"Nobody knew health care could be so complicated." Those were the words that President Donald J. Trump spoke on his 39th day as president on February 28, acknowledging what radiation oncologists, cancer patients, providers, insurers and others have known for a long time.
April 29 will mark President Trump’s 100th day in office—a milestone presidents regularly set to demonstrate significant changes they’ve made since taking office. However, the first 100 days of the Trump presidency have been anything but regular.
One way to begin assessing a new presidency is to look at the lineup of key officials. Of the hundreds of positions requiring Senate confirmation, only 22 have been confirmed as of mid-April. Among those 22, though, are the two key positions that directly affect radiation oncology: Department of Health and Human Services (HHS) Secretary Tom Price and Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma.
Secretary Price was a natural choice for HHS, as a physician and actively engaged member of Congress on health policy issues while a representative from Georgia serving on the House Ways and Means Committee. Verma is a more unconventional pick, given that her health policy experience has been almost entirely focused on Medicaid, not Medicare. ASTRO urged the Senate to confirm both nominees, recognizing that radiation oncology would not support all policy positions taken by Dr. Price and Verma, but that it is critical ASTRO work closely with both of them on issues facing radiation oncology and cancer patients.
Both Dr. Price and Verma have been tasked early on with working with Congress to repeal the Affordable Care Act, also known as Obamacare. The first attempt at repeal was through legislation known as the American Health Care Act, which would roll back Obamacare’s insurance mandates and change its system of tax credits, as well as many other revisions. In early February, ASTRO released a set of policy principles for Congress and the Administration to consider when making further health reforms. ASTRO’s principles focused on avoiding disruptions in coverage and care for cancer patients; maintaining the bans on both pre-existing condition exclusions and annual and lifetime limit caps; and prohibiting cost-shifting to cancer patients and providers.
After seven years of trying to prod President Obama to sign a repeal of his signature law, Republicans finally had their chance to fulfill their biggest campaign promise: doing away with the Affordable Care Act. However, Republicans ran into a buzz saw of opposition externally, as Democrats universally opposed any changes because they believed it would leave millions uninsured. Meanwhile, internally within the GOP, moderate and conservative Republicans couldn’t agree on key policies, including whether to preserve Obamacare’s coverage requirements for essential health benefits, such as radiation therapy.
Despite a full-court press by President Trump and House Speaker Paul Ryan (R-Wisc.), a vote on repeal was called off at the last second as Republicans didn’t have enough votes to pass the bill. In the days following, there were conflicting reports about whether President Trump and Congressional Republicans would move on from legislation to repeal Obamacare, and instead focus on administrative changes to the law. This pivot, however, is not without its complications, as the administration and Congress need to wrestle with whether to make policy changes that support continuation of Obamacare, particularly its subsidies to buy insurance.
With Obamacare repeal possibly moving to the back burner, issues that more directly impact radiation oncology are starting to get more attention from the administration, particularly implementation of the new physician payment system, known as the Quality Payment Program (QPP). ASTRO has been actively working to educate radiation oncologists about the program and help practices succeed in getting bonus payments, whether by initially participating in the program’s Merit-based Incentive Payment System or, in the near future, participating in an alternative payment model (APM).
Later this Spring, the administration is expected to take its first crack at adjusting the rules for the QPP starting in 2018. ASTRO is urging the administration to continue elements of the program’s “Pick your Pace” approach, which allows flexibility in initial participation. ASTRO also urges the administration to ensure that radiation oncologists have an opportunity to participate in an advanced APM specific to radiation oncology.
In April, Secretary Price asked medical specialty societies to develop and propose APMs, and ASTRO is doing just that—putting the finishing touches on a model that would create episode payments for cancers treated with radiation oncology and incentivize adherence to relevant clinical guidelines. ASTRO met with Medicare officials in March to discuss the model and we are pleased by the agency’s positive reception and interest in collaborating. ASTRO-backed legislation passed in 2015 requires Medicare to issue a report to Congress on the development of an APM for radiation oncology, and ASTRO is hopeful that the report will embrace ASTRO’s efforts. Medicare has scheduled a public forum to discuss the report and radiation oncology APMs on May 3, and ASTRO is working closely with stakeholders to build support for the model.
While there are some early reasons for optimism on Medicare physician payment issues with the new administration, President Trump’s first budget proposal could mean dire consequences for the medical research community. In March, the administration proposed a $1.2 billion cut for the current fiscal year to the $32.3 billion budget for the National Institutes of Health, which would also cut funding for the National Cancer Institute, and a $5.8 billion reduction for 2018. Testifying on Capitol Hill, Secretary Price justified the cut as needed to rein in overhead expenses at research institutions and reduce redundancies and waste.
ASTRO and cancer research advocates quickly challenged the proposal as a devastating blow to cancer diagnosis and treatment and noted that the proposal comes on the heels of the recent bipartisan breakthrough on research funding through passage of the 21st Century Cures Act. ASTRO is pleased that many influential members of Congress have said they have no interest in reversing course and accepting President Trump’s proposed cuts to medical research.
The whirlwind first 100 days culminates around the same time legislation funding the government runs out, setting up a spending battle as Republicans will need at least some Democratic votes in the Senate to avoid a government shutdown. While both sides are indicating that a shutdown is unwanted, there’s enough tension and hot-button issues at play that anything is possible.
It’s not fair to judge a presidency with more than 1,350 days remaining, but with 2018 midterm election campaigns underway, contenders already jockeying for the 2020 presidential election and major radiation oncology issues yet to be resolved, it’s already time to begin assessing the Trump administration’s impact on cancer policy. With many pressing issues ahead, ASTRO and radiation oncology advocates will need to remain vigilant and engaged.