Center for Medicare and Medicaid Innovation: Scoring Assumptions and Real-World Implications

The Affordable Care Act gave extraordinary power to the Centers for Medicare and Medicaid Services to change the way health care providers are paid and the way services are delivered. The Center for Medicare and Medicaid Innovation is the vehicle through which a multitude of new models are being tested, and the HHS Secretary has the authority to implement any model that is certified to reduce program spending or improve quality without going through Congress. The move by CMMI to demonstration projects that mandate participation by providers results in changing policy, at least for those providers. A decision by the Secretary to require nationwide implementation of a specific model that was tested in a demonstration project would be a de facto change in law without the inconvenience of congressional debate.

Congress has several options to address this shift in power, but any change in the current situation is likely to be difficult. Legislation could make adjustments to individual demonstration projects as issues arise. Alternatively, Congress could repeal CMMI as it now stands. In its place, CMS would perform research into new payment and delivery models without the authority to require participation by providers or the power to unilaterally impose new models on the health sector.

The Congressional Budget Office would score such proposals as increasing the deficit. That does not mean Congress could not find a savings offset. It also does not mean that Congress must find an offset to enact legislation. The issue in this case is not the deficit, but the separation o f powers between the executive and Congress. No President would voluntarily return the authority given by the ACA. If Congress wants that authority back, it will have to act.

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