preparations and early steps to repeal and replace the Affordable Care Act (ACA).
However, despite all the chatter, Republicans have not reached consensus or announced details on their plans, and the path forward is shrouded in much uncertainty. At this point, most reports are more speculative than substantive.
Even after Republicans start releasing legislative text in coming weeks, uncertainty will persist to some degree as Republicans continue to figure out process and details of repeal, and begin navigating the challenges of developing and passing a replacement plan.
In that light, below is a summary of what we know and what remains unknown at this point in the process.
Many of the questions our Chief Research Officer Chas Roades proposed in the aftermath of the election remain open.
What we know
There are some noteworthy measures, however, that require approval by a simple majority, including confirmation of presidential appointees and budget reconciliation.
The vote on the budget resolution is scheduled to occur this week and will likely include a marathon session during which the Senate will consider dozens of amendments. Many of these amendments will be health care-related but few of them will actually become law, and the passed resolution will then move to the House for its consideration.
Passage of a budget resolution with reconciliation instructions is the first step on the road to ACA repeal.
It is in this committee phase that we would expect to see specific language repealing (portions of) the ACA. The resolution introduced last week calls for committees to submit their proposals by January 27.
At one point, Republicans had talked about having the repeal bill ready for President-elect Trump to sign on his first or second day in office, but that now looks impossible. Reports last week suggested Republicans are now aiming to send the ACA repeal bill to the president on February 20, a month after the inauguration.
Even this timeline, however, is ambitious and continuing concerns about the lack of an immediate replacement plan may further complicate this effort.
We will be watching the confirmation hearings closely for any hints as to how Rep. Price would approach key issues as HHS Secretary. Assuming Rep. Price is confirmed, the Senate would then consider Seema Verma's nomination for CMS administrator.
What we (still) don't know
However, Republicans' ability to go beyond those provisions may be limited by the rules of reconciliation in the Senate, where the Parliamentarian is required to certify that included provisions have a budgetary impact. Although some Republicans have indicated a desire to repeal more of the ACA than the previous bill did, the Parliamentarian's ruling will be a crucial factor.
It is also worth noting that some Republicans—particularly Republican governors in states that expanded Medicaid—have expressed interest in preserving Medicaid expansion in some form.
The current expectation is that Republicans won't make significant progress on a replacement plan until after passing repeal, though a couple of Republican Senators expressed concern last week about passing repeal without a replacement plan ready.
Assuming Republicans pass repeal without a replacement plan finalized, it's not clear how quickly they would propose and pass a replacement plan, especially since they will likely need votes from at least eight Democrats in the Senate to pass a replacement plan.
Speaker Paul Ryan did say last week that Congress will pass a replacement plan this year, but some in Congress remain skeptical that will happen.
We will be watching confirmation hearings and early activities of the new administration to get a better sense as to the future evolution of payment reform.
But without more insight from HHS Secretary-nominee Price or others in the Trump administration, any predictions regarding changes to MACRA would be speculative at this point.
However, despite all the chatter, Republicans have not reached consensus or announced details on their plans, and the path forward is shrouded in much uncertainty. At this point, most reports are more speculative than substantive.
Even after Republicans start releasing legislative text in coming weeks, uncertainty will persist to some degree as Republicans continue to figure out process and details of repeal, and begin navigating the challenges of developing and passing a replacement plan.
In that light, below is a summary of what we know and what remains unknown at this point in the process.
Many of the questions our Chief Research Officer Chas Roades proposed in the aftermath of the election remain open.
What we know
- Republicans have a narrow margin in the Senate
There are some noteworthy measures, however, that require approval by a simple majority, including confirmation of presidential appointees and budget reconciliation.
- Senate Republicans took the first step toward ACA repeal last Tuesday by introducing a budget resolution that includes reconciliation instructions
The vote on the budget resolution is scheduled to occur this week and will likely include a marathon session during which the Senate will consider dozens of amendments. Many of these amendments will be health care-related but few of them will actually become law, and the passed resolution will then move to the House for its consideration.
Passage of a budget resolution with reconciliation instructions is the first step on the road to ACA repeal.
- It will likely be at least a couple of weeks before we see details of a plan to repeal the ACA
It is in this committee phase that we would expect to see specific language repealing (portions of) the ACA. The resolution introduced last week calls for committees to submit their proposals by January 27.
- Ultimately, passage of ACA repeal may not happen until February or March
At one point, Republicans had talked about having the repeal bill ready for President-elect Trump to sign on his first or second day in office, but that now looks impossible. Reports last week suggested Republicans are now aiming to send the ACA repeal bill to the president on February 20, a month after the inauguration.
Even this timeline, however, is ambitious and continuing concerns about the lack of an immediate replacement plan may further complicate this effort.
- Confirmation hearings for HHS Secretary-nominee Tom Price are likely to begin on January 18 with a Senate HELP Committee hearing
We will be watching the confirmation hearings closely for any hints as to how Rep. Price would approach key issues as HHS Secretary. Assuming Rep. Price is confirmed, the Senate would then consider Seema Verma's nomination for CMS administrator.
What we (still) don't know
- Which parts of the ACA will be included in the repeal bill
However, Republicans' ability to go beyond those provisions may be limited by the rules of reconciliation in the Senate, where the Parliamentarian is required to certify that included provisions have a budgetary impact. Although some Republicans have indicated a desire to repeal more of the ACA than the previous bill did, the Parliamentarian's ruling will be a crucial factor.
It is also worth noting that some Republicans—particularly Republican governors in states that expanded Medicaid—have expressed interest in preserving Medicaid expansion in some form.
- The length of any transition period to wind down the ACA
- Details and timing of a replacement plan
The current expectation is that Republicans won't make significant progress on a replacement plan until after passing repeal, though a couple of Republican Senators expressed concern last week about passing repeal without a replacement plan ready.
Assuming Republicans pass repeal without a replacement plan finalized, it's not clear how quickly they would propose and pass a replacement plan, especially since they will likely need votes from at least eight Democrats in the Senate to pass a replacement plan.
Speaker Paul Ryan did say last week that Congress will pass a replacement plan this year, but some in Congress remain skeptical that will happen.
- What steps the Trump administration will take via executive action to stabilize the exchange market and impacted programs
- The evolution of payment reform and fate of CMMI
We will be watching confirmation hearings and early activities of the new administration to get a better sense as to the future evolution of payment reform.
- The new administration's approach to MACRA
But without more insight from HHS Secretary-nominee Price or others in the Trump administration, any predictions regarding changes to MACRA would be speculative at this point.
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