Health Reform and HITECH Implementation after the Election: commentary and interviews by Neal Neuberger 

The November 2nd mid-term elections mean big changes starting in Washington and across the states next year. The 111th Congress will reflect at least a 60-vote swing in the House of Representatives, with a new Republican majority of 239 to 185. (A few of races are still outstanding). In the Senate, the Democratic majority will narrow, likely to 53 to 47. Every single chairmanship in the U.S. House of Representatives will now transfer from Democrat to Republican control.

In addition, there will be 10 new Republican Governors, and 20 state legislatures turning from blue to red. Moreover, it is thought that there will be at least 20 new state insurance commissioners. This is particularly important given the Federal-State partnerships envisioned under both health reform and the “e-enabling” of the healthcare environment.

Neal Neuberger asked some of the nation’s leading healthcare insiders how the dramatic political changes would likely impact new healthcare reforms and also what it may mean for ongoing implementation of the HITECH provisions in the American Recovery and Reinvestment Act (ARRA).

Interviewees included Edward Howard, Executive Vice President,Alliance for Health Reform; Gary Capistrant, Senior Director, Public Policy, American Telemedicine Association; , Richard Hodge, Senior Director, Congressional Affairs, HIMSS, and Joel White, Executive Director, HIT Now Coalition.

NN: Do you see any changes to health care reform happening as a result of the elections?

Howard: I don’t expect major changes before the 2012 elections. For one thing, Democrats still control the Senate and the White House – both of which are up for grabs in 2012. What’s more, so much of the funding for reform was actually enacted as part of the reform law itself that most of the implementation activity can go on despite threats by Republicans to “starve” reform through the appropriations process.

Capistrant: I expect the annual appropriations process will be a major focus to starve or cut back on specific ACA initiatives. And there will be lots of partisan theatrics and positioning.

Hodge: No doubt the new majority in the House will attempt to make good on their campaign promises to change some of the Health Care Reform provisions before they become effective. There may be significant attempts to provide the states more flexibility in how they operate Medicaid and CHIP. For the most part, the HIT funding provisions will not be a primarily focus of health reform efforts. However, we will be monitoring very closely against any reductions in HIT funding.

White: Yes, a fair amount. I think many Members are very concerned about the debt and deficit and will be trying to tackle those issues in a comprehensive way. Because you cannot address either without addressing rising health costs, many provisions of the reform law will be under scrutiny. These include Medicare, Medicaid, individual health subsidies and incentives for meaningful use

NN: How do you see the change over in Chairmanships affecting the process?

Howard: In the House, both the committees with jurisdiction over health care and the Oversight Committee will be keeping a very close and public eye on the Administration as it implements the remaining parts of ARRA HITECH and the reform law. Expect a lot of hearings, a lot of demands for data, and a lot of close scrutiny of proposed regulations. The substantive committees will also report legislation to slow down or shut down implementation of reform, but the fate of those bills, given the Democrats’ control of the Senate and the White House, is uncertain at best.

Hodge: The change in House committee chairmanships as the majority changes from Democratic to Republican is much less significant than who specifically will take the Chairs of committees of interest. Because the Republicans have rules on Chairmanship tenure, the Chair in the 112th Congress will not automatically be the current ranking minority member.

 What kinds of improvements would the ATA like to see vis a vis Telemedicine to strengthen the provisions of HITECH?

Capistrant: Making HITECH more high service, high value. Our major focus will be telehealth coverage for Medicare and Medicaid patients.
White: Better standards within the limited Meaningful Use (MU) context. By this, I mean higher percentages for e-prescribing, CPOE, etc. More use of clinical decision support. Again, that is within the current MU context.

Outside of the current context, we need to do four things to make the MU program work such that it actually promotes information integration between clinicians to improve patient care:

1. Define the data and how to share it. This requires uniform vocabulary and content exchange standards;
2. Require bilateral interoperability for MU participants. Clinical exchange of information should be a requirement for the program;
3. Require systemic integration for exchange and make that a focus of the incentive program;
4. Incentives should include non-financial means, including legal safe harbors for providers that meet the MU defined best practices of care.

 Should we be concerned about unobligated funds for (especially the discretionary portions) of ARRA HITECH ? How about changes to the incentives?

Hodge: Yes, we should be concerned about reductions and we will be paying very close attention to these issues as the Congress moves to significantly reduce the Federal deficit.

White: I think everything is on the table, including the ARRA HITECH incentives. What the HIT Now Coalition has been focused on is educating policy makers that the incentives should be more meaningful to ensure health care quality, delivery, outcomes and the cost picture are improving continuously. Because the programs deal with information shared and used by health care providers about the treatment decisions they make about patients, and the fact that those decisions are sometimes life and death conclusions, the standards must be very high.

The second thing we should understand is that the Congressional Budget Office “scored” the incentive program as saving $13 billion in administrative costs, reduced tests, and other program efficiencies unrelated to any penalties for non-adoption. That’s real money, and the first time to my knowledge that CBO scored savings in a health program this way. Repealing the incentives would eliminate those savings.

I think it is also important to understand that the discretionary programs that are so important to expand use in rural areas are part of a comprehensive approach to improving care. Repealing one and keeping others makes little sense in the broader context of improving care and lowering costs.

NN: Thank to all of you for your insights.