What happens to Medicaid in California under a Trump administration? -AND- MACRA will move forward largely untouched when Trump steps in, experts say

CAL/AAEM News Service calaaem.news.service1 at gmail.com
Tue Dec 6 09:36:44 PST 2016



November 11, 2016


What happens to Medicaid in California under a Trump administration?



ornia-under-a-tru/> Southern California Public Radio (89.3KPCC)



President-elect Donald Trump has vowed that he will repeal and replace
Obamacare. Specifics are scarce, but one plan Trump has outlined would
change how the federal government funds Medicaid, health coverage for
low-income people.


Twenty-million Americans now have health coverage because of Obamacare. A
full quarter of them are in California. And most of them are covered by
Medi-Cal, California's version of Medicaid.


"Winding back the clock would create all kinds of turbulence and
disruption," says Larry Levitt, senior vice president for special
initiatives at the Kaiser Family Foundation.


Right now, the federal government shares the cost of Medicaid with the
states, no matter how many people are enrolled. But Trump wants to put a
limit on that funding and give states a fixed pot of money called a block


"A block grant would give California greater flexibility in running the
Medi-Cal program, but it would also give the state less money," Levitt says.


California would feel the pain more than other states. "The effect is
magnified in California in part because the state has been so successful in
getting people signed up for coverage," Levitt says.


And in California, 62 percent of Medi-Cal enrollees who have signed up since
Obamacare allowed states to expand Medicaid are Latino, African-American, or


To save money, some states could pay doctors and hospitals less. But in
California, payment rates are already the second lowest in the country.


"California can't really pay much less than it does to providers," says
Gerald Kominski, a professor of health at the University of California, Los


In the face of severe budget cuts, Kominski says, the only choice California
really would have is to reduce services or reduce the number of people who
get Medi-Cal.


"That would have a devastating consequence on the Medicaid expansion
population in California, and would basically put everyone who's been newly
enrolled in the program back off the program," he says.


It's unclear how soon a Trump administration would change Medicaid funding,
so health advocates are encouraging people to continue signing up for
Medicaid and other coverage during the current Obamacare open enrollment


"California is not an island," says Anthony Wright, executive director of
Health Access, an advocacy group, adding that the state "must engage fully
in the coming national debate on the future of health reform - especially as
an example of what has been achieved, and what we can't give up."




November 11, 2016


MACRA will move forward largely untouched when Trump steps in, experts say 



ntouched-when-trump-steps-experts-say> Healthcare Finance



By Beth Sanborn


With Donald Trump's election comes mass speculation on the direction his
healthcare plans will take. He has long sworn to repeal and replace the
Affordable Care Act, and the proposal floated on his presidential transition
website reiterates this promise and provides hints as to other aspects of
his plans.


While some of MACRA is tied up in the ACA, experts said for the most part
MACRA is safe, and will move forward largely untouched.


Anders Gilberg, senior vice president of government affairs for the Medical
Group Management Association, said they are advising members to simply
continue preparation for MACRA implementation. 


"We don't see that that is going to be repealed. It was bipartisan, nearly a
unanimous vote."


Christopher Kerns, managing director at The Advisory Board, also said MACRA
is safe.


"MACRA is not in trouble, but mechanisms by which they control spending is
what could change."


Kerns said there might be a shift away from accountable care organizations
as a principal driver of controlling spending, and more toward bundled
payments or price control, cuts, or other forms of utilization control in
the form of reduction in reimbursement for different kinds of services.


"So far the ACO results that have been published have been tepid at best.
There is not a lot of evidence that they have saved CMS a lot of money. It
may be that congress does not have the patience for it," Kerns said. 


Much of the conversation about what could change revolves around the Center
for Medicare and Medicaid Innovation, otherwise known as CMMI. It is
responsible for testing innovative payment and care delivery models, and
whether it remains intact, undergoes some changes, or is scrapped outright
along with the ACA remains to be seen.


When it comes to many CMMI programs, Kerns said it's possible Congress may
want to assert more control, and not provide them as much authority to make
payment changes. Instead, they may opt for more mechanisms related to
payment cuts.


He said the greatest criticism of CMMI is that the changes they make are not
subject to congressional approval, so for what is one of the largest
spending programs on earth, Medicare, Congress doesn't get much say in how
payment is going to be reformed going forward. But CMMI is part of the ACA,
so if they repeal the law, CMMI goes with it.


On the other hand, CMMI does provide the administration powerful tools to
change payment and to control spending on its own without congressional
approval -- though they've been subject to Congress' criticism, Kerns said
the incoming administration may see value in keeping it around.


"Congress could also settle for limited authority, but the truth is we
really don't know."


Gilberg said that even though he feels the law is safe overall, because CMMI
is embedded in the ACA, it could at least end up under the microscope.
However, just like the ACA, it can't be scrapped altogether without a viable


"CMMI and the billion dollars that come with it, is something that they'll
definitely be looking at but they still have to create a pathway to
alternative pay models," Gilberg said.


The Medicare Shared Savings program is also also enshrined in the ACA, and
is the main vehicle for alternative payment models. A shift away from MSSP
as the main vehicle, possibly a dramatic one, is possible, along with some
changes in bundled payment models as well.


"Pioneer and NextGen, mandatory bundled payments are part of CMMI. The ACA
authorized CMMI to enact these as long as they were shown to save money and
not damage quality. These are things that this Congress might be open to
adjusting," Kerns said.


However, he does believe MACRA fits into a bipartisan reform landscape in
general, since it repealed the sustainable growth rate and moved physicians
towards performance-based payment, which has support on both sides of the


He listed three major point the industry should focus on in the coming
months. First, he'll be looking at what kind of authority over payment
reform congress wants to have over payment reform, something that could
forecast whether CMMI survives. That is important for MACRA as the center
develops many of the programs that count as APMs within MACRA.


Second, the new Congress' view of ACOs in general will be telling.


"Are they willing to continue to double down on them and use downside risk
as a means of controlling spending or will they opt for reimbursement cuts
moving forward?"


Third, it will crucial to see how much emphasis Congress places on
performance-based penalties and bonuses. This means looking at are they
going to look to achieve their performance based payment by increasing the
penalties and bonuses for quality performance, Kerns said.


In a statement, the American Academy of Family Physicians said they don't
believe MACRA as a whole is in any real danger of repeal.


"The election of Mr. Trump will have a limited impact on the MACRA law in
the short-term. The law goes into effect January 1, 2017, before he is
installed as president. Looking forward, this bi-partisan law was supported
by 91 percent of Congress to bring about long needed value-based payment
reform and repeal the flawed SGR. Based on the bipartisan support for the
law, It is currently difficult to see how there would be any fundamental
changes to the law under the Trump administration," said AAFP President John
Meigs Jr.


Gilberg said that they have long regarded MACRA as a "living breathing
thing" that will continue to evolve, even yearly, and where changes and
adjustments should be expected, especially in 2018.


"There will always be refinements as we learn more in 2017 and we can expect
this administration to be open to simplification, but I don't think the core
is in jeopardy at all."




Jeff Wells
Deputy Editor, CAL/AAEM News Service


Brian Potts MD, MBA
Managing Editor, CAL/AAEM News Service

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