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CAPITOL PERSPECTIVES column By J. McManus WHAT A REPUBLICAN SENATE MAY MEAN FOR HEALTH POLICY LIFESCIENCELEADER.COM NOVEMBER 2014 10 J O H N M c M A N U S The McManus Group What A Republican Senate May Mean For Health Policy ust days before the election, the president's approval rat- ings are at an all-time low, and Democratic Senate candidates are running against the presi- dent, with the Democratic candidate in Kentucky refusing to disclose whether she even voted for him, claiming a con- stitutional right to privacy. If the tra- jectory holds, the Republicans should take the Senate and control both houses of Congress. What would this mean for health pol- icy for the last two years of the Obama presidency? A new Republican Senate majority will likely move early to try to repeal Obamacare. But even in the minority, a unified Democratic conference can block an up or down vote from pro- ceeding. Even if Republicans peel off the necessary Democrats to reach the 60-vote filibuster-proof super-majority, the president will be sure to veto a repeal of his most cherished domestic legislative achievement that now bears his name. Following this fruitless exercise, Congress could tackle real issues. J The present "SGR [sustainable growth rate] patch" blocking massive, pend- ing Medicare payment cuts for phy- sicians is set to expire March 31. Congress achieved a rare bipartisan breakthrough on replacing and reform- ing that payment formula earlier this spring, but could not agree on whether or how to finance the $120 billion price tag of eliminating those unsustain- able cuts. March is probably too soon for a new Congress to develop biparti- san consensus on an offset, and a six- month punt may set up a more serious Medicare bill for the fall. A newly installed House Ways and Means Committee Chairman Ryan may try to tie SGR reform to broader Medicare reforms such as consolidating Parts A and B's disparate cost-sharing and move Medicare to a more competi- tive premium support model. Such a package could move through the Senate under "budget reconciliation" — a par- liamentary tactic that requires only a 51-vote majority, so long as the provi- sions have a fiscal impact. But don't necessarily expect bold action from Senate Republicans in 2015. Republicans will be defending 23 seats in 2016 and wary about exposing vulnerable members to controversial votes that can be demagogued as "end- ing Medicare as we know it." Many of these seats will be in Democrat- leaning states such as Pennsylvania, Illinois, and Maine. Moreover, several sitting Republican senators will be running for president (e.g. Cruz, Paul, and Rubio) and have more interest in laying out an agenda for the 2016 elec- tion than bipartisan lawmaking with the current president. Perhaps a more interesting conun- drum will be how a Republican Congress reacts to an imminent Supreme Court decision, which may prohibit premium subsidies flow- ing to individuals who enrolled in health insurance through the Federal Exchange. Earlier this year, three fed- eral courts issued conflicting opinions on whether the statutory language providing subsidies for "an exchange established by the State" permits the IRS to funnel subsidies to the vast majority of Americans living in the 36 states that refused to establish state