ASHINGTON — She has inflammation in her gallbladder, frequent facial pain, and near paralysis on her left side ever since a stroke a few years back — but 74-year-old Sylvia Hollie is still living at home.
It’s a creaky but stately home in D.C.’s increasingly gentrified Mt. Pleasant neighborhood, with well-worn banisters and a wooden wheelchair ramp out front — and it means everything to Hollie. It’s the home where she took care of her ailing mother, and it’s been in the family for 50 years. It’s the home where she listens to daily Catholic Mass, propped up on pillows beneath a painting of the Last Supper one of her neighbors gave her. And it’s the home where she gets to visit, though never as often as she’d like, with her four grandchildren.
Hollie gets to stay in that home thanks to a house call pilot program aimed at many of Medicare’s sickest — and costliest — patients.
And while her immediate care isn’t in jeopardy, the federal support for the pilot program is, after funding and authorization for it and dozens of other health initiatives expired at the end of September. On their face, these so-called “extenders” — named because the policies they describe usually need to be reauthorized, reinstated, or extended at regular intervals — aren’t especially controversial. But in the midst of partisan tension over all things health-related, the programs are facing a more uncertain future than ever before.
In Hollie’s case, the program is Medicare’s Independence at Home Demonstration project. For patients who otherwise would be seeing multiple specialists, in and out of waiting rooms and hospital beds, the program instead pays doctors in 15 pilot practices — including her physician, Dr. Eric De Jonge at the MedStar Washington Hospital Center — to coordinate care and travel to the patient’s home, rather than the other way around. Hollie is one of about 10,000 participating patients.
When Hollie gets sick and needs X-rays, blood tests, or EKGs, for example, she calls De Jonge and his team instead of going to the ER. (“It took me a long time to get that in my head, that they were available for me 24 hours a day,” she said.)
The patients love it.
“To be here, as opposed to someplace else — you have no idea how wonderful that is,” Hollie said as De Jonge was zipping his bag after his last visit.
And perhaps counterintuitively, that coordinated concierge care actually saves Medicare money. Together, the 15 practices in the IAH program saved Medicare more than $34 million in their first two years.
But despite that statistic — and glowing reviews from patients like Hollie — the program’s future is mired in the partisanship that has consumed congressional efforts to reform health care since President Trump took office. The program — along with nearly two dozen other health-care related projects and funding streams — expired at the end of September.
Hollie won’t stop getting her care through MedStar’s broader house call program — but De Jonge can’t enroll anyone else in the Independence at Home program until it is reauthorized. Nor can MedStar count, with any real certainty, on getting any financial bonuses related to improving care for Hollie and the rest of her cohort.
The other expired programs run a broad gamut. They include higher-profile federal funding for the Children’s Health Insurance Program and community health centers.
Another program that lost funding helps seniors navigate the complexities of Medicare, still another gives payments aimed at keeping smaller, often rural hospitals financially afloat. Others offer grants to providers and other businesses working to address childhood obesity or improving abstinence education efforts.
In the past, Congress has reauthorized this slate of extenders with bipartisan support. Already this year, two House committees have approved tweaks or reauthorizations of many of the programs, teeing them up for further consideration from the full legislative body. The Senate also approved several of the programs, including a broad expansion of the Independence at Home program, as part of a bill aimed at improving care for individuals with chronic conditions. A handful of programs considered more urgently in need of funding were tucked into an unrelated Federal Aviation Administration package.
But the expired programs each cost the federal government somewhere between $100 million and $1.1 billion every two years. Though lawmakers agree generally on the policies, they are nowhere close to an agreement on how to offset those costs.
Hospital and health industry lobbyists said they have no reason to think that nearly all of the programs won’t ultimately be reauthorized. But lobbyists are nonetheless ramping up their visits to Capitol Hill as they field calls from hospitals and clinicians around the country who want some certainty about their funding as they make hiring decisions and set their budgets.
“These expiring programs must be extended, or it will have a crushing impact on many small and rural hospitals and the communities they serve,” said Erik Rasmussen, vice president of legislative affairs for the American Hospital Association. “These programs can mean the difference between a rural hospital maintaining or eliminating certain services for patients who rely on these hospitals as a vital — and often only — source of care.”
Most of the time, lawmakers lump these smaller Medicare and Medicaid policies in with a larger and more critical piece of legislation. For nearly two decades, Congress almost annually tackled the so-called “doc fix,” a constant legislative request from clinicians who wanted to avoid a major Medicare cut. The so-called extenders nearly always rode along.
When Congress passed its so-called “permanent doc fix” in 2015, however, lawmakers declined to make most of the extenders permanent, too.
Lobbyists across the health care industry have since suggested the programs could be reauthorized at the same time as the annual Children’s Health Insurance Program reauthorization. Congress missed its deadline to fund that program — considered vital to state children’s health programs across the country — in September, too. Congressional aides in both parties cautioned, however, that CHIP legislation might not be substantial enough to proceed on its own.
Negotiations on the program are stalled, as House Democrats push back against a series of overwhelmingly partisan cuts to Medicare and the Affordable Care Act that House Republicans have suggested as tradeoffs for their support for the children’s health insurance funding. Key senators have been working on a separate agreement for how to fund the program. It’s not clear either would include money for the extenders.
If lawmakers can’t reach a deal, both CHIP and the other programs might be reauthorized when Congress must pass legislation to finance the government, aides in both chambers and lobbyists said. The current authorization expires Dec. 8.
Several lobbyists suggested a new bipartisan Obamacare stabilization package, released this week by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) could include enough savings to help pay for the children’s health insurance program and the extenders, but that package has not yet been evaluated by the Congressional Budget Office, which makes those determinations.
For now, De Jonge and his team will keep visiting Hollie and the 620 other patients in MedStar’s house call program. And he himself will continue to push Congress to reauthorize his program and to expand it to more sites across the country.
“A lot of Medicare payment incentivize the wrong behavior, more procedures,” De Jonge said. “I know that if I do the right thing and keep Ms. Hollie out of the hospital, out of the ER, spend extra time on my visit, try to convince her to stop smoking, make sure she has her meds — if I take extra time with the patient — we will be rewarded by the IAH program. It encourages the right behavior, it encourages us to do the right thing.”