Two weeks have passed since the Senate left town without taking action on legislation to permanently repeal Medicare's sustainable growth-rate formula for paying doctors. That left the deal in limbo and disappointed healthcare advocates who thought that a permanent “doc fix” was imminent.
But with Congress set to return on Tuesday, no serious threats to the deal have emerged and the Senate appears poised to end the decade-plus cycle of short-term fixes.
“I don't see anything that could actually disrupt the final outcome,” said John Rother, president of the nonpartisan National Coalition on Healthcare and previously a longtime lobbyist for AARP. “I do think that people understand the importance and the desirability of putting an end to this charade.”
The House passed the $200 billion package, which also includes a two-year extension of the Children's Health Insurance Program and $7.2 billion in funding for community health centers, by an overwhelming bipartisan margin. That put pressure on the Senate to act on the deal cooked up behind closed doors by House Speaker John Boehner (R-Ohio) and Minority Leader Nancy Pelosi (D-Calif.).
But the procedural rules of the Senate could still make passage tricky if any member wants to derail the legislation. Despite the overwhelming support in the House, the repeal package remains controversial on both sides of the aisle.
Conservatives are angry that only about a third of the cost of the package is offset by spending cuts, resulting, according to the Congressional Budget Office, in $140 billion added to the federal deficit over a decade. “There's a lot of optimism that it will get worked out,” said Dean Rosen, a partner with the lobbying firm Mehlman Castagnetti Rosen Bingel & Thomas and a former GOP Senate staffer. “The biggest threat seems to be from those on the Republican side of the aisle who are concerned about the fact that it's not paid for.”
Sens. Jeff Sessions (R-Ala.) and Ben Sasse (R-Neb.) have expressed opposition to the legislation on these grounds. “We're talking about an unpaid for, not responsible” plan, Sessions said during a speech on the Senate floor prior to adjournment for spring break. “This is what brings this Congress in disrepute.”
Senior advocacy groups remain concerned about increased costs for Medicare beneficiaries. Roughly half of the $70 billion in spending reductions are generated by raising premiums for wealthier enrollees and eliminating Medigap plans with no deductibles. The AARP and its allies are still pushing changes that could mitigate those costs.
And advocates for children's healthcare coverage remain committed to a four-year extension of CHIP. They're worried that it could replace SGR as the perennial vehicle for healthcare policy if it gets stuck on a two-year re-authorization cycle.
All of those concerns could be addressed through amendments offered on the Senate floor. But if any succeed it would require the House to again take up the measure. Given the rare bipartisan support shown for the current package, there's little stomach for that prospect.
“They haven't quite worked out what they're going to do at this point,” Rosen said. “The question is, can they structure it in a way that it's going to prevent amendments from actually passing?”
Conversations about crafting rules for consideration of the legislation that will placate all interest groups without endangering enactment are taking place this week, according to a Republican Senate staffer involved in those talks. “Let's all see what the conversation is going to be when members get back,” the staffer said, “because it's likely to be a very different conversation.”
Sen. Ron Wyden (D-Ore.), the ranking member of the Finance Committee, has been among the Democratic skeptics of the SGR deal. In particular, he's voiced concern about only extending CHIP for two years and increased costs for Medicare beneficiaries. But Wyden indicated in a briefing with reporters on Thursday that he intends to back the deal as long as there is an opportunity for senators to provide input by offering some amendments.
"I have long wanted to retire this outdated, inefficiency-rewarding, common sense-defying Medicare formula," Wyden said. "I have wanted to put it in the junk bin of history and move to a system that rewarded value and more-coordinated, high-quality care."
Heightening the difficulty for the Senate is the narrow window to avert a 21.2% cut in payments to doctors. The CMS has indicated that it can delay processing claims through April 15, but not beyond. That leaves just two days for the Senate to take action.
Supporters of SGR repeal are continuing to lobby senators to back the bill. The National Association of Community Health Centers planned to send out an action alert to about 80,000 supporters on Thursday urging them to call Capitol Hill on Monday in support of the bill.
If the legislation is enacted, it could augur a more productive, less acrimonious tone on healthcare issues going forward. “It was divorced from the 'repeal Obamacare' stuff rhetorically in a way that allowed real compromises,” Rother said of the deal. “I think it's actually a very, very positive sign that we may not be as gridlocked on healthcare.”