Health Policy Report

March 7, 2016

The Week in Review
Politics arguably outweighed policy last week, as the “Super Tuesday” primary elections delivered commanding leads for real estate mogul Donald Trump and former Secretary of State Hillary Clinton in their respective presidential nomination races. After winning seven of the eleven contests on Tuesday, Trump went on to win two more states – Kentucky and Louisiana – in Saturday’s elections, but Sen. Ted Cruz (R-TX) actually narrowed the gap on the Republican frontrunner by winning Kansas and Maine. As it stands, Trump maintains an 82 delegate lead on Cruz and over double that amount on the next closest competitor, Sen. Marco Rubio (R-FL). On the Democratic side, conventional wisdom dictates that Hillary Clinton has a seemingly insurmountable lead in both delegates and the party insiders known as “superdelegates” after winning seven states on Super Tuesday and Louisiana on Saturday. However, Bernie Sanders (I-VT) strung together weekend wins in Colorado, Nebraska and Maine, bringing his win total to 8 states, as compared with 11 for Clinton. The next votes will be cast tomorrow, with both parties voting in Michigan and Mississippi, and Republicans also holding contests in Hawaii and Idaho.

In Washington, the Senate made progress on a measure (S. 524) that would help combat the growing epidemic of prescription opioid abuse by authorizing additional grants from the Health and Human Services (HHS) and Justice Departments. An amendment submitted by Sen. Jeanne Shaheen (D-NH) that would add $600 million in emergency funding to bolster treatment programs was narrowly rejected in the upper chamber. Minority Leader Harry Reid (D-NV) said the failure to add the funding will shortchange the programs the bill would authorize, but Minority Whip Dick Durbin (D-IL) indicated last week that Democrats do not plan to block the bill.
In the House, Members considered measures related to Medicaid program reform, challenges to the Administration’s rules on emissions from brick and clay ceramic tile manufacturers, and a bill related to presidential transitions. The first of these bills (H.R. 3716) aims to combat fraudulent payments by requiring states and Medicaid managed care plans to report identifying information for terminated Medicare, Medicaid, and Children’s Health Insurance Plan (CHIP) providers. The legislation also includes a provision from another bill (H.R. 3821) that requires state Medicaid agencies to publish, on public websites, a directory of providers who furnished care to Medicaid enrollees in the prior 12 months. House lawmakers approved the bill on a unanimous vote of 406-0.
Later in the week, the House passed a bill (H.R. 4557) along more partisan lines, 238-163, that would prevent emission standards for brick and clay manufacturers from going into effect until judicial reviews of the rules are complete. Finally, a bill was passed under suspension of the rules to require the White House to have a transition team in place at least six months prior to the presidential election and direct the General Services Administration (GSA) to serve as transition coordinator.
The Week Ahead
With the House in recess this week, the Senate will try to finish up three pieces of unfinished business – separate bills to address the epidemic of opioid abuse, to boost energy efficiency, and to combat Flint, Michigan’s contaminated water. Senate Majority Leader Mitch McConnell (R-KY) has scheduled a cloture vote on a substitute amendment for the bill targeting opioid abuse for this evening. A separate amendment (amendment #3378) sponsored by Sen. Joe Donnelly (D-IN) that would provide follow-up services to individuals who have received opioid overdose reversal drugs is also set to be considered. A vote on the underlying bill is expected sometime this week.
Also in the Senate this week, look for votes on long-stalled energy legislation (S. 2012), which would revise programs related to energy cybersecurity, efficiency, infrastructure, and supply management. The bill’s fate has been tied to a measure that would help the City of Flint respond to its contaminated drinking water disaster. Sen. David Vitter (R-LA) has reportedly placed a hold on the energy package in an attempt to add language to promote fishing opportunities in the Gulf of Mexico. Additionally, an amendment offered by Sen. Lisa Murkowski (R-AK) would promote recreational hunting, fishing and shooting opportunities on federal lands, but does not include the Gulf-specific provisions sought by Vitter. Under an agreement negotiated by Senate leadership, passage of the energy package would clear the way for consideration of a separate measure to address the Flint water crisis.
Senate Nears Agreement on Opioid Legislation
The Senate will resume consideration this week on legislation intended to address the growing epidemic of opioid abuse, despite the fact that Senate Republicans blocked an amendment last week to add emergency funding for drug treatment by $600 million. While Democrats have suggested that they would support the Comprehensive Addiction and Recovery Act (CARA) despite the outcome of the amendment, they had been pushing hard for weeks to get the funding included, arguing that the money is needed to quickly aid communities affected by opioid abuse. Republicans have argued that there is plenty of money available for CARA in the omnibus spending bill passed late last year, suggesting that the emergency funding is unnecessary. 
The otherwise bipartisan bill would authorize $77.9 million a year from fiscal 2016 through 2020 for a range of programs to battle prescription drug and heroin abuse, including education and prevention, as well as increasing the availability of naloxone, a drug to treat overdoses. Sens. Kelly Ayotte (R- NH), Mark Kirk (R-IL) and Rob Portman (R-OH), who are facing tough reelection bids, as well as Sens. Susan Collins (R-ME) and Lindsey Graham (R-SC), were the only Republicans to support the failed amendment. Senators have a procedural vote on the bill scheduled later this evening, with 60 votes needed to overcome the hurdle.
Senate Committee to Mark Up Mental Health Bill
Legislation to overhaul the nation’s mental health system is gaining speed in the Senate, but appears to be losing momentum in the House. In the Senate, the Health, Education, Labor and Pensions Committee (HELP) is planning to mark up a new package to address mental illness and substance abuse disorders from the panel’s top lawmakers next week. While the bill has yet to be released, it will likely focus on the Substance Abuse and Mental Health Services Administration’s (SAMHSA) efforts to assist individuals with mental illness and substance abuse as well as the enforcement of existing mental health parity rules. Furthermore, the measure is expected to pull pieces from Senator Cassidy’s (R-LA) Mental Health Reform Act (S.1945), as well as ideas drawn from other committee members. Additionally, senators are coordinating ongoing efforts in the Finance, Judiciary, and Appropriations committee.
Meanwhile, in the House, Rep. Tim Murphy’s (R-PA) Helping Families in Mental Health Crisis Act (HR 2646) has staggered after partisan divides emerged during a November markup of the bill over privacy laws, court-ordered assisted outpatient treatment programs, and resources for SAMHSA. After hours of debate and a series of amendment votes, the legislation eventually advanced mostly along party lines and has yet to receive consideration from the full committee. Murphy and several other lawmakers headed to the House floor last week to press Republican and Democratic Leadership to stop delaying a vote on the legislation, arguing that despite having 133 Republican and 50 Democratic co-sponsors in the House, “it is still being held captive by a vocal minority of opponents of crisis mental health reform.” In the meantime, a group of House Democrats have unveiled their own alternative version to the legislation, highlighting many of the unresolved tensions that still remain.
CMS Ahead of Schedule in Linking Medicare Payments to Quality
Medicare officials estimate that almost $1 of every $3 spent in the traditional fee-for-service program now runs through one of the special projects that are designed to judge the quality of care provided to the nation’s elderly and disabled. Last week, the Centers for Medicare and Medicaid Services (CMS) announced that it had reached a goal of tying 30 percent of fee-for-service reimbursements to alternative payment models (APMs), such as accountable care organizations (ACOs) that require providers to coordinate on patients' care. As of January, about $117 billion of a projected $380 billion in annual fee-for-service payments were estimated to flow through these payment models.
CMS Chief Medical Officer Patrick Conway cited the January announcement of 121 new accountable care organizations as a sign of the success of these efforts and a reason for reaching the 30 percent goal ahead of HHS’ 2016 target. Before implementation of the Affordable Care Act (ACA), Medicare paid essentially nothing through alternative payment models, CMS said. By 2014, about 20 percent of payments were made through alternative payment models..
ACA Enrollment Reaches 20 Million 
The Obama administration has reported that roughly 20 million people have gained health insurance through the Affordable Care Act (ACA), marking the lowest rate of uninsured the country has ever seen. In a speech delivered Thursday, President Obama called out Republican lawmakers for their attempt to repeal the law and for not putting forward a replacement plan. He also went on to say that people’s insurance has improved overall since the ACA became law, and that Americans are “getting more for what [they’re] paying for… even if [they] didn’t know it.” 
According to the Department of Health and Human Services (HHS), the 20 million figure includes 6.1 million people between the ages of 19 and 25, which is noteworthy because young people were some of the most likely to forgo coverage before the law, and are a critical part of a more stable risk pool, as they are often healthier and help drive down premiums.
Donald Trump Unveils HealthCare Plan
On Wednesday, the Republican presidential front-runner, Donald Trump, released a framework detailing some aspects of his healthcare plan if he were to be elected in November. Trump had been largely criticized by his opponents on the campaign trail for failing to explain his seemingly contradictory healthcare ideas. While Trump’s released plan generally follows mainstream Republican ideas on healthcare, he’s also adopted traditionally Democratic positions on issues related to prescription drug pricing. And while his plan did not explicitly mention it, his stump speech has routinely called for the federal government to negotiate prices directly with manufacturers, a position that has historically been anathema to Republicans.
According to his release, Trump calls for allowing drugs to be re-imported from overseas “in order to increase competition and drive down prices,” an idea that Democratic presidential nominees Hillary Clinton and Bernie Sanders have also supported. Included among the other details of his plan are: (1) repealing the Affordable Care Act (ACA), including eliminating the individual mandate; (2) allowing health insurance to be sold across state lines; (3) permitting people to make tax-free contributions to Health Savings Accounts (HSAs); (4) allowing individuals to fully deduct health insurance premium payments from their tax returns under the current tax system; (5) requiring price transparency from all healthcare providers; and (6) turning the Medicaid program into block grants to the states.