We have learned in the past few years that our Founding Fathers were wise to put most federal lawmaking authority in the hands of Congress. I saw that firsthand in the House and Senate, where I served the people of Indiana under three presidents — George W. Bush, Barack Obama and Donald Trump. Each of these men sought to increase the powers of the executive branch relative to Congress.
This is not a partisan dynamic (since it involves presidents, speakers and majority leaders of both parties), but a constitutional one. Nowhere is this struggle playing out more than in the Center for Medicare and Medicaid Innovation.
Properly used, CMMI is a great tool to improve health care that came out of the Affordable Care Act. It was created to foster a laboratory of good ideas for better health care inside the Center for Medicare and Medicaid Services. CMMI could try out different ways to build a better mousetrap inside the vast and complex federal health care bureaucracy, measure the results, consult with experts and ultimately work with Congress to make changes to federal programs in a serious, data-driven way.
The ultimate goal of CMMI is for patients to get better care at more affordable prices — something that Democrats, Republicans and independents can all embrace.
Unfortunately, sometimes CMMI has been used as a backdoor to change these federal health care programs in a wholesale way.
Don’t take my word for it: A coalition of patient advocates ranging from the Arthritis Foundation, the Kidney Cancer Association and the Vietnam Veterans of America sent a letter to CMMI at the beginning of the Trump administration asking for several basic principles to be respected. These “guardrails” included the following: fostering strong and scientifically valid testing prior to expanding a CMMI experiment; respecting Congress’ role in making health policy changes; consistently being transparent and letting stakeholders engage; improving data sharing; protecting beneficiaries; and working in cooperation with the private sector. These are commonsense “rules of the road” that have all too often been ignored by the Trump Administration to the detriment of patients.
My former colleague Sen. Bob Casey (D-Pa.) and I, along with 13 of our colleagues, wrote last year to CMS Administrator Seema Verma about CMMI and the way it was doing business. In our letter, we expressed concern that CMMI was attempting to change the Medicare rules for out-of-pocket costs without an act of Congress, something far beyond its authority. Furthermore, we lamented the ambiguity and lack of transparency in how CMMI was conducting its affairs.
We were concerned that Medicare beneficiaries were not given sufficient notice or the ability to opt out of CMMI experiments. Older adults and people with disabilities needed to be protected from higher costs. Patient advocates and others needed to be heard. Those concerns remain to this day.
Again, CMMI has the potential to be a good thing when properly implemented. It should be what it claims to be: a center for innovation inside the Medicare and Medicaid programs. It is not a backdoor health care mini-Congress, writing legislation in the executive branch. CMMI activities must be transparent, reviewable and accountable.
Congressional oversight is an absolutely necessary part of a well-functioning CMMI. The director of CMMI should be required to regularly testify before all the relevant committees in Congress at least once a year.
Believe it or not, the CMMI director has never once been required to testify before the Senate Finance Committee. At the beginning of this Congress, House Ways and Means Committee Chairman Richard Neal (D-Mass.) and ranking member Kevin Brady (R-Texas) sent a joint letter to CMMI signaling an intent to do robust oversight.
The Congressional Budget Office should regularly review its scoring conventions when it comes to CMMI demonstration projects. Congress needs to have more of a hand in authorizing expansions of CMMI experiments than it does today.
Attempts to rein in CMMI by Congress often get scored by CBO as increasing the national debt — the theory being that an experiment stopped is a savings not achieved. That’s just not right.
Ensuring that the proper safeguards are in place for CMMI should not be a partisan exercise.
Political winds blow back and forth. A Republican CMMI director gives way to a Democratic CMMI director, and vice-versa. It’s in the country’s interest to make sure that an executive agency such as CMMI is not used for aggressive partisan gain. Instead, CMMI should be a transparent, reviewable and accountable agency focused on improving the quality of health care at the most affordable costs. That would be truly innovative for all Americans.
Joe Donnelly is a former Democratic United States senator from Indiana and is currently a senior adviser to the Akin Gump law firm.
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