By Dylan Scott
The ranks of the uninsured have dropped dramatically since the passage of the Affordable Care Act six years ago. But administration officials are now hustling to use other parts of the law to reshape how health care itself is delivered across the United States.
They're trying to tackle the biggest health care issue of the day -- drug prices -- and setting ambitious goals for revamping how primary care is provided. They have also undertaken significant new efforts when it comes to paying for surgeries and preventing disease.
"What will happen over the next eight months is as much as these projects can be accelerated, they will be," said Kathleen Sebelius, the former US Health and Human Services secretary. "The time clock is very much in everybody's mind."
Every administration tries to get as much done as it can before time runs out, but this White House has a tool that none of its predecessors did: an agency created by the Affordable Care Act and given $10 billion over 10 years to test new models for paying for and delivering health care.
The administration seems intent on stretching the authority given to this new agency, called the Center for Medicare and Medicaid Innovation, as far as it can in its final days. The agency, for instance, recently proposed a new plan for overhauling Medicare Part B drug payments -- and it's mandatory for many providers.
"They are definitely taking a broad interpretation of the authority and using it as a vehicle," said Caroline Pearson, senior vice president at Avalere Health, an independent consulting firm. "They're trying to push through as much regulatory reform as they can."
The administration said that 34 initiatives have been announced or are currently being tested at CMMI.
Broadly speaking, the agency has stuck to widely supported ideas for improving health care. That means paying doctors as a group to treat a patient instead of for each individual service, which should foster cooperation. And it means encouraging preventive care to forestall more costly problems down the road.
"We believe delivery system reform, and the work of the innovation center, is truly bipartisan," said Dr. Patrick Conway, chief medical officer at the Centers for Medicare and Medicaid Services, who oversees CMMI. "We think it will continue beyond this administration."
But some of its work is highly controversial -- and will still be in its infancy when the next administration takes over, putting it at risk of being undone.
The second part of the Medicare drug overhaul, which aims to encourage doctors to prescribe less expensive drugs without sacrificing the quality of care, is currently expected to take effect after Jan. 1, 2017.
The pharmaceutical industry is lobbying hard against it, and some physician and patient groups have also said they are deeply concerned. Republicans in Congress have already urged the White House to withdraw the proposal altogether. The opponents describe the plan as an overreach of what CMMI was intended to do and warn it could compromise the care that cancer patients receive.
"The part that maybe was unforeseen was the size of the demo, the fact that it was mandatory, the length of time that it was in existence, and the lack of detail about pretty significant changes" to drug payments from the insurance program, Lori Reilly, executive vice president of policy and research at PhRMA, told reporters at a recent briefing.
There is some disagreement about what would need to be done to undo what the Obama White House is trying to accomplish -- Could a President Trump just sign a piece of paper? Or would he need to go through the regulatory process? What about any contracts that have been signed? -- but everybody acknowledges that a GOP president and a Republican Congress could find a way to stop the plans that this administration has put into motion.
"If the Republicans win and get their acts together, I think Phase 2 never gets implemented," Pearson said. "It probably doesn't go anywhere."
Those who worked at CMMI over the years say limbo has become a semi-permanent state at the agency after the Supreme Court cases and congressional repeal votes of the last seven years.
"We were always in a constant state at CMMI of wondering whether or not we had a future," said Andy Shin, who helped launch the agency. "The worst thing for us to do is to start something that's reversed tomorrow."
Conway has overseen much of this work so far, and he talks with great enthusiasm about the center's efforts.
He said he read a book called "The Other Side of Innovation," which outlines how to turn "big ideas" into tangible results and spoke with venture capitalists about how to encourage a "startup" mentality inside one of the federal government's biggest bureaucracies. The tools at his disposal were immense.
"It always was known within the department how broad that authority is," Sebelius said. CMMI "is probably the single most potentially impactful element of the ACA."
Conway remembers walking through the halls of HHS in earlier years, where then-CMS administrator Don Berwick would tell him: "You're doing a great job, Patrick. Just keep going faster and better."
CMMI's output suggests Conway took that to heart. But the work has always been about negotiating between short-term and long-term goals, a friction all the more relevant as the administration winds down.
"We always feel the urgency of the need to move," he said.
But at the same time, "we view this a long-term journey," he said. "The way we have tried to manage is: One, where do we want to be in several years? We really manage then down to 90-day cycles. What do we have to do in the next 90 days?"
The agency has been credited with some staggering improvements in health care quality. A government report last year found thousands of lives and billions of dollars have been saved since 2010 because fewer people are experiencing complications at the hospital, and it pointed to the new payment models as a contributor. Its first-of-its-kind agreement with the state of Maryland to cap health care costs has shown encouraging early returns, according to Health Affairs.
Not every test has been a success, though. Initial results of one program targeting primary care didn't show any savings. "What we're seeing is delivery service reform is really hard," Pearson said.
"Most of its efforts and investments are going to take a little bit of time to know," said Cindy Mann, a former top CMS official, said. "There's no silver bullet in this business."
That only increases the stakes of the presidential election for CMMI and projects like the Medicare drug-payment demonstration. A Trump-led government could of course repeal the entire law and yield the whole experiment moot.
Or, in the other direction, the next administration could follow the Obama administration's lead and take an expansive view of what CMMI is allowed to do. What that would lead to under a Republican administration is anybody's guess.
"We're watching this administration use CMMI to its maximum potential to achieve its goals, and a new administration could easily do the same," said Tricia Neuman at the Kaiser Family Foundation. "We don't know what that means."