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What the mid-term elections mean for EMS

Forecasting how the Democratic House and GOP Senate will impact drug and healthcare billing, Medicaid expansion and the ACA


Overall, the Democrats’ takeover of the House changes the dynamic on healthcare issues, which played a prominent role in the mid-term elections.


By Kim Krenik, government relations director, NAEMT; Terry David, advocacy committee chair, NAEMT; Matt Zavadsky, president-elect, NAEMT

Nov. 6, 2018, shifted the balance of power in the nation’s capital. Democrats gained the majority in the House of Representative and Republicans added to their ranks in the Senate.

As the dust settles, we sought the insight of National Association of Emergency Medical Technician’s Government Relations Director Kim Krenik and Advocacy Committee Chairman Terry David to help explain what the mid-term elections may mean for EMS.

Overall, the Democrats’ takeover of the House changes the dynamic on healthcare issues, which played a prominent role in the mid-term elections. Here’s a look at likely scenarios in the 116th Congress under a Democratic House and GOP Senate.

The House Democratic Caucus is hungry for change. As the Democrats take the majority in the House, picking up 26 seats (possibly more once recounts are completed) on January 3, they will kick off an agenda that will focus on lowering healthcare costs, lowering prescription drugs, increasing paychecks for the middle-class, strengthening our nation’s infrastructure and rolling back the GOP tax cuts for corporations and high-income individuals, along with campaign finance, ethics and voting reform.

While the Republicans still control the Senate and the White House, the House Democratic leadership change could provide new opportunities for EMS, particularly in the area of domestic healthcare (e.g., tax incentives for volunteers, and funding for naloxone and other drugs that EMS needs the most).

The 2010 Patient Protection and Affordable Care Act (ACA)

The Issue: This healthcare law remains a divisive and politically charged issue a year after Republicans fell short of overhauling it (PL 111-148, PL 111-152). Congress has been unable to move a bipartisan compromise on legislation to update the law in a significant way and that is unlikely to become easier in a divided Congress.

The Outlook: House Democrats intend to conduct significant oversight of the Trump administration’s implementation of the law and could explore the idea of “Medicare-for-All” or other programs that would move toward universal healthcare. They are likely to consider legislation meant to bolster the exchanges. In the Senate, Republicans could keep their broad focus on healthcare costs. A ruling in a Texas lawsuit seeking to overturn the law could also prompt both chambers to act if U.S. District Judge Reed O’Connor strikes down parts of the law.

Drug Prices

The Issue: Democrats made prescription drug prices a central part of the campaign in a rare alignment with the Trump administration. Drug prices have a significant impact on healthcare spending and people’s ability to fill prescriptions. It also is a major cost driver for many EMS agencies. Some analysts suggest that the drug shortages facing many EMS systems are a result of the lower margins for long-established drugs serving as a disincentive for manufacturers to produce those drugs.

The Outlook: Senate dynamics will likely make it hard for Congress and the Administration to address prices significantly. Democrats want to give Medicare more power to negotiate prices with drug companies, which Republicans are reluctant to allow. The Administration has a bold proposal to base Medicare reimbursement rates for certain drugs on the lower prices paid overseas. That largely fell flat with congressional Republicans.

This is one area where the new power structure on the Hill might make a difference. For years, there have been bipartisan proposals to discourage brand-name drug companies from blocking the sales of drug samples to generic drug makers trying to get approval for equivalent cheaper versions.

House Republicans never moved forward with a bill (HR 2212), but a vocal minority of Senate Republicans, led by Iowa’s Charles E. Grassley, managed to get their bill (S 974) a markup over the summer. With a Democratic majority, House committee chairs may also take a more aggressive approach by investigating manufacturers and other sector stakeholders, such as pharmacy benefit managers, for pricing increases and other practices.

Surprise Medical Bills

The Issue: The economics of America’s complex healthcare system often results in unexpectedly high medical bills, frequently for hospital procedures that involve out-of-network providers, even when operating at in-network facilities. The practice of “balance billing,” as it’s known, has been widely reported in the media, and consequently, is a major issue for Congress, particularly for emergency care. The National Governor’s Association recently held a roundtable in Washington, D.C., with major healthcare payers, provider associations (including NAEMT and AAA), and state healthcare policy makers to try and determine a logical approach to the balance billing issues.

The Outlook: This is one issue that both Democrats and Republicans can get behind. And while rising drug prices will continue to dominate the headlines, high medical bills will also garner plenty of attention. Sen. Bill Cassidy, R-LA., and Sen. Maggie Hassan, D-NH, recently introduced legislation to block balance billing for emergency care. Many states have instituted their own restrictions on the practice, but Congress will have to act to ensure that millions of Americans with employer insurance are protected. With both parties wanting to take aim at surprise medical bills, this is an area we will likely see legislation on in the near future.

Medicaid Expansion

The Issue: With the passage of the Affordable Care Act, many states elected to expand Medicaid. This has had some economic impact on EMS agencies. Some patients previously uninsured were able to be placed into Medicaid, which improved the payer mix for collections. However, some employees previously insured through employer health plans who may have had large employee contributions, or high deductibles, opted out of their coverage and enrolled in Medicaid. This had a negative impact on EMS reimbursement. In January 2018, the Trump Administration gave states the power to impose work requirements on Medicaid enrollees and some states have begun implementing this requirement.

The Outlook: Of the variety of state-level health policy decisions voters made in the mid-term elections, perhaps the most significant was related to Medicaid expansion. In states where elected officials blocked Medicaid expansion under the ACA – Nebraska, Idaho and Utah – voters passed the expansion through public referenda. In contrast, voters in Montana rejected funding the Medicaid expansion that the state enacted temporarily in 2015 by an increase to the state’s tobacco tax. Montana’s expansion is now scheduled to lapse in July 2019 if the legislature doesn’t act to maintain it. Finally, Democratic gubernatorial wins in Maine, Kansas and Wisconsin will make Medicaid expansion more likely in those states.

NAEMT has developed and maintains strong relationships with leadership in both parties and we are well positioned for the next Congressional session that begins on January 3. We look forward to educating all the new members of Congress on issues important to our profession. The 116th Congress promises to be a very interesting two-year legislative session and all EMS practitioners need to stay actively engaged with your professional associations to promote issues that are important to EMS. Read more about NAEMT’s Advocacy activities here. View all pending federal EMS legislation on NAEMT’s Online Legislation Service.

Matt Zavadsky, MS-HSA, EMT, is the chief transformation officer at MedStar Mobile Healthcare, the exclusive emergency and non-emergency Public Utility Model EMS system for Fort Worth and 14 other cities in North Texas that provides service to 436 square miles and more than 1 million residents and responds to over 170,000 calls a year with a fleet of 65 ambulances. MedStar is a high-performance, high-value Emergency Medical Services system, providing advanced clinical care with high economic efficiency.

MedStar is one of the most well-known EMS agencies in the county, and operates a high-performance system with no tax subsidy, and the recipient of the EMS World/NAEMT Paid EMS system of the Year, and the only agency to be named an EMS10 Innovator by JEMS Magazine.

He is also the co-author of the book “Mobile Integrated Healthcare – Approach to Implementation” published by Jones and Bartlett Publishing.

He has 42 years’ experience in EMS and holds a master’s degree in Health Service Administration with a Graduate Certificate in Health Care Data Management. Matt is a frequent speaker at national conferences and has done consulting in numerous EMS issues, specializing in high-performance EMS operations, finance, mobile integrated healthcare, public/media relations, public policy, transformative economic strategies, and EMS research.

Matt is also immediate past president of the National Association of EMTs, and chairs their EMS Economics Committee.