What the Midterm Elections Could Mean for Physicians

During Tuesday's midterm elections, the Republican Party took control of both chambers of Congress. While it's unclear exactly what this means for physicians, it does raise some big questions regarding healthcare reform.

To identify some potential areas physicians should watch, we asked Chris Emper, director of government and industry affairs for healthcare technology provider NextGen Healthcare, to weigh in.

Physicians Practice: How do you think Republican control of both the U.S. Senate and House of Representatives will affect physicians most directly?

Chris Emper: As a result of last Tuesday's elections, Republicans will take control of the U.S. Senate for the final two years of President Obama's term, but physicians shouldn't expect to see huge impacts as a result. The Republicans would love to repeal The Affordable Care Act, but President Obama has made it clear that while he will be willing to negotiate with Republicans on some of their priority issues, The Affordable Care Act will not be one of them and he will veto any effort to repeal the law. On the flip side for Republicans, leadership has indicated that they are not interested in another government shutdown or standoff over the law, so expect them to push, but not too far. Beyond a full repeal, expect to see the new Congress pass bills targeting individual provisions of the [reform law]. Because some Democratic lawmakers support repealing or amending certain provisions, including the medical device tax and the employer mandate, it is possible that President Obama won’t veto every [reform law] bill that hits his desk. However, repeal of most of these provisions would have indirect or minimal effects on physicians.

Physicians Practice: Looking specifically at health reform, what effect do you think the shift could have on physicians when it comes to the reimbursement shift to value and new payment models, such as accountable care organizations?

Chris Emper: Again, the effects should be minimal. Both Democrats and Republicans support movement into new value-based reimbursement models. The bipartisan SGR repeal bill (that ultimately failed to pass because the parties couldn't agree on the pay-fors) is a perfect example. The transition to new value-based payment models will continue to advance over the next two years, and we could see new bills around telemedicine, health IT, and data transparency pass that could in fact accelerate the transition. In addition, the Affordable Care Act offers CMS fairly broad discretion to accelerate the transition on its own if it so chooses.

Physicians Practice: What could the effect be on health coverage and patients' access to health coverage? Could we experience major shifts from coverage expansion efforts that have been occurring over the past two years?

Chris Emper: The results of several key gubernatorial races will have a much greater effect on coverage than the change in the Senate leadership. Republican Governors in Florida, Georgia, Kansas, Maine, and Wisconsin who have opted not to expand Medicaid all defeated Democratic challengers who campaigned on expansion, so Medicaid expansion remains unlikely in each of these states. In another state, Pennsylvania, Republican Gov. Tom Corbett, who is the process of implementing an alternative Medicaid expansion plan, lost his reelection bid to Democrat Tom Wolf. Wolf has indicated would like to scrap Corbett's plan in favor of a traditional Medicaid expansion, a change that is sure to impact coverage for many across the Keystone state.

Physicians Practice: Finally, what effect do you think this could have on the SGR? Is it any more or less likely that the SGR formula will be repealed and replaced?

Chris Emper: Some were holding out hope that the SGR repeal bill would be taken up again in the lame duck session, but now that the Republicans are set to take over the Senate in January, they'll have little

interest in engaging the current Senate leadership in negotiations for the pay-fors. However, with the current "doc fix" set to expire March 31, 2015, the new Congress will be forced to address the issue early next year and we should see a renewed push for a permanent repeal. SGR repeal is a rare bipartisan issue, with both parties agreeing in principle that we need to repeal the formula and reform Medicare's Part B payment policies.  That being said, the parties disagree in principle with regards to how to pay for the bill’s $180 billion cost and leadership changes coming to both the Senate Finance and House Ways and Means committees in January probably mean the process will have to start over from scratch. Congressman Paul Ryan (R-Wisc.), who is expected to become the next chairman of the House Ways and Means Committee, will be a key player in the process moving forward. All factors considered, passing a permanent fix remains a heavy lift and the most likely outcome is that we’ll see another short-term SGR patch next year.

Physicians Practice: Other thoughts relevant to physicians?

Chris Emper: For physicians, the bigger news of last week may have come on Friday when the U.S. Supreme Court made the decision to hear the King v Burwell Affordable Care Act case. This case considers the legality of premium tax credits offered to enrollees on the federal insurance exchange, healthcare.gov, the legal challenge being based on a plain-letter reading of the law, which states that tax credit subsidies may be offered only in exchanges “established by the state.” Because 36 states chose to rely on the federal exchange as opposed to establishing their own state exchanges, this case puts premium subsidies at risk for the enrollees in these 36 states (currently estimated to total 5 million.) If the Supreme Court determines the subsides are illegal, these enrollees would likely find coverage unaffordable, which in turn could also unravel the law’s employer and the individual mandates, which are based on the exchanges functioning and offering affordable coverage options. What would this all mean for physicians? Physicians in the affected 36 states who are seeing new patients covered under the exchange plans might be at risk of providing services that turn out not to be covered. The prospect of this outcome alone may cause some physicians to delay accepting new patients covered by these exchange plans until the outcome of the case is known. Given the potential impacts, physicians should expect to hear a lot more about this case between now and June, when a final decision by the justices is expected.