What Does the New President and New Congress Hold for O&P?

The 119th Congress was sworn in just after the new year started and began its work immediately. The first order of business was to elect a Speaker of the House, which occurred January 3 on the first ballot. The vote could not have been closer, with the incumbent, Mike Johnson (R-LA), achieving the 218 votes he needed to be reelected to that position. The fact that the vote had to be held open while Republican leaders convinced two holdouts to vote for Johnson is foreshadowing for the difficult task that lies ahead for House Republicans to execute on the Trump agenda. Incoming President Donald Trump was inaugurated on January 20 as the electoral college votes were officially counted and certified by Congress on January 6. To get bills through the House, President Trump will need to exert his influence on some House Republicans who have a recent history of voting against their party. It is likely that some bills will only pass the House with at least some Democratic support, which is another way of saying that bipartisanship may prove to be necessary in many instances. Little is known of Trump’s plans for healthcare, but momentum for a return to his first-term effort to repeal the Affordable Care Act (ACA) seems to have waned for now. Healthcare Committee Assignments As the 119th Congress begins, key healthcare committees have begun to round out their new membership. These members will play a critical role in overseeing healthcare policy and shaping proposed legislation, particularly in relation to the incoming president’s agenda. The Senate Finance Committee will be led by Republican Chair Mike Crapo (ID), with Democrat Ron Wyden (OR) serving as ranking member. The committee has added six new members, the majority of whom caucus with the Democrats: Tina Smith (D-MN), Ben Ray Luján (D-NM), Raphael Warnock (D-GA), Bernie Sanders (I-VT), Peter Welch (D-VT), and Roger Marshall (R-KS). This traditionally bipartisan Senate committee has jurisdiction over entitlement programs such as Social Security, Medicare and Medicaid, and tax policy, which means that these new members will be quickly immersed in debates around the expected Budget Reconciliation bill that is expected to form a major part of this year’s agenda. The Senate Health, Education, Labor, and Pensions (HELP) Committee will be led by Republican Bill Cassidy (LA) as chairman, while Sanders, the former chair, will serve as ranking member. The HELP Committee will welcome three new members: Angela Alsobrooks (D-MD), Lisa Blunt Rochester (D-DE), and Andy Kim (D-NJ). The HELP Committee has jurisdiction over public health and research programs, training and medical education programs, and many other areas, many of which they share with the Finance Committee. The HELP Committee will be instrumental in restructuring the National Institutes of Health, which will likely be a priority in the 119th Congress. In the House Energy and Commerce Committee, Republican Brett Guthrie (KY) will serve as chairman, being elevated from Health Subcommittee Chair in the previous Congress and replacing Republican Cathy McMorris Rodgers. Democrat Frank Pallone (NJ) will serve as ranking member of the full committee. This bodes well for the Medicare O&P Patient-Centered Care Act (H.R. 4315 and S. 3977) as Rep. Guthrie was a cosponsor of that legislation in the 118th Congress. Rep. Earl “Buddy” Carter (R-GA) will lead the Subcommittee on Health. New members of the committee are: Cliff Bentz (R-OR), Craig Goldman (R-TX), Erin Houchin (R-IN), Gabe Evans (R-CO), Julie Fedorchak (R-ND), Laurel Lee (R-FL), Michael Rulli (R-OH), Russell Fry (R-SC), Tom Kean (R-NJ), Alexandria Ocasio-Cortez (D-NY), Kevin Mullin (D-CA), Troy Carter (D-LA), Jennifer McClellan (D-VA), Greg Landsman (D-OH), and Jake Auchincloss (D-MA). In the House Ways and Means Committee, Jason Smith (R-MO) will continue to serve as chairman, and Richard Neal (D-MA) will continue to serve as ranking member. Republicans Aaron Bean (FL), Max Miller (OH), Nathaniel Moran (TX), and Rudy Yakym (IN) have been added to the committee. House Democrats had not yet announced their committee assignments at the time of this writing. End of Year Wrap Up Historically, legislation with certain characteristics—such as a low cost or simple reauthorizations of existing programs—has a higher chance of passing through Congress and becoming law, especially at the end of a Congressional term when the pressure is on elected officials to agree to a bill and return to their home state or district. For instance, the current continuing resolution (CR) that is funding the federal government included provisions to extend Medicare telehealth flexibilities for a three-month period to track the expiration of the current CR. However, likely due to the cost of the provision, nothing was included in the CR to reduce or eliminate the cut to the Medicare physician fee schedule, which means that physicians, physician extenders, and therapists received a 2.8 percent pay cut as of the first of January. In contrast, O&P providers received a 2.4 percent increase based on the statutory formula for annual inflation adjustments that applies to the O&P fee schedule. Very few healthcare provisions wound up in the final year-end legislative package despite bipartisan negotiations in the House and Senate that went on for weeks behind closed doors. When the multipronged tentative agreement was released days before the CR expired on December 20, 2024, many House conservatives balked. Elon Musk contributed to the pile-on by tweeting repeatedly in opposition to the bipartisan bill, ultimately prompting incoming President Trump to also oppose the legislation. The lengthy compromise largely wound up on the cutting room floor and a pared down CR passed instead with only a few healthcare provisions, averting a government shut down by only a few hours. The fate of that compromise healthcare package is unknown at this time, but many believe it will form the basis for the start of negotiations of the package expected in late March, which is also expected to accompany another CR or an omnibus spending bill to fund the federal government through the end of the fiscal year, September 30. Expect O&P to Have to Play Some Defense In addition to a flurry of executive orders that are expected to be issued on day one of his presidency, some of which will likely impact healthcare, incoming President Trump is expected to press for a reconciliation bill (or bills) that will extend the Trump tax cuts and seek hundreds of billions, if not, trillions of dollars in government savings over a ten-year period, the typical budget window that the Congressional Budget Office uses to “score” legislation. This cannot be easily achieved without impacting programs such as Medicare and Medicaid, although the incoming president has promised to protect Social Security, and there is interest in also protecting Medicare. Recent pronouncements from Energy & Commerce Committee Chair Guthrie, however, have indicated that “site-neutral” payments under Medicare—which do not typically impact O&P care—and Medicaid spending are primary targets for achieving savings in these programs. The O&P community will need to educate new members of Congress about the value of O&P care and elevate our priorities to ensure O&P is not either left behind or used as a target for savings. All healthcare provider organizations will need to be playing defense during the upcoming reconciliation debate to try to hold off efforts to target their sector for savings. In the case of O&P, the profession will be working to prevent cuts or freezes in the Medicare O&P fee schedule and other proposals to save money, including potential expansion of competitive bidding. Pressure on Health Insurance Coverage Although no major changes to Medicare eligibility criteria are currently in the mix for the coming year, reconciliation legislation may significantly impact the ability of Americans to afford healthcare coverage through both Medicaid and the Marketplaces established under the ACA. ACA plans rely on subsidies that enable enrollees to afford their premiums, and the subsidy funding levels that were increased during the COVID-19 public health emergency will expire this year. In addition, many in Congress are openly talking about curtailing the growth of Medicaid through so-called block grants that would peg the federal contribution to states based on population, not based on Medicaid costs. If both these programs are underfunded, the rate of the uninsured will increase, perhaps dramatically, and this could lead to fewer individuals with limb loss and limb difference being able to afford O&P care. In December 2024, the Centers for Medicare & Medicaid Services (CMS) released updated enrollment figures for Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and Marketplace coverage. These programs serve as key connectors to care for millions of Americans. As of September 2024, over 67.9 million individuals were enrolled in Medicare, an increase of over 160,000 since the last report. Of these individuals, approximately 33.6 million are enrolled in traditional Medicare, and approximately 34.3 million are enrolled in Medicare Advantage plans. Additionally, about 54.6 million individuals are enrolled in Medicare Part D, which provides prescription drug coverage. Approximately 8 million individuals qualify for Medicare under the disability criteria—meaning they are less than 65 years old and are not able to work due to a disability—and approximately 60 million qualify as seniors over the age of 65. As of September 2024, over 79.3 million individuals are enrolled in Medicaid and CHIP, a decrease of approximately 77,000 since the last CMS report. Approximately 72.1 million individuals are enrolled in Medicaid, and approximately 7.1 million individuals are enrolled in CHIP. Over 8 million individuals are dually eligible for both Medicare and Medicaid. As of December 2024, a record 16.6 million consumers signed up for Marketplace coverage in plan year 2025. Of these individuals, nearly 2 million are new to the Marketplace. O&P Legislative Priorities for 2025 In addition to playing defense this year, the O&P community will have to take stock of its proactive legislative priorities for the 119th Congress, including the Medicare O&P Patient-Centered Care Act, the Veterans SPORT Act (H.R. 9478), and advocacy to fund O&P outcomes research through the US Department of Defense (DOD). The Patient-Centered Care Act contains three major provisions that would benefit O&P, including an exemption for O&P practitioners from Medicare off-the-shelf competitive bidding, the banning of drop shipment of custom fitted or fabricated orthoses and prostheses, and extension to custom orthotics of the “reasonable useful lifetime” rules that currently apply only to prosthetics. Significant progress was made in the 118th Congress on this bill, and all the Senate and House champions are well positioned in the 119th Congress to reintroduce the bill early in the 119th Congress and advance it further. The Veterans SPORT Act would cover activity-specific prostheses for veterans, raising to the federal level the debate taking place in the states involving the So Every BODY Can Move campaign. The O&P Alliance organizations all support this bill as do multiple nonprofit organizations and veterans’ groups, but the Department of Veterans Affairs (VA) opposes the legislation. They assert that activity-specific prostheses are already covered under the VA benefit and the legislation is duplicative of current policy. However, while in some areas of the country individual VA hospitals may cover this care, this is by no means consistent across the VA. The VA SPORT Act would clarify this coverage and make veteran access to activity-specific prostheses more consistent. Finally, after extensive efforts by the O&P Alliance organizations with strong support by the Amputee Coalition, Congress included strong report language in the FY 2025 spending bill to fund O&P outcomes research through a peer-reviewed medical research program within the DOD. Congress chose to fund this research through a competitive model that funds other designated areas of medical research with an overall budget of $370 million, of which O&P research would be a part. This approach replaced a congressionally directed spending account for O&P outcomes research at $15 million per year, a program that had been in existence since 2014 but that was zero funded in FY 2024. With the final spending bills for FY 2025 still unresolved, the status of these research dollars is unclear, and the decision will not be made until at least late March. In the meantime, the O&P community will have to make efforts to preserve and advance O&P outcomes research funding into the next fiscal year, FY 2026, efforts which must begin in early 2025. CMS to Bolster O&P Practitioner Notes In mid-December 2024, CMS responded to a request from the O&P Alliance organizations to bolster the Medicare Program Integrity Manual (PIM) by including references to statutory language enacted several years ago to recognize the clinical notes of the prosthetist or orthotist in determining the medical necessity of O&P care. CMS noted the inclusion of this language in one section of the PIM but acknowledged that another section describing providers whose clinical notes are relevant to determining medical necessity should also include this statutory language and confirmed that the PIM would be updated in the coming months. This added language should help better define O&P medical necessity and provide added professional recognition to certified and licensed O&P professionals, further distinguishing O&P care from durable medical equipment. Peter W. Thomas, JD, is general counsel for the National Association for the Advancement of Orthotics and Prosthetics and counsel to the O&P Alliance. Emma Gunter is a legislative project assistant, Powers Law Firm.

What Does the New President and New Congress Hold for O&P?

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