President's PerspectiveThe level of activity in our nation’s capital continues to increase with President Trump issuing a steady stream of executive orders and tweets. The good news is most of this activity isn’t focused on health care. However, activity has increased related to the important work SDAHO members do every day.

Sen. John Thune and Sen. Heidi Heitkamp (D-N.D.) introduced legislation that would permanently suspend enforcement of supervision rules governing outpatient therapeutic services. Companion legislation has been introduced in the House of Representatives. The bill would apply to critical access hospitals (CAHs) and rural hospitals with fewer than 100 beds.

The supervision rules were first imposed in 2010, but have never been applied to CAHs and small rural hospitals. Congress approved an enforcement moratorium for 2016 in the closing hours of the last Congress. Given the focus on the Affordable Care Act (ACA), it is especially challenging to identify a path forward at this time for bills like the supervision moratorium.

The initial fast-paced schedule for action on the ACA continues to decrease, reflecting a significant shift in the tone and substance of the debate in Congress. A month ago, it appeared that Congress would repeal the ACA immediately and replace it later. Today, members are discussing how to “repair” and “rebuild” our health care system simultaneously. Current projections are that the full House would vote on a package in early April.

There is also an emerging political divide between Senate Republican moderates who argue for a slower-paced approach and House conservatives who want a vote now on repeal. Finding consensus on a proposal that bridges this divide will be difficult.

A number of components of a repeal plan are emerging:

  • No individual, employer mandate
  • Incentives to encourage coverage, including premium subsidy and penalties
  • High deductible insurance plans, with tax credits for investing in HSAs
  • High risk pools for persons with pre-existing conditions and the sickest patients
  • Elimination or reducing the ACA’s essential benefits requirements
  • Transition Medicaid expansion to something else
  • Convert Medicaid to a block grant or per capita cap program with flexibility
  • Expanded insurance pooling allowing insurers to sell insurance across state lines

However, a fundamental question remains: Will these proposals and the level of people who are covered by health insurance create a large enough insurance pool to support the ACA’s insurance reforms? There is still much we do not know.

In other action, the House Energy and Commerce Health Subcommittee recently met and discussed drafts of four bills dealing with critical insurance provisions in the ACA. The debate marked the first step toward the GOP’s goal of repealing and replacing the 2010 health reform law.

The proposals aim to deal with people who have pre-existing health conditions, revise how much more to charge seniors compared to young people for insurance and address how to encourage people to keep continuous coverage throughout their lives.

Specifically, the bills would require patients to pre-verify their eligibility for special enrollment periods, allow states to reduce the grace period for subsidized coverage, revise the age-rating ratio and prohibit individual and group health plans from limiting or excluding benefits related to pre-existing conditions if the ACA is repealed.

The subcommittee action reflects the growing view that Republicans will not put forward a major ACA replacement bill, but will instead replace the law through a set of smaller measures. Three of the four bills had been introduced in previous years.

Finally, Rep. Tom Price’s nomination for Secretary of Health and Human Services moved to the Senate floor and will likely be up for a vote this week. Although controversial, his nomination is expected to be approved.