The latest deal to avert a shutdown could affect Medicare, MACRA, CHCs, and more

Congress on Thursday is expected to vote on a Senate spending package that would, in addition to funding the government through March 23, raise 2018 and 2019 budget caps for defense and domestic programs, including those to combat the opioid misuse epidemic and fund community health centers.

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The spending package's new budget caps are the product of months of negotiations between House and Senate leaders. While the package sets new two-year spending limits for the federal government, it does not allocate any appropriations for those years. Instead, the package is expected to contain a House-passed continuing resolution that would fund the government through March 23, giving lawmakers more time to write the specific appropriations bills, according to Vox.

However, the new budget caps deal is facing opposition in the House, and lawmakers have until midnight Thursday to pass a spending bill to avoid a second government shutdown this year.

What's in the new budget caps deal

On Wednesday, Senate Majority Leader Mitch McConnell (R-Ky.) and Minority Leader Chuck Schumer (D-N.Y.) announced a two-year deal that would increase spending on defense and domestic programs by about $300 billion over the next two years, including a $160 billion budget bump for defense and a $128 billion budget bump for domestic programs.

The increases for domestic programs, which include those overseen by HHS, would include:

  • $80 billion in disaster relief funding;
  • $20 billion to for infrastructure programs, including those for water and rural broadband;
  • $7 billion and a two-year reauthorization for Community Health Centers;
  • $6 billion toward opioid and mental health treatment;
  • $4 billion for Veterans Affairs (VA) to rebuild and improve VA hospitals and clinics;
  • $2 billion for NIH research projects; and
  • Nearly $500 million for the National Health Service Corps.

The deal also includes a 10-year reauthorization for CHIP, up from the six-year reauthorization package Congress passed last month. In addition, the deal would extend Medicare programs that expired on Sept. 30, delay scheduled cuts to disproportionate share hospital payments for FYs 2018 and 2019, and repeal the Affordable Care Act's Independent Payment Advisory Board.

According to Axios' "Vitals," the proposal also would accelerate efforts to close Medicare's "doughnut hole"—a coverage gap in Medicare prescription drug coverage. Beneficiaries who reach the current coverage limit have to pay out-of-pocket for the full cost of drugs costs until catastrophic coverage kicks in. The proposal aims to close that gap by increasing discounts pharmaceutical companies are required to provide to affected beneficiaries.

The bill also includes some changes to MACRA, Modern Healthcare reports. CMS next year plans to raise the weight for the Merit-based Incentive Payment System's (MIPS) cost category to 30%. However, the bill would allow CMS to keep 2018's cost category weight, set at 10% of a clinician's total MIPS score, through 2021. In addition, the bill proposes that MIPS not take into account clinicians' prescribing rates under Medicare Part B, which often include intravenous medications administered in clinical settings to sick beneficiaries, such as those with cancer, hypertension, macular degeneration, and rheumatoid arthritis.

The budget cap deal does not address immigration—a controversial subject that contributed to last month's government shutdown. Instead, the Senate is expected to hold an open floor debate on the issue next week.

Next steps

According to Vox, the Senate on Thursday plans to take up a separate House-passed continuing resolution and will amend the House measure to include the new budget cap deal. The Senate is expected to pass the measure and send it back to the House before the Thursday night deadline to avoid a federal shutdown. Trump on Wednesday signaled he would sign the new budget agreement if it reached his desk.

However, the Senate's budget deal faces opposition in the House. Several conservative Republicans have come out against the bill's spending increases, meaning the bill is likely to need Democratic support to pass.

But House Minority Leader Nancy Pelosi (D-Calif.), in a dramatic eight-hour speech on Wednesday, said she would not support the spending package "without a commitment from Speaker Ryan comparable to the commitment from Leader McConnell" on immigration. McConnell has promised to hold a floor debate on various proposals related to the Deferred Action for Childhood Arrivals program as early as next month, provided federal government does not shut down.

However, Ryan declined to make such a commitment, reaffirming his position to bring an immigration deal to the floor only if it has President Trump's support.

If the House does pass the Senate's bill, Congress would then begin work on a longer-term spending bill that would fund the federal government through September at the new budget levels (Everett/Bresnahan, Politico, 2/7; Bruce et al., ABC News, 2/7; Williams/Lesniewski, Roll Call, 2/7; Golshan, Vox, 2/7; Gaudiano, USA Today, 2/7: Bade et al., Politico, 2/7; Mattingly, CNN, 2/8: Baker, "Vitals," Axios, 2/8; Dickson, Modern Healthcare, 2/7).

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