With election results still rolling in, one thing is clear: the 2014 midterm elections dealt an unequivocal win to Republicans, helping them pick up more than the six seats needed to gain the majority in the Senate, bringing both chambers of Congress under GOP control. While this will mean big changes in leadership and the legislative agenda for the remainder of President Obama’s term, it may have fewer implications for healthcare than many anticipated. Here’s why.
The Affordable Care Act (ACA)
One of President Obama’s signature achievements, the ACA faces little chance of repeal in the remainder of the President’s term. Depending on the election results in Louisiana – the last undecided Senate race – in early December, Senate Republicans will hold 53 or 54 seats, falling well short of the 60 vote super-majority needed to get most things passed in today’s Senate. Even more important, Senate Republicans do not have the two-thirds majority to overcome a presidential veto. This means that even if incoming Senate Majority Leader Mitch McConnell rounds up the votes needed to pass repeal, he will not have enough votes to overcome the President’s all-but-guaranteed veto. In the end, even if Republicans control Congress, we can expect that the ACA will remain largely intact.
So does this mean the entire law is safe? Not exactly. Republicans are already outlining a different strategy, in which they will target individual ACA provisions for repeal or significant modifications. The list includes the 2.3% medical device tax; the employer mandate to provide qualified, affordable coverage; and the ACA definition of a full-time employee as 30 hour/week. We can expect the Senate to take votes to roll back these provisions in the next Congress.
The real fate of the ACA may lie with the Supreme Court. Earlier this year, conflicting rulings came from the Appeals Courts on the legality of providing subsidies to those accessing coverage through the federally-run health insurance exchanges, as the law appears to stipulate that subsidies may only be provided to those in state-based exchanges. The Supreme Court recently announced it would take up the case, and is expected to issue a ruling in June 2015. With the federal marketplace serving 34 states and expected to enroll nearly 11.8 million people in 2016 – an estimated 7.3 million of whom would receive federal subsidies – the Court’s decision could have enormous implications for the success of the law.
Sustainable Growth Rate (SGR)
Last year we saw the best opportunity to permanently repeal the SGR. A bipartisan bill had broad support, and the price tag was (comparatively) low at $138 billion – but Congress could not come together to determine how to pay for it. Instead, Congress passed another short-term patch that will expire in March 2015, which prevented roughly a 24% cut in Medicare physician reimbursement rates for 12 months. In keeping with previous fixes, Congress cut healthcare expenditures to pay for the extension. The Congressional Budget Office (CBO), Congress’ official budgetary scorekeeper, recently re-estimated the cost of the bipartisan legislation at $144 billion over 10 years. This is still considered a bargain by most policymakers, and although we can be hopeful the new Congress will consider the legislation, do not be surprised if another short-term patch is what we’re stuck with; despite an “on sale” SGR fix, offsets continue to be a critical stumbling block.
For more than 18 months providers have faced sequester-mandated cuts to Medicare payments, and more than 10 years remain of the 2% Medicare claims reduction. This year, H.R. 1416, a bill that halts the cuts on reimbursement for cancer drugs, garnered some support, but not enough to pass in either chamber of Congress. Many advocacy organizations will push to have the bill reintroduced next year, but H.R. 1416 will remain difficult to pass as part of any stand-alone healthcare bill. The best chance for a solution will be to attach some kind of fix to a larger bill, such as SGR reform.
A number of other issues may come up in the 114th Congress, including oral parity and prompt pay discounts, but would likely be included in larger healthcare-related vehicles. Stay tuned.
The Association of Community Cancer Centers will host a Capitol Hill day for its members on March 16, 2015. We encourage all of our members to attend this annual event and educate elected officials on these important issues. For more information, please click here.