Insights^

Will Joe Manchin leave the Democratic Party?  Ever since the Democratic Senator from West Virginia blew up negotiations on the Build Back Better Act, pundits have been speculating that Manchin will leave the party to become an independent.  While Manchin has bluntly thrown cold water on the idea of leaving the party in the past, such a move wouldn’t be without precedent.  Here are some examples of the dozen or so legislators who have made the uncommon decision to switch party affiliations in the last two decades.

Senators

• Arlen Specter (Republican to Democrat).  First elected to the Senate in 1980 as a Republican, Specter was a staunch centrist.  The Pennsylvania Senator switched over to the Democratic Party in 2009 due to what he viewed as the Republican Party moving “farther and farther to the right.”  Specter ultimately lost the 2010 Democratic primary race to Joe Sestak, who went on to lose the general election to current Sen. Pat Toomey (R-PA).  Specter died of non-Hodgkin’s lymphoma in 2012.
• Joe Lieberman (Democrat to Independent).  Lieberman was the Democratic nominee for Vice President in the 2000 general election, but then he  ran under the independent “Connecticut for Lieberman” party in his 2006 Senate reelection bid after losing the Democratic primary to current Connecticut Gov. Ned Lamont.  After winning reelection, Lieberman was officially listed as an independent but continued to caucus with the Democratic Party in the Senate.
• Jim Jeffords (Republican to Independent).  Elected to the Senate in 1989 as a Republican, Jeffords became an independent and caucused with the Democrats in 2001 due to disagreements over the Bush tax cuts.  Jeffords’ switch was particularly consequential because it changed control of the senate from a Republican majority to a Democrat majority. This was the first time such a switch had changed party control.  After his retirement in 2007, Jeffords was succeeded by Sen. Bernie Sanders (I-VT), an independent who also caucuses with the Democrats.

Representatives

• Jeff Van Drew (Democrat to Republican).  The New Jersey State Senator was elected  to Congress in the 2018 midterm elections that saw Democrats flip nearly 40 seats in the House.  However, in late 2019, Van Drew became a Republican due to his opposition to then-President Trump’s impeachment.  Van Drew won reelection in 2022 and continues to represent his purple district in southern New Jersey as a Republican.
• Justin Amash (Republican to Independent to Libertarian).  First elected in 2011, Amash announced in a 2019 op-ed his decision to leave the GOP and become an independent after becoming “disenchanted” and “frightened” by party politics and saying that he did not feel “well represented” by either major party.  The Michigan Congressman later joined the Libertarian Party in April 2020, becoming the first Libertarian to serve in Congress.  However, Amash declined to seek reelection in 2020.
• Paul Mitchell (Republican to Independent).  Mitchell took office in 2017 to represent a solid Republican district near Detroit, Michigan.  However, in July 2019, Mitchell announced he would not seek reelection in 2019, namely due to the “rhetoric and vitriol” in the federal government and a desire to spend more time with family.  Just a year later, Mitchell formally became an independent out of disagreement with then-President Trump’s efforts to overturn the results of the 2020 presidential election.  Mitchell died in August 2021 after a long battle with cancer.

2022 is shaping up to be a busy year for Congress, with potential implications for health care policy.  Lawmakers’ challenging agenda is partly due to unfinished business from 2021, including spending for Fiscal Year (FY) 2022 and the Democrats’ $1.7 trillion social and climate spending package, the Build Back Better Act.

At the top of the 2022 agenda are must-pass items tied to specific deadlines.  Here’s an overview of what Congress must take care of in the new year, no matter what.

• FY 2022 Appropriations.  The short-term spending bill that’s keeping the federal government running is set to expire on February 18, 2022.    The House has already passed most of its FY 2022 spending bills, including a bill that provides a nearly 20% increase in funding for the Department of Health and Human Services (HHS) compared to the FY 2021 level.  However, the Senate Appropriations Committee has only approved three spending bills for FY 2022.  Going forward, lawmakers are hoping a bicameral and bipartisan deal comes together quickly to avoid passing another Continuing Resolution and can finalize FY 2022 appropriations.

• MACRA.  A 5% bonus for providers participating in an Advanced Alternative Payment Model (A-APM) under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is set to expire at the end of 2022. To circumvent the provisions in MACRA from expiring, the Senate Finance Committee is expected to hold hearings to review implementation of MACRA in 2022, and health care providers have been pushing for the bonuses to be extended.  On a related note, legislators are also planning to hold hearings on how MACRA has affected the Physician Fee Schedule.

• Medicare Cuts.  In December, President Joe Biden signed into law a bill to extend the moratorium on 2% Medicare sequester cuts until April 1, 2022 and reduce the cuts to 1% from April 1 to June 30, 2022.  Providers will likely advocate for an extension of the moratorium due to continued stress from the COVID-19 public health emergency but are also looking to work with Congress to find a longer-term solution regarding the Medicare pay system.

• PDUFA VII.  The current Prescription Drug User Fee Act (PDUFA VI) expires at the end of September 2022.  Regulators and industry stakeholders spent 2021 negotiating the details of PDUFA VII, which will determine drug user fees in FY 2023-2027.  It will be up to Congress to reauthorize the next iteration of PDUFA by October 1, 2022, and lawmakers are expected to hold hearings on PDUFA VII in spring 2022.

Other items on the 2022 legislative agenda are top policy and political priorities, particularly for Democrats, who will be fighting to retain their majority in Congress in the upcoming midterm election.  Additionally, health care stakeholders are urging legislators to make progress on pressing health care issues that saw little movement in 2021.

• Build Back Better.  The White House and congressional Democrats had initially hoped to pass a $1.7 trillion social and climate spending package know as Build Back Better before the end of 2021, but progress halted after Sen. Joe Manchin (D-VW) rejected the measure due to concerns over its cost.  However, Democrats are hoping to pass a scaled-down version of Build Back Better that Manchin can support, with the hope that a revised measure will retain some of the original proposal’s health care provisions, including expanded eligibility for Affordable Care Act (ACA) subsidies and expanded Medicaid coverage in 12 states.

• Cures 2.0.  In November 2021, bipartisan members of the House Energy and Commerce Committee introduced the Cures 2.0 Act, which would build on the success of the 21^st Century Cures Act that passed in 2016. CURES 2.0 would authorize the Advanced Research Projects Agency-Health (ARPA-H), streamline the Food and Drug Administration (FDA) review process, enhance Medicare and Medicaid coverage of new technologies, and expand access to telehealth.  Lawmakers initially hoped to advance Cures 2.0 by the end of 2021, but a busy congressional agenda pushed work on the measure into the new year.  Since legislators expect 2022 to be just as busy, it’s possible elements of Cures 2.0 may find their way into PDUFA VII.

• Behavioral Health Care.  In September 2021, bipartisan leaders of the Senate Finance Committee issued a request for information (RFI) on policy proposals to boost access to mental health care services.  Some of the reforms mentioned in the RFI include strengthening the health care workforce, improving parity laws, and increasing the use of telehealth.  Underscoring the need for behavioral health care reform is the upsurge in demand for mental health care during the COVID-19 public health emergency.  The Finance Committee may incorporate responses to the RFI in a potential bipartisan bill in the new year.

• Prior Authorization.  In a bipartisan fashion, 246 House members cosponsored legislation to streamline prior authorization in Medicare Advantage and require rapid determination of the services that plans generally approve.  The Trump administration proposed to streamline prior authorization requirements in Medicaid (but not Medicare Advantage), but the Biden administration has since paused the initiative. Provider groups are advocating for new rulemaking or legislation to include Medicare Advantage in any push to improve prior authorization. (https://jensen-jensen.com)

Health care providers breathed a sigh of relief nearly two weeks ago when President Joe Biden signed into a law a bill to override certain Medicare payment cuts scheduled to take effect next month.   Congress taking action to prevent Medicare cuts isn’t exactly new – in fact, it seems to have become a regular occurrence.

What’s in the bill?  On December 10, President Biden signed into law S. 610, the Protecting Medicare and American Farmers from Sequester Cuts Act.  The bill specifically extends the moratorium on 2% Medicare sequester cuts until April 1, 2022, and reduced the cuts to 1% from April 1 through June 30, 2022. Additionally, the measure provides a one-year increase in the Medicare physician fee schedule of 3%, less than the 3.75% increase for 2021. The bill also delays the 4% statutory Pay-As-You-Go (PAYGO) sequester from taking effect early next year and now cuts won’t go into effect until 2023.

Medicare Sequestration, in Brief

Medicare sequestration began under the Budget Control Act (BCA) of 2011, which required a mandatory 2% reduction in Medicare provider payments, also known as sequestration.  The sequester was originally intended as an incentive for the so-called “super committee” of congressional leaders who convened that year to design a bipartisan plan to reduce the budget deficit by $1.5 trillion from Fiscal Year (FY) 2011 to FY 2021.  However, Congress failed to reduce the deficit, thus setting the stage for automatic spending cuts.

But the Medicare cuts never came.  The Medicare sequester was originally set to end in 2021 under the BCA, but cuts have delayed and the sequester period extended a total of seven times.  More recently, the Coronavirus Aid, Relief, and Economic Security (CARES) Act delayed the 2% automatic cuts to Medicare through March 2021, and the American Rescue Plan Act subsequently delayed the cuts until the end of 2021 until the Protecting Medicare and American Farmers from Sequester Cuts Act was signed into law earlier this month.

So why hasn’t the Medicare sequester ever gone into effect?  Medicare is extremely popular among voters. Also, generally lawmakers from both parties are especially hesitant to cut payments to doctors and nurses, especially now during a public health emergency.

PAYGO, In Brief

The current version of Statutory Pay-As-You-Go (PAYGO) was signed into law on February 12, 2010 under the Statutory PAYGO Act of 2010.  While PAYGO also uses sequestration to reduce government spending, it differs from the Medicare sequester in that it only applies to new government spending that increases the deficit.  Increased deficit spending under the American Rescue Plan Act of 2021 triggered PAYGO cuts that recently signed legislation delayed until 2023.  While the Medicare sequester is capped at 2%, PAYGO caps Medicare cuts at 4%.

Kicking the Can Down the Road

Per the BCA, the Medicare sequester was supposed to end in 2021, but that timeline has since been pushed back another 10 years.  To help pay for the delay in Medicare cuts, and in the case of the need for offsets for the Infrastructure Investment and Jobs Act, Congress has added additional years to the duration of the sequester.  An exception to this is the recently enacted law, the Protecting Medicare and American Farmers from Sequester Cuts Act, which paid for the delay by increasing the percentage of sequester for the last year of the cuts.  These actions by Congress to continually delay or extend the sequester could be interpreted as little more than a “budget gimmick” to ensure that Medicare cuts to providers never actually occur.

So… is there a long-term solution on the horizon to fix these cuts?

Medicare sequestration and PAYGO sequestration cuts cannot be fixed in the Build Back Better Act (BBBA), as these provisions cannot go through the reconciliation process. Therefore, both parties would need to negotiate on passing a whole different bill.  However, Republicans think overriding the PAYGO sequestration cut could be meaningless if the BBBA is enacted later and PAYGO is triggered again. Additionally, providers are starting to grow tiresome of the “budget gimmick” feel when addressing Medicare sequestration and the American Medical Association President Gerald Harmon in a statement urges Congress to find  “more in-depth reforms to the Medicare pay system.”

Nothing is ever certain in Congress, but both parties will have to come together at some point and address these issues.  Could Congress take up these fixes during 2022 and create a longer-term solution? It’s a possibility, but currently Senate Democrats are facing a heavy lift on passing a version of the BBBA and voting rights legislation early next year. Also, don’t forget Congress is heading into an election year, so whether they provide a longer-term solution is still up in the air, which in turn could lead to continuing to kick the can down the road.

It’s tradition for many Americans to swap gifts during the holidays. But does the tradition of holiday gift-giving also apply in Congress, where Senators, Representatives, and their staff face ethics rules on the kinds of presents they can receive?

In short, members of Congress can receive Christmas presents, although there are a lot of limitations. According to ethics rules, members can receive gifts valued at no more than $50, as long as the gift isn’t from a registered lobbyist or foreign agent.  A notable exception to this rule is family members, so members of Congress have nothing to worry about when it comes to exchanging gifts at home on Christmas morning.

However, the rules get a little tricky when involving gifts from non-familial relationships. Friends and romantic partners, like boyfriends and girlfriends, can give gifts valued at up to $250 to members and staff. Beyond this amount, any gift is subject to approval from the House and Senate ethics committees. To receive approval, a legislator or staff member must disclose the approximate value of the gift, the relationship to the gift-giver, and the gift-giver’s occupation. A notable exception to this rule is fiancés and fiancées, who are considered to be in the same category as family members under ethics rules.

While punishments for violating gift-giving rules can range from a warning to a fine, no lawmaker has been punished for accepting a Christmas gift since current rules were first adopted in 2007.

A Forgotten Gift-Giving Tradition in the Senate

Long before ethics rules were imposed, there was once a strong tradition of exchanging Christmas presents among Senate staff.  Shortly after Christmas was made a national holiday in 1857 and the Senate began to take a brief holiday recess, Senate staff began a tradition of exchanging gifts. Key examples from the early days of gift-giving include a gold-topped cane for a longtime Senate page supervisor in 1862 and a lump of coal for the Senate Sergeant at Arms in 1902, which was actually used to heat the Capitol.

Towards the end of the 19^th century, the Christmas gift-giving tradition in the Senate became more focused on pages.  California Senator Leland Stanford gave each Senate page a five-dollar gold coin each Christmas during the 1880s and 1890s, and Vice President Thomas Marshall began a tradition in 1913 hosting an annual Christmas dinner with Senate pages in the Senate dining room. This tradition continued for 20 years and generally involved a gift exchange between the pages and the Vice President.

However, the tradition came to an end in 1933 with the adoption of the 20^th Amendment to the Constitution, which moved the start of the annual congressional sessions from December to January.  As a result, pages were no longer on duty in the Capitol during the holidays, and the Senate’s gift-exchange tradition faded into history.

Spring ahead, fall back.  Twice a year, we adjust our clocks to accommodate the shift between Standard Time and Daylight Saving Time (DST).  While the change on your wristwatch or phone may seem innocuous, the change for your internal clock may have bad implications for your health.

A Brief History of Daylight Saving Time

Daylight saving dates back to the ancient world, when the Romans adjusted the length of hours to account for the amount of daylight.  In 1784, Benjamin Franklin suggested the concept of daylight saving in a satirical essay where he recommended that people get out of bed earlier to save on candles by taking advantage of more daylight hours.  The US briefly adopted DST during the First and Second World War, and the post-war period saw a patchwork of DST policies that varied between different states and jurisdictions.   Confusion in the transportation industry led to enactment of the Uniform Time Act of 1966, which was the first step in establishing a federal DST standard.  Currently, DST starts on the second Sunday in March and ends on the first Sunday in November, with the time changes taking place at 2:00 a.m. local time.

What’s Wrong with DST?

A major consequence of the annual loss of an hour’s sleep in March is forced sleep deprivation.  While the change in clocks only takes place in the early hours of Sunday, people can experience a 30-minute reduction in sleep time each night for the remainder of that week.  Sleep deprivation has many negative implications, including higher risk of stroke or heart attack, and performance deficits on reflex and attention.

Health practitioners, take note: A study found sleep deprivation in health care workers caused by the springtime change led to a 18.7% increase in patient-safety related incidents in health care settings.

It’s not just the spring.  Gaining an hour’s sleep with the fall shift to Standard Time can disrupt the circadian rhythm, desynchronizing the body’s internal hormonal balance and causing symptoms similar to jet lag.  Additionally, the number of patient safety-related incidents in health care settings increased by 5% after the fall clock adjustment.

There are implications for health care technology, too.  Not all electronic health records software systems can handle shifts between DST and Standard Time, requiring health care facilities to implement burdensome workarounds or requiring clinicians to switch to paper charts for one hour.  Unfortunately, these inconveniences can result in longer wait times in emergency departments or records to be inadvertently deleted.  There are also examples of DST affecting medical devices like pacemakers, defibrillators, and glucose monitors.

What’s Being Done to Fix DST?

In recent years, momentum has been growing at the state-level to do away with the biannual time shift by making DST permanent year-round.  Since 2018, nearly a dozen states including South Carolina, Arkansas, Delaware, Maine, Oregon, Tennessee, Washington and Utah have approved or enacted legislation on permanent DST, while several other states including Alabama and Maryland have considered similar legislation.   However, congressional approval is required for states to implement permanent DST legislation, and to date, Congress has yet to sign off.  (While Hawaii and most of Arizona do not observe DST, they were able to opt out or get an exemption from the Uniform Time Act shortly after the bill’s enactment. (https://www.magiklights.com/) )

However, Congress is paying attention.  On November 4, 2021, Sen. Patty Murray (D-WA) introduced the Sunshine Protection Act, which would allow states to make DST permanent.  In an op-ed coauthored with Sen. Marco Rubio (R-FL), Murray cited the negative health effects of resetting clocks twice a year, and she pledged in a floor speech to press the Biden administration for executive action to grant states the authority to move to permanent DST.

The Sunshine Protection Act has 14 cosponsors in the Senate, but given the busy agenda facing Congress this fall, the bill is unlikely to see any movement in the 117^th Congress.  However, as more and more states pick up on the idea that ditching biannual time changes could lead to better health outcomes, a growing number of federal lawmakers could one day take proposals to make DST permanent more seriously.