ASHINGTON — The Republican health care bill, at least for now, is dead. So what happens next?
Senate Republicans have already announced plans to pivot to legislation that would repeal much of the Affordable Care Act without spelling out a replacement plan, after two additional GOP senators defected from the party’s controversial plan to simultaneously repeal and replace parts of the law. President Trump, too, tweeted his support for that approach.
But the abrupt change of plans brings to the fore a laundry list of other health policy bills that remain on Congress’ agenda for the coming months. Some are must-pass items with rapidly approaching deadlines: agreements that represent about $1 billion in private funding for the Food and Drug Administration, as well as the authorizations for federal funding for the Children’s Health Insurance Program and several Medicare programs, all of which expire in September.
Republicans will also almost certainly have to consider new proposals to reassure insurers reeling from 2017’s wildly uncertain political environment. To do that, they’ll likely have to collaborate with Democrats.
The collapse of the GOP health care legislation also postpones plans to address the U.S. opioid crisis with $45 billion in funding — money that would have made up for a rollback in Medicaid spending — and a policy that targeted federal funding for Planned Parenthood. Upcoming plans to extend the debt ceiling and pass a budget could reignite those other debates.
Whatever they do, Republicans are starting from scratch on a whole host of major policy changes — with deadlines looming increasingly close. Here’s a deeper dive into Congress’s health care to-do list for 2017.
Stabilizing the insurance markets
Right now, the insurance market established by the ACA is in turmoil. Some 38 counties in three states currently lack even a single insurance plan on HealthCare.gov for 2018. Unless that changes, an estimated 24,000 Americans would have no way to use the health insurance subsidies they get under the ACA for next year’s coverage. In other places, consumers might end up paying much higher premiums next year than they would have in a more certain political environment.
The companies have to nail down where they want to sell plans, as well as their specific monthly premium rates, before this fall. Now those deadlines are looming closer than ever — in many places, they’ll have to make the final call by September.
Congress could take a number of steps to try to improve the insurance market, many of which require more funding. Democrats are eager to work with Republicans on some of the policies Republicans have already backed in their repeal legislation — several have signed onto a plan for state-based or federal reinsurance programs that help offset costs for especially sick patients and that resembles a provision in the GOP’s abandoned bill. The party has also pressed to ensure funding for an Obamacare subsidy program that helps low-income families, which is in jeopardy because of a House Republican lawsuit.
Several health industry lobbyists cautioned, however, that Republicans would need time to quell their disappointment before turning to shore up the health care law they have opposed for so long — especially if Democrats celebrate the Republicans’ failure.
Authorizing FDA payments amid a drug pricing debate
An easier task for Congress: reauthorizing the so-called user fee agreements that help fund more than 4,000 jobs at the Food and Drug Administration. The contracts, which must be renewed every five years, spell out how much private industry is willing to pay to support the drug and device approval processes at the agency.
Unlike almost every other legislative priority this year, the user fee agreements have sailed through both House and Senate committees with overwhelming bipartisan support. The House has already cleared the measure, using a fast-track process set up for non-controversial legislation.
The Senate approval process could prove more partisan, especially after Monday. Both Republican and Democratic senators have signaled interest in attaching controversial policy provisions, including some aimed at lowering the costs of prescription drugs or allowing terminally ill patients to try experimental drugs. Either could slow or derail the process for passing the agreements.
Trump is another wild card. Though congressional Republicans support the legislation, the administration has called for the drug industry to pay about twice as much toward the FDA approvals work. Its latest statement castigated Congress for ignoring that request.
Both Capitol Hill and the broader health industry are also waiting for an executive order targeting high drug prices. Several lawmakers have already criticized proposed drafts as too industry-friendly and suggested they may seek ways to change those policies.
Funding the Children’s Health Insurance Program
Far less congressional attention has been dedicated to the Children’s Health Insurance Program, which must also be reauthorized before September. The program helps fund state programs that provide health insurance to children in families with modest incomes that might be too high to qualify for Medicaid.
Unlike the user fee agreements, CHIP has been the subject of only a single congressional hearing. There’s no public legislation for the effort, despite the looming timeline.
The problem is pressing. Five states will exhaust their children’s health insurance funds by the end of this year without action from Congress. Dozens more will run out by next March.
But congressional approval won’t be easy. Despite bipartisan support for the idea of children’s health insurance, partisan fights have overtaken and threatened to derail several of the most recent attempts to reauthorize the program’s funding.
The central issue: Democrats and many governors want to retain or even increase spending on the program, after the ACA boosted its funding across the country. The Trump administration and congressional Republicans don’t. They’ve also called for more structural reforms to the broader program.
Considering separate funding for opioids
Among the original bill’s biggest critics were those who said it would have had a devastating effect on the country’s ability to treat addiction. Most experts said the bill would have slashed the availability and purchasing power of Medicaid, the biggest national payer for addiction treatment services.
The repeal-only bill Republicans are now eyeing would abruptly end the Medicaid expansion, kicking 14 million people off their insurance coverage. But it wouldn’t include the massive cuts to the original program that proved so controversial with moderates.
Two senators — Rob Portman (R-Ohio) and Shelley Moore Capito (R-W.Va.) —negotiated in the Senate’s first attempt at repeal for a $45 billion, 10-year fund meant to mitigate the impact Medicaid cuts on addiction treatment. John Kasich, the Republican governor from Portman’s home state, likened the fund to “spitting in the ocean.”
But other than Medicaid, the opioid crisis is a point of bipartisanship in Congress. Two bills from the previous session, the 21st Century Cures Act and the Comprehensive Addiction and Recovery Act, authorized nearly $700 million in spending this year to combat the epidemic.
The questions now is whether Congress considers that enough — and some members seem to believe it is.
“I think it’s not unreasonable to think carefully about how much money you can add to the system all at once,” Sen. Roy Blunt (R-Mo.), who oversees the Senate’s health appropriations committee, told STAT in June when asked about the $45 billion fund.
Others aren’t so convinced, and a large bipartisan group of House members last month unveiled a package of legislation that would make a number of changes to the current system, tweaking privacy laws, funding treatment centers for opioid-dependent infants, create new pain research centers and fund additional access to the opioid-reversal drug Narcan.
But the original Republican repeal efforts had been seen as a flash point. With that debate over, it’s decision time.
Addressing Planned Parenthood funding
White House budget director Mick Mulvaney was asked at a press conference in May whether Trump’s budget proposal eliminated federal funding for Planned Parenthood. The answer, Mulvaney said, was yes — but only in that the budget assumed the enactment of the House’s health reform legislation, which included a provision targeting Planned Parenthood directly.
Now, other than with a successful reset — the 2015 repeal-only bill does eliminate Planned Parenthood funding for a year — congressional GOP leaders and the White House have few mechanisms for defunding the organization that wouldn’t require 60 votes in the Senate, a non-starter for a body with 52 Republicans.
But targeting the organization is a major priority for a number of GOP members in the House. The House Appropriations Committee will consider a half-step this week unrelated to ACA repeal: an elimination of the Title X family planning program, worth nearly $300 million annually.
Some Planned Parenthood clinics that receive Title X money would struggle without it. But most of that money is distributed to local health departments. And a Title X cut alone is not likely to mollify many House conservatives.
The budget containing the Title X cuts is unlikely to become law, either — leaving Republicans without a major vehicle to attach an anti-Planned Parenthood measure.