A New, Republican CMMI?

As the repeal and replacement of the Affordable Care Act winds its way through Congress, one of the more popular parlor games in Washington these days is guessing what a post-ACA world will look like. If you’re using House Speaker Paul Ryan’s “A Better Way” as a guide, one thing is a safe bet – the Center for Medicare and Medicaid Services’ Center for Medicare and Medicaid Innovation is about to go the way of the individual mandate.

Before making that guess, however, first consider that a recent Congressional Budget Office estimate concluded CMMI will save $34 billion from 2017 to 2026. Given the strong Republican drive to reduce spending and slash the federal deficit, some in the GOP may balk at doing away with CMMI savings.

But a Republican health care plan that includes CMMI will not be based on fiscal arguments alone. CMMI was created as an innovative body, vested with the authority to operate with flexibility outside of the direct oversight of Congress. It’s that structure — which Republicans oppose in other institutions including the Consumer Financial Protection Bureau — that could end up saving CMMI.

As Republicans grapple with health care provisions to replace the ACA, they are sure to consider ideas whose success or failure will be difficult to judge. A prime example of this is premium support for Medicare, a long-held Republican ideal that has yet to be proven.

Republicans oppose the scope of CMS demonstration projects, but the GOP supports changing the way health care is reimbursed. GOP policymakers would benefit from testing payment reform ideas via a newly managed CMMI. And changing existing mandatory programs to voluntary ones, like the Comprehensive Care for Joint Replacement model, could give nervous industry sectors a much-needed boost.

President-Elect Donald Trump’s nominee for Health and Human Services Secretary, Rep. Tom Price (R-Ga.), has been a vocal critic of CMMI (and of CJR in particular). Specifically, he has labeled the introduction of mandatory, wide-ranging programs an unconstitutional overstep of CMMI’s authority. Price called for CMS to cease all current and planned mandatory initiatives, not to cease the center’s operations.

Some groups, including the Healthcare Leadership Council, have begun calling for transitioning CMMI to a demonstration center, letting CMMI continue testing ideas on a smaller scale and with less power to turn successful pilots into permanent payment policy. GOP leaders are considering whether CMMI in the Trump era could serve as a vehicle for a radical conservative overhaul of government health care — a means of introducing or testing some of the GOP agenda without legislation.

Certainly, a new CMMI will be renamed and rebranded, to “Republicanize” it. Demonstrations would include guardrails and strict congressional oversight, and an evaluation of all existing programs would be likely, as while quality appears high, reporting has proven onerous and savings inconclusive.

Most importantly, value-based care is here to stay, and CMMI plays a large role in that transition. In six short years, CMMI has launched more than 30 new payment models, with varying degrees of success. Replacing the ACA while keeping voters happy is going to be hard work; it’s tough to imagine Republicans ignoring such an obvious avenue for getting health care right.


Ipsita Smolinski is managing director of Capitol Street, where she advises clients on national health care policy and emerging trends.

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