Episode 3

In this episode, experts from the Practice Organization’s government relations office discuss President Trump’s approach to repealing the Affordable Care Act and the new administration’s stance on different health care policies.

About the experts:
Doug Walter, JD and Diane M. Pedulla, JD

Doug Walter, JDDoug Walter, JD, is the Associate Executive Director for Government Relations for the American Psychological Association Practice Organization. He served as Legislative and Regulatory Counsel since 1995 and has represented psychologists before Congress and regulatory agencies since 1991. Walter participated in development of President Clinton’s Health Security Act in 1993. He helped draft the Bipartisan Consensus Managed Care Improvement Act, sponsored by Congressmen John D. Dingell and Charlie Norwood, which passed the House of Representatives in 1999. Mr. Walter was a principle negotiator in discussions between mental health and insurance advocates that led to passage of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Treatment Act of 2008. He helped formulate the privacy protections in the Health Insurance Portability and Accountability Act Privacy Rule and in the Health Information Technology for Economic and Clinical Health Act of 2009, and he is a leading health privacy advocate in Washington, D.C. In 2008, Walter was chosen by the Senate Health, Education, Labor and Pensions Committee to represent the mental health and substance use communities in public “stakeholders” meetings to develop, and he drafted portions of the legislation that was enacted into law as the Affordable Care Act of 2010.

Diane M. Pedulla, JD, is the Director of Regulatory Affairs at the American Psychological Association Practice Organization. She is responsible for monitoring federal laws and policies that affect the independent practice of psychology, including Medicare coverage, reimbursement and quality reporting.


Jewel Edwards-Ashman: On January 20, 2017, Donald J. Trump took the presidential oath of office in front of the U.S. Capitol and became the 45th President of the United States. He succeeded former President Barack Obama who served two terms and was able to enact a sweeping health care reform law. While running for president, Trump made it clear that one of his first actions as president would be to repeal the Affordable Care Act, also known as Obamacare. This law has extended comprehensive insurance coverage to millions of Americans since it was enacted nearly a decade ago.

Doug Walter: The Affordable Care Act is actually a coverage law. It fundamentally didn’t change the employer-based coverage system in the country. But what President Obama wanted to do with the law was to deal with the 40 to 45 million people who were uninsured in the country.

Jewel Edwards-Ashman: That’s Doug Walter, head of the government relations office for the APA Practice Organization. And I’m Jewel Edwards-Ashman. For this episode of Progress Notes, I sat down with Doug Walter to discuss the Trump Administration and Congress’s approach to repealing the Affordable Care Act, and how one of President Obama’s signature policies managed to survive Trump’s first 100 days in office.

During last year’s presidential campaign, President Trump ignited supporters with promises that he would take action to repeal the Affordable Care Act as soon as he took office.

Doug Walter: Unlike in other policy areas where I think he has some very strong convictions, such as in taxation or business or trade, he seems to be deeply involved. So what I have heard him say, such as with his speech to Congress in late February, is basically he’s toeing the Republican line. It’s a fundamental difference in opinion on how health care should be provided in the country.

So where we had President Obama who wanted a more centralized system and coverage for all I think that what I see with President Trump is a desire to let market forces work. That is his beef, shall we say, with the Affordable Care Act in that it puts too many requirements on the market.

Jewel Edwards-Ashman: After spending less than one full day in office, Trump issued his first executive order—an order aimed at giving states and regulators more leeway on how they could enforce the Affordable Care Act. As far as executive orders go, Doug Walter, says the order was too vague to have a significant impact on insurers or patients. But just the act of issuing the order sent a strong message to elected officials and the public.

Doug Walter: As a political symbol, about what he wanted to do with the law, I think it was very powerful, particularly hours after his inauguration. What he’s basically saying is what his intent is when he becomes president. In other words, very early in his presidency he intends to repeal and replace in some way Obamacare.

Very clearly early on both the president and the Republican majority in Congress signaled that they were going to do it through a few avenues. The first was through a reconciliation process where they would take parts of the law that had impact on federal spending and they would modify and repeal parts of the law related to that. Secondly, Secretary Tom Price, secretary of Health and Human Services, has rulemaking authority to reinterpret some of what the law says. So that would be a second area where the law would be repealed and replaced although a more limited avenue. And thirdly, they would repeal and replace the law with regular order, in other words through the usual bill enactment process in Congress. So it was basically looking at this in sort of a rolling order. Reconciliation, Secretary Price looking at regulation, and then the usual bill process for those parts of the law that reconciliation couldn’t touch. So the American Health Care Act was only the first part of this three-part process. The American Health Care Act was a bill that came out of the reconciliation process.

Jewel Edwards-Ashman: The American Health Care Act, or H.R. 1628, was released by House Republicans to the public on March 6, 2017.

Doug Walter: We wanted to signal to the president and to Congress that anything was on the table. We were willing to look at repeal and replace of the Affordable Care Act as long as those people in our country had equally reliable coverage for their mental health and substance use disorder treatments. We ultimately did oppose the bill because it became quite clear that the bill would be damaging and the damaging aspects of the bill are around coverage. Remember the Affordable Care Act was a bill basically to extend coverage to those who were uninsured. What the Congressional Budget Office determined when they looked at the bill--and the Congressional Budget Office scores bills and analyzes bills for congress--when the Congressional Budget Office looked at the bill and said that 24 million Americans would lose their coverage with the repeal provisions of the bill, that’s when we came out against the bill. We know that millions of Americans get their mental health and substance use treatment because of the Affordable Care Act, and we thought that was too high a price to pay in this process.

The Affordable Care Act expanded coverage through two avenues. First of all it created a marketplace for working families in the individual and small employer market. And when the president and Congress say that Obamacare is failing, they’re actually talking about this aspect of the expansion of the law. That these marketplaces aren’t working as well as they could. The second way the Affordable Care Act expanded coverage was that it lowered the poverty threshold in Medicaid and expanded Medicaid to that poor adult population. These were very, very important aspects of the law when it was enacted for us. And so that’s why ultimately we opposed it and so did most consumer and provider groups and ultimately it’s just why it did not make it through the House of Representatives.

Jewel Edwards-Ashman: Not only were most consumer groups and health care groups not on board with the American Health Care Act, Doug Walter says there were a number of Republicans, members of Trump’s own political party, who were still not convinced of the bill’s merits.

Doug Walter: You have in the House of Representatives a fairly narrow Republican majority and there are in the House a number of Republicans who are members of what’s known as the Freedom Caucus. And these are what we call “tea partiers,” which is a grassroots populist movement in the country which actually congealed in opposition to Obamacare back at the beginning of the decade. So these members of Congress are the members who are always calling for repeal and replacement of Affordable Care Act.

So what was happening then and why the law failed is that the speaker of the House, Paul Ryan, was trying to get enough votes in the House to get the American Health Care Act enacted. So what he was doing was he was bargaining to get more of these Freedom Caucus members to vote for it, but as he was getting more Freedom Caucus members to vote for it, he was losing more of his moderate Republican base who simply were too uncomfortable with the huge loss of coverage associated with the bill. So ultimately the bill didn’t make it through the House, the speaker actually took the unusual step of withdrawing the bill just a few hours before the house was to vote on it, because he simply didn’t have enough votes.

Jewel Edwards-Ashman: Doug says this action taken by Speaker Ryan, suddenly withdrawing a bill right before it’s about to go up for a vote, is not typical.

Doug Walter: Well the Speaker of the House has tremendous power through rulemaking to get legislation done. He has to because he has so many members of the House that he has to get on his bill to vote for it. It’s unusual in that right up to the withdrawal of the bill both the speaker and the White House were saying that they had the votes. So it’s very unusual for a speaker at the last minute to pull a bill from the floor. Usually long before that vote happens, the speaker thinks that he has enough votes and he usually—or she usually—does.

Jewel Edwards-Ashman: While Speaker Ryan was trying to gather votes, the government relations staff at the Practice Organization and APA were working with members of Congress

Doug Walter: Well this was actually an all hands on deck sort of effort. And when I say all hands on deck I’m not just talking about the APAPO government relations office. But all the government relations offices in APA—science, public interest and education--were involved in some way because the law is such a large law impacting so many of our constituencies. So basically we were so concerned right off the bat with what looked to be a rollback of years of our work on various health care reform provisions that were part of the Affordable Care Act, which again was a profound step forward in the coverage and treatment of those with mental illness and substance use addiction. So shortly after the election, as we discussed earlier, we realized that the president was going to make repealing and replacing the law his priority. We met with some key Republicans to offer expertise. We also met with some Democratic offices. We clearly saw that the Democratic caucus in both the House in the Senate was not going to play, so to speak, unless the Republican majority was going to offer a real replacement plan and all signals early on was that the Republican majority wasn’t there yet.

So in December we wrote to Speaker Paul Ryan, Senate Majority Leader Mitch McConnell, again offering to help and be part of the discussion. We also wrote to then President-Elect Donald trump offering him basically the same input.

We lobbied early on in some key offices and but our goal was, in our lobbying to always bring up our side of the story our unique sidek which is what the law did again for expansion of mental health and substance use coverage.

In our lobbying, we were on the Hill. We’re meeting with members. We start up a grassroots campaign. Again, this was an APAPO and APA shared grassroots campaign. A drumbeat basically on what the law did. Again, no repealing the law, was our message, without replacing it with a strong law for mental health and substance use services. In that campaign over time, on the APAPO side, more than 15,000 communications from our practitioners went into their members of Congress urging them not to repeal the law without replacing it.

We gathered stories because nothing is more impactful to a legislator than to hear stories about the impact of the law. We received dozens of those which we shared with members of Congress.

We had a “Hill Day” as part of our Practice Leadership Conference, on March 7th right when the reconciliation legislation was going through Congress. And during our Hill Day nearly 400 psychologist leaders from across the country went and met with their senators and representatives delivering their message.

Jewel Edwards-Ashman: Psychology PAC, the political action committee, also played an important role in this fight to protect Mental Health benefits.

Doug Walter: When psychologists give to the PAC, it shows that we’re supporting financially the political aspirations of our allies and those who we think could be our allies. And so we were targeting our money toward those members of Congress that were really going to help us in this fight and so that’s what we did very early on.

Jewel Edwards-Ashman: Doug says the repeal attempts aren’t over, but he doesn’t expect to see any serious ground made on repealing and replacing the Affordable Care Act in the short term. Health and Human Services Secretary Price could take action to change how the law is enforced, but it’s unclear what that action may be.

Doug Walter: Now that we see that reconciliation hasn’t passed, so he has no direction from Congress, what he can do then is more limited than what he could have done if Congress had enacted the American Health Care Act.

We do have to remember he is the secretary of Health and Human Services just as President Trump heads the executive branch. And the Affordable Care Act, as President Trump said after the defeat of the American Health Care Act, remains the law of the land. So they actually have an obligation to make the law work as well as they possibly can. So I think agency action here is narrowed after the defeat of the American Health Care Act.

Jewel Edwards-Ashman: So what’s the Practice Organization focused on right now?

Doug Walter: We will continue to work on the Affordable Care Act. Our priority legislation though is the Medicare Mental Health Access Act. This would be a change to the Medicare statute, which would put psychologists under the Medicare “physician definition.” Now that’s not really a definition limited to physicians. There are number of non-physicians included in it, such as chiropractors, podiatrists and dentists. Getting psychologists included in that definition, in that statutory provision, would greatly enhance their stature in the program, and specifically take them out from under psychiatrist- and physician-supervision in several Medicare treatment settings. We’re going to look for any vehicle, any Medicare legislation, possibly coming down the pike this year that we could get that bill attached to.

Jewel Edwards-Ashman: Diane Pedulla, director of regulatory affairs for the Practice Organization, says that any future Medicare legislation could impact select group of psychologists, some who may be new to Medicare due to aging clientele.

Diane Pedulla: We estimate about 28,000 psychologists are currently Medicare providers. We often find that psychologists who maybe have been dealing with some patients for a number of years, as those patients are getting older and leaving the workforce and are going to be on Medicare that might be around the time that some psychologists that have not been Medicare providers previously start to inquire whether it’s worth it for them to enroll as Medicare providers.

In some locations, Medicare is actually one of the better third-party payers, one of the more reliable, consistent and on-time third-party payers. In some locations, psychologists may feel like the rate is much lower than what they are able to earn by dealing with private insurance patients.

Jewel Edwards-Ashman: Over the past few years, Congress and Health and Human Services have made significant changes to Medicare, most notably, the Medicare Access & CHIP Reauthorization Act went into effect. The law basically created a new system in which Medicare’s payments to health care providers are tied to quality and performance. Psychologists in Medicare do not have to start reporting under this new system until 2019.

Diane Pedulla: The most important thing that they need to understand right now is that they have a bit of a breathing period before they need to worry about MACRA taking effect. MACRA for 2017 is instituting the Merit-based Incentive Payment System and Advanced Alternative Payment Models.

The first one is where most health care providers are going to be. Known as MIPS, it is going to reward quality and value. Most people are going to be average and some people unfortunately are going to see cuts in payment because they are not keeping up with their peers. The key is for 2017 this applies to physicians and certain physician extenders like nurse practitioners. It does not yet apply to psychologists and psychologists would not enter MIPS until 2019 at the earliest.

Jewel Edwards-Ashman: With a new presidential administration, that has new ideas on how the health care system should work, some health care providers are wondering if the way MACRA is implemented could change.

Diane Pedulla: We don’t know if there might be some changes coming to MACRA, other than the one that CMS was already anticipating would take place as the program grows.

Jewel Edwards-Ashman: But even if there are new proposals to change the way Medicare or any other health care policy is implemented, Diane says psychologists can play a big role in ensuring that the practice of psychology is protected.

Diane Pedulla: One of the most important things is that psychologists have such powerful stories to tell. Because they deal with people who need assistance in being able to live their lives. So the work that psychologists do is so valuable, not just to the individual people, but also to their families to their ability to participate in the workforce or get themselves through school. It’s truly life changing and supportive of the life they are trying to live but many people in places like Capitol Hill don’t realize that and they need someone to explain to them, what it is that psychologists do and the many different ways in which they help people live better lives.

Jewel Edwards-Ashman: And that ends this episode of Progress Notes. One the next episode, we’ll hear from psychologists about the challenges and rewards of rural practice.

Dr. Julie Takishima-Lacasa, Phd: You’re not just a specialist in terms of your ability to understand and competently practice as a generalist and treat whatever walks through the door. But also you become competent on the specific culture, the conditions, the context that differs from probably every rural community because every rural community has their own histories and contexts and biases and strengths.

Jewel Edwards-Ashman: This episode of Progress Notes was produced by me, Jewel Edwards-Ashman, along with Hannah Calkins and Luana Bossolo. You can listen to Progress Notes on iTunes, SoundCloud and our website apapracticecentral.org.