A Divided Congress: What It Means for Transportation and Infrastructure

By Brian Waldrip, Senior Vice President

The Senate Commerce, Science, & Transportation and the House Transportation and Infrastructure Committees will look very different in 2019

HOUSE:  With the Democrats winning the House this midterm and several retirements on the GOP side, the House Transportation and Infrastructure Committee will have a very different composition in January.

Current Ranking Democratic Member, Peter DeFazio (OR04), is expected to take over as the Chairman of the Transportation Committee in the 116th Congress.  First elected to Congress in 1986, Mr. DeFazio has a strong background in transportation and infrastructure policy, serving on the Committee for his entire tenure and leading committee Democrats since 2014.  The Chairman will set the committee agenda and direct legislative efforts.

Other changes to the House Democratic Committee roster include the departures of Rail Subcommittee Ranking Member Michael Capuano (MA07), Rep. Richard Nolan (MN08), and Rep. Elizabeth Esty (CT05).  With these changes, expect a Subcommittee Chairmanship reshuffling in January.

In comparison, big changes are in store for House Transportation Committee Republicans.  Retiring from the Committee are Chairman Bill Shuster (PA09), Committee Vice Chairman John Duncan, Jr. (TN02), Aviation Subcommittee Chairman Frank LoBiondo (NJ02), Economic Development and Emergency Management Chairman Lou Barletta (PA11), and Rep. Todd Rokita (IN04).  The midterm elections claimed the seats of Rail Subcommittee Chairman Jeff Denham (CA10) and Reps. Mark Sanford (SC01), Barbara Comstock (VA10), John Faso (NY19), and Jason Lewis (MN02).  Rep. Rob Woodall (GA07) appears on track to win re-election by an extremely tight margin.  These ten Republican departures represent four out of seven committee leadership positions and losses of at least 27 percent of total committee GOP membership.

Leadership of Committee GOP members is uncertain.  The two leading candidates for the Committee Ranking Member position were Highways and Transit Subcommittee Chair Sam Graves (MO06) and Rail Subcommittee Chairman Jeff Denham (CA10).  With Denham’s loss, Graves is poised to be Ranking Member but could potentially face a last-minute challenger. 

Expect the Republican Steering Committee to decide the Committee Ranking Member in early December, and the Democratic Steering Committee to confirm Rep. DeFazio as chair.  Both Steering Committees will likely set committee rosters in early January and announce Subcommittee Chairs and Ranking Members toward the end of that month.

SENATE:  The Republicans retained control of the Senate in the midterm elections, most likely picking up two seats.  However, changes are also expected for the Senate Commerce, Science, & Transportation Committee. 

On the GOP side, Senate Leadership reshuffling is expected to elevate current Senate Commerce Chairman John Thune (SD) to Senate Whip, and Sen. Roger Wicker (MS) is expected to take over as Chairman.  Further, Sen. Dean Heller (NV) lost his reelection, which potentially creates an open slot on the committee.

On the Democratic side, Senate Commerce Committee Ranking Member Bill Nelson (FL) narrowly lost to Republican Gov. Rick Scott.  It is expected that Sen. Maria Cantwell (WA) will relinquish the top Democratic slot she currently holds on the Energy & Natural Resources Committee to be Ranking Member on Senate Commerce. 

Transportation and infrastructure issues and efforts in the upcoming Congress

Under new Democratic leadership in the House next year, expect all committees, especially Transportation and Infrastructure, to strongly exert an oversight role.  Some of the investigations that may gain steam under Chairman DeFazio include review of post disaster efforts following the hurricanes and wild fires, possibly in the context of climate change; the GSA plan to relocate or rebuild the FBI headquarters; airline conduct, especially regarding passenger rights; the lease of the Old Post Office to the Trump organization; air and water quality matters; and scrutiny of Secretaries and Administrators within the jurisdiction of the committee, possibly including previous officials such as former EPA Secretary Scott Pruitt.

Legislatively, expect Chairman DeFazio to emphasize funding for national transportation and infrastructure projects.  An item high on Mr. DeFazio’s agenda to provide additional resources to the system will be fundamental changes to the “gas tax”. 

Republicans and Democrats broadly agree that more should be spent on transportation and infrastructure programs.  The main funding mechanism for highways and transit programs is the gas tax, which replenishes the Highway Trust Fund (HTF) to fund these programs.  However, the gas tax is not pegged to inflation and is accessed at the same level since 1993 (18.3-cents-per-gallon gasoline and 24.3-cents-per-gallon diesel).  The HTF continues to be challenged as consumers are buying more fuel-efficient vehicles, more electric vehicles are on the road, and Americans are driving fewer miles annually.  The Congressional Budget Office projects the HTF transit account to be insolvent by 2021 and the highway account by 2022.

Though specific gas tax policy adjustments are the primary jurisdiction of the House Ways and Means Committee, expect Chairman DeFazio to work closely with expected Ways and Means Chairman Richard Neal (MA01) as Congress may consider increasing the gas tax or moving to another option like a “vehicle miles traveled” (VMT)/“road usage charging” (RUC) based system of taxation.  It is less likely the Senate will lead on this issue, but it may follow House action.

Regarding the potential of an “infrastructure bill”, President Trump and soon-to-be Chairman DeFazio have indicated a desire to implement legislation to invest in American infrastructure.  However, there are stark differences to the scope and financing of such legislation.  With very different proposals put forth by the White House and Senate and House Democrats, it hard to imagine that sides could come together on compromise legislation—especially as posturing for 2020 races are already underway. 

The best hopes for legislative accomplishments come in the reauthorizations of a national highway and transit programs and a water resources bill.  The most recent reauthorization of highway and transit programs became law in 2015 as the Fixing America’s Surface Transportation (FAST) Act.  The five-year reauthorization sets policy for federal highway, transit, highway safety, motor carrier safety, hazardous materials, and passenger rail programs and expires in September 2020.  With a deadline approaching, a highway and transit reauthorization will likely be on the agenda for the upcoming Congress.

The House and Senate have also signaled their intent to reauthorize federal water resources programs every two years.  The previous Water Resources Development Act (WRDA) was signed into law in October 2018 and invests in harbor, waterway, flood protection, and other water infrastructure improvement programs.  This reauthorization is also expected to be addressed in 2020.

Potentially relevant to both reauthorizations is the unsettled question regarding permissibility of Congressionally directed spending – or “earmarking” federal funds for specific local projects.  Many House Democrats – and some Republicans – favor a return to earmarks with transparency and safeguards, but some previous instances of misuse and waste make the matter politically fraught.  The question of earmarks will likely remain unsettled until the House passes its rules package in January, which may have an impact on the path the Senate takes. 

Finally, some additional matters that may be considered in the 116th Congress include the implementation of positive train control (PTC) across the rail system; development and integration of autonomous vehicles/systems, not only on roads but also in aviation and maritime capacities; and the development of commercial space operations.

The 116th Congress will no doubt be contentious; however, in crisis there can be opportunity.Stay tuned, and we will share further developments as the dust settles.

A Divided Congress: What It Means for Health and Medicine

This is another of a series of analyses CRD Associates will publish examining the midterm election results and their likely impact on key federal policies

Prepared by the Team at CRD Associates

Democrats parleyed a growing wave of health care concerns into a majority of the House of Representatives, propelled in large part by promises to protect Americans with preexisting health conditions and lower prescription drug costs.

Fueled by Republicans’ repeated efforts to roll back the Affordable Care Act and disciplined Democratic campaigns focused on protections for those with preexisting conditions—and perhaps bolstered by Senate Majority Leader Mitch McConnell’s (R-KY) recent statements calling for Medicare and Medicaid reforms—exit polls taken on Election Day showed health care was a top concern for voters.

In fact, in a Kaiser Family Foundation poll taken in mid-October voters said health care was the top issue on their minds, even over the economy. That concern included the all-important independents and voters in swing states and districts.

 Following is an analysis of how key health-related issues are likely to fare in the next Congress.

Appropriations good news/bad news

The good news is that funding for the National Institutes of Health enjoys bipartisan support in Congress—support that led to annual increases of $2 to $3 billion, for a total of $9 billion over the last four years for the nation’s top research agency.

The bad news is that other public health programs, like mental health and workforce training and education programs, have not gotten as much love from Congress, due in part to tight limits on discretionary spending.

That may change in the 116th Congress when Rep. Nita Lowey (D-NY) assumes the chair of the House Appropriations Committee and Rep. Rosa DeLauro (D-CT) leads the Labor-HHS-Education Subcommittee. Both will be in a better position to allocate more money for public health. But that won’t be easy because the two-year budget deal that raised spending caps imposed by the Budget Control Act of 2011 is due to expire next year. Absent another deal, non defense discretionary programs face cuts of $55 billion in fiscal year 2020, or about 10 percent below current spending.

Rep. DeLauro has said she wants to build upon a $325 million fund at the Centers for Disease Control and Prevention set up to respond to infectious disease outbreaks and other emergencies. Rather than fund those emergencies at the expense of other public health programs, DeLauro will push to have that spending designated as an emergency, freeing up funds to support ongoing public health programs.      

ACA: Mother of all issues

The ACA was arguably the issue that cost Democrats control of Congress back in 2010. Ironically, all signs indicate that the health law was the reason Democrats regained control of the House for the first time since then. What was then an anchor is now a boon.

The turnaround began in early 2017, when public opinion of the ACA was tied at 46 percent between voters who approved and disapproved of it. A few weeks later, Republicans in the House voted to repeal the ACA—with no Democrats supporting it. Since then, more Americans have approved of the 2010 law than disapproved, saying that they blamed Republicans for anything going wrong in the law now that the GOP tried to undo it, i.e. you break it, you own it!

By last month, 82 percent of voters said health care is one of the most important issues in their votes for Congress; the same polls found voters trust Democrats over Republicans to improve their health care situation.

As for the future, the ACA remains a divisive and politically charged issue. Despite agreement on both sides that there are problems to be addressed and that the law should be updated, doing so will be difficult in a divided Congress. Democrats, for example, may try to block or amend administration rules expanding short-term, bare-bones health plans, health reimbursement accounts and loosely regulated association health plans.

In the meantime, House Democrats say they will conduct significant oversight of the president’s implementation of the ACA, work to bolster the exchanges, and possibly examine the idea of “Medicare for All,” broadening the federal health insurance program from covering primarily people 65 and older to a single-payer plan covering Americans of all ages. Rep. John Yarmuth (D-KY), who will likely head the House Budget committee, already plans to hold a hearing on the subject.

Also in the House, where the Energy and Commerce Committee will now be headed by Rep. Frank Pallone (D-NJ), long-term care is likely to be on the legislative agenda. In addition to being a strong advocate of the Affordable Care Act, Pallone is also the author of a proposal entitled The Medicare Long-Term Care Services and Supports Act, which promotes the prospect of long-term care getting some long-overdue attention.

Drug pricing on the front burner

The Democrats’ takeover of the House has injected new life into efforts to combat high drug prices—perhaps with bipartisan support.

House Democratic leaders and President Trump believe they share some common ground over drug pricing, and Senate Majority Leader Mitch McConnell (R-KY) has expressed some openness to addressing the issue in 2019, though he has not offered any specifics.

Allowing Medicare to negotiate drug prices has long been a goal of Democrats. And a few weeks ago, the Trump administration floated a proposal to tie the prices it pays for Medicare Part B drugs to those paid by consumers abroad. But it’s also possible that more targeted drug pricing actions could be attached to larger, must-pass legislation, such as appropriations bills. Along these lines, advocates have pushed for passage of the bipartisan CREATES Act, which seeks to crack down on delay tactics against approval of generic drugs.  

More Medicaid expansion?

Voters propelled the biggest expansion of Medicaid in heavily Republican states since the early years of the Affordable Care Act, with hundreds of thousands of working poor and vulnerable residents standing to gain health coverage as a result of the midterm elections.

Idaho, Nebraska, and Utah approved ballot initiatives to include in their Medicaid programs adults with incomes of up to 138 percent of the federal poverty line, broadening the safety-net insurance that GOP-controlled state legislatures had balked at for years. In addition, Maine voters elected a new governor, Democrat Janet Mills, clearing the path for a Medicaid expansion that voters approved by referendum a year ago. (The outgoing GOP governor, Paul LePage, was an ardent foe of the expansion and had blocked it for a year.)

Successes in those handful of states give other ballot organizers a blueprint on how to expand Medicaid in states that have resisted—a move that would not only help improve health coverage for their residents, but also help stabilize hospitals, particularly those in rural areas, by cutting down on uninsured patients and uncompensated care. Incoming Kansas Democratic Governor Laura Kelly has already promised to advocate for Medicaid expansion in her first year in office; Wisconsin Governor-elect Democrat Tony Evers, a supporter of Medicaid expansion may increase the prospects of expansion in that state; and while the outcome of the Georgia gubernatorial race is still pending, if elected, Democrat Stacey Abrams plans to make Medicaid expansion her first priority.

The major threats to Medicaid, including converting funding to a block grant or imposing a per capita spending limit, virtually disappear in a divided Congress. In fact, the Democrats’ House takeover could draw attention to expanding home and community-based services for Medicaid recipients, and block or revise administration rules governing work requirements.

Data privacy legislation has a fighting chance

Democrats’ takeover of the House could open the way to data privacy legislation, particularly with Rep. Pallone chairing the House Energy and Commerce Committee. Pallone has listed privacy and data security protection as among his top priorities for the next Congress—more specifically, ensuring that consumers, not tech companies, have control over the collection and use of their own personal information. But Pallone isn’t the only lawmaker promoting data privacy. Ranking Senate Finance Committee member Senator Ron Wyden (D-OR) and Senator-elect Marsha Blackburn (R-TN) have both suggested legislation that promotes internet privacy and data protection.

For decades, companies like Google, Facebook and Amazon have successfully monetized the personal information of their users with almost no oversight or regulation. Seven times this year big tech has been called on the carpet to answer for data breaches, fake news, political meddling on the internet and the endless amounts of personal information being gathered on Americans. As a result, their size, power and ability—or willingness—to police themselves are being called into question. Driven in part by steps already being taken by the European Union, a consensus is developing that something has to change. 

Sensing what may be the inevitable, Facebook, Twitter, Google and Amazon are now saying they could support a U.S. privacy law if they were given considerable input. The Internet Association says it would support giving Americans reasonable access to their information and some privacy rights now enjoyed by Europeans.

Patient Centered Outcomes Research Institute (PCORI) up for renewal

Established in 2010 to set priorities for the conduct of comparative clinical effectiveness research (CER), PCORI’s current authorization will expire September 30, 2019. To date, PCORI has invested nearly $2.4 billion in more than 600 patient-centered CER studies and related projects.

PCORI is funded through the Patient-Centered Outcomes Research Trust Fund (PCOR Trust Fund), which receives income from three revenue streams: appropriations from the General Fund of the Treasury, transfers from the Centers for Medicare and Medicaid trust funds, and a fee assessed on private insurance and self-insured health plans. The bulk of PCORI’s funds—more than $250 million annually—come from the PCOR fee. 

In the Senate, two lawmakers, Senators Bill Cassidy (R-LA) and Mark Warner (D-VA), are leading the charge to reauthorize the program and its funding beyond the end of this fiscal year. However, questions remain about the details of the reauthorizing legislation, including at what funding level the program should be continued, for how long and the extent of stakeholder participation in decision-making.

Older Americans Act Reauthorization

The law authorizing Older Americans Act (OAA) programs expires September 30, 2019. First enacted in 1965, the legislation supports 11 million, or 1 in 5, older Americans, allowing them to remain independent by reducing hunger and food insecurity, offering opportunities to socialize, and supporting access to preventative care. 

The committees of jurisdiction are the House Committee on Education and Workforce and the Senate Health, Education, Labor and Pensions (HELP) Committee.  (Education and Workforce will also be responsible for reauthorizing the Healthy, Hunger Free Kids Act, which expired in 2016.)  While OAA’s reauthorization was not a priority for the 115th Congress, the law’s renewal would represent a bipartisan win.

The House panel is expected to be chaired by Rep. Bobby Scott (D-VA), a long-time advocate who helped secure passage of the Elder Abuse Victims Act.


by Dom Ruscio, Partner

This is the first in a series of analyses CRD Associates will publish over the next several days examining the midterm elections and their likely impact on key federal policies

By the numbers

With groundbreaking victories for female, black, gay, Native American and Muslim candidates, the 2018 midterm elections produced a night of firsts—diversifying the faces in the House, Senate and statehouses across the nation.

  • A record-breaking 100+ women were elected to the House of Representatives, up from 84 in the current Congress.

  • Deb Haaland of New Mexico and Sharice Davids of Kansas will be the first two Native American women to serve in the House.

  • Former representative Marsha Blackburn will become the first woman to represent Tennessee in the Senate.

  • Maine elected its first female governor in Janet Mills, and Massachusetts elected its first person of color to Congress in Ayanna Pressley. 

  • Jared Polis was elected Governor of Colorado, becoming the nation’s first openly gay governor.

  • Michigan’s Rashida Tlaib and Minnesota’s Ilhan Omar became the first Muslim women to serve in Congress.   

Apart from those ground breaking firsts, from a national party perspective the midterm elections delivered a split verdict, ushering in a new Democratic majority in the House as Republicans expanded their numbers in the Senate.

With 12 races yet to be called, Democrats have won 225 House seats to Republicans’ 198, with many of Democrats’ 31 pick-ups centered in suburban districts. This marks the first time Democrats have held a majority in the House since 2010, and an end to two years of the Republicans’ unified control of government.  Republicans will control 51-54 Senate seats, depending on the results of uncalled races in Arizona and Florida, and a runoff in Mississippi later this month.

Governing: Now the hard part

 As one pundit put it, the election brought “bragging rights for everybody and nobody.” Indeed, voter anger and discontent may make a deeply divided nation even more difficult to govern.

For Democrats to take control of the House, it took a lot of wins in center- and center-right congressional districts. That’s an opportunity for Democrats to own the middle, but it’s also a challenge for their leaders to unify a caucus made up of new centrists as well as restive progressives.

For Republicans, an expanded majority means the ability to confirm judicial appointments but, in practical policy terms, not much else since they do not have a filibuster-proof majority.

For all intents and purposes, the divergent outcomes in the House and Senate may simply mean more of the same when it comes to policy battles.

The elephant in the room

For all the elation both sides may feel today, once incumbents and new members of Congress take a sober look at the budget situation, their ambitions are likely to shrink when they come to realize that just keeping the government’s lights on is a major challenge.

In a few days, the Republican-controlled Congress returns for a lame-duck session, presumably to wrap up seven unfinished appropriations bills for fiscal year 2019—Agriculture, Financial Services, Interior-Environment, State-Foreign Operations, Transportation, HUD and Homeland Security. They’ll have until December 7 to do that, when the current continuing resolution expires.

But President Trump insists that one of the spending bills, Homeland Security, must include funding for a border wall. Republicans need Democratic support to advance Homeland Security. The price for that cooperation, however, could require the president to forgo his $5 billion funding for the wall, settle for a lesser or token amount, postpone any final spending decisions until a new Congress is sworn in—or risk a government shutdown.

As if that weren’t enough, next year’s budget battles will get even tougher and more far- reaching.

A two-year budget deal that provided relief from tight spending caps expires next September, forcing defense and nondefense discretionary programs to revert back to spending limits imposed by the Budget Control Act of 2011. Absent another budget deal, the BCAs caps mean $126 billion in cuts to defense and nondefense spending for fiscal year 2020—or about 10 percent below current spending.    

If all that isn’t enough of a challenge, lawmakers will have to vote on raising the federal debt limit in the first half of 2019.

So, despite grand proclamations about investigations and subpoenas and an active legislative agenda including ethics reform, infrastructure, and prescription drug prices, Congress’s first responsibility – keeping the lights on – will not be an easy lift.

Midterms could usher in a wave of health-related professional experience

By David Eaton, Policy Associate, CRD Associates

Health care is consistently polling as one of the top tier issues on the minds of voters heading into the 2018 midterm elections and is likely to be a policy priority for lawmakers during the first 100 days of the next Congress. Leaders of both parties have signaled that they intend to work on addressing concerns over quality of care, barriers to access, out-of-pocket costs and other pressing matters, although no timelines have yet been publicly stated.

With a high rate of turnover expected, at least in the House--whether the result of a “wave” election, or just an injection of new blood on both sides of the aisle--an infusion of lawmakers with health-related backgrounds could presumably affect the way lawmakers approach the debates on the Affordable Care Act and other important health-related legislation.

There’s no doubt about it: Getting your priorities in front of freshmen members as early as possible is always a smart move. And having an understanding of their professional backgrounds can help you connect with those members who may be sympathetic to your cause.

A major overhaul of seats in a new Congress is especially frustrating to advocates-- losing your issue champions to retirement or ousting can leave your priorities voiceless, and changes in the majority could thrust other policy and programmatic priorities ahead of your own. In those cases, understanding the professional backgrounds of the incoming decision-makers could be especially important for crafting legislation vital to patients, providers, researchers, and other communities you represent.

With that in mind, I’ve carefully scoured the field of incumbents and front-runner challengers in this year’s midterm elections. The results: We could see a boom of health-related professionals entering Congress next January.

Click here for a spreadsheet of the relevant House and Senate candidates and their health-related professional experience (includes several tabs).

Of the 870 front-runner candidates for seats in the House of Representatives, nine percent (80) have health-related professional experience, with physicians making up the bulk of the health professionals (27), followed in a descending order by candidates with backgrounds in nursing (7), higher education (6), dentistry(5), executive health (5), health care advocacy (5), mental health/ behavioral health (4), obstetrician-gynecology (3), veterinary medicine (3), and research (1). Additionally, there are six candidates with various backgrounds in social services and two health care lawyers.

Thirty-five House candidates are incumbents with health-related experience (15 Democrats and 20 Republicans), while 45 challengers have experience (27 Dems and 18 Republicans).

Out of the 33 Senate races, eight candidates have health-related professional experience; three are incumbents (two Democrats and one Republican) while five challengers look to capture seats (three Democrats and two Republicans).

The total number of health professionals in Congress has remained relatively stagnant for most health occupations over the past decade, though some occupations have decreased ever so slightly over the last three Congresses. According to the Congressional Research Service-

  • the number of physicians serving in Congress has hovered around 18 to 20, but dropped to 15 in the current session (including two ob-gyns);

  • those with nursing backgrounds have oscillated between 3 and 6 seats;

  • scientists have consistently averaged three seats;

  • mental health experts generally occupy four seats;

  • the same two or three dentists and veterinarians have held onto their seats for the past 10 years; and

  • social workers remain one of the highest represented health occupations, averaging nine seats per Congress.

This year, the departure of three retiring Members of Congress will open up some leadership positions on key health-related committees, including Senate Finance, House Energy and Commerce Health Subcommittee, and House Ways and Means Health Subcommittee, which would have a trickle-down effect, opening rank-and-file committee seats that could be filled by freshman members.

Senate Finance Committee Chairman Senator Orrin Hatch will retire when the new Congress is sworn in this January, leaving open the top Republican position on the Senate panel that oversees Medicare, Medicaid, and tax and trade policies. On the House side, Energy and Commerce Health Subcommittee ranking member Gene Green is also retiring, leaving open the top Democrat seat on the panel that oversees private and public health insurance (e.g. the Affordable Care Act, Medicare, Medicaid, CHIP), biomedical research and development, mental health, and health information technology. On the House Ways and Means Health Subcommittee, ranking member Sander Levin will not seek reelection, opening up the top Democrat seat on the health panel that covers health insurance premiums and health care costs, Medicare prescription drugs, and programs providing payments for health delivery systems or health research.

Additionally, there will likely be some movement amongst the rank-and-file, with members switching committees or losing elections.

Regardless of which party comes out on top, this election could usher in a heap of new health professional experience that would theoretically lend additional expertise to policy making.

Watch this space.

Stefanie Winston Rinehart Joins CRD Associates

CRD Associates is proud to announce that Stefanie Winston Rinehart has joined the firm as Vice President. Stefanie brings to the firm her extensive experience in Medicare reimbursement policy as well as her in-depth knowledge on a wide variety of appropriations and legislative issues.

In particular, Stefanie has extensive experience working with the Food and Drug Administration, Centers for Disease Control and Prevention, Centers for Medicare and Medicaid Services, National Institutes of Health and the Health Resources and Services Administration.

Prior to joining CRD Associates, Stefanie worked at the Academy of Nutrition and Dietetics for four years, where her responsibilities included advocating for the availability of quality health care services as well as adequate reimbursement for health care providers. While at the Academy, she advocated on Capitol Hill for improved reimbursement for nutrition services in Medicare and Older Americans Act programs as well as for strong investments in public health programs. She also worked with members of Congress and top officials at CMS on coverage and reimbursement for medical nutrition therapy; implementation of the Medicare Diabetes Prevention Program; and increased utilization of diabetes self-management programs. Prior to joining the Academy, Stefanie analyzed state and federal health legislation and provided technical assistance to federal grantees at the MayaTech Corporation, located in Silver Spring, Maryland.

Stefanie received a joint Juris Doctor and Masters in Public Health from Emory University School of Law and Rollins School of Public Health. She graduated from Vanderbilt University with her Bachelor in Arts, majoring in Classics and French.

Welcome to the CRD Associates team, Stefanie.

Reducing Health Care Costs: Striving to Eliminate Excess Health Care Spending While Decreasing Administrative Spending

By Nicholas L. Cavarocchi, Vice President

When attempting to get at the root of the problem of the rising cost of health care and what is causing it, the one major factor that comes to mind is waste.  This can include high administrative and overhead costs or medical tests, services, procedures, or medications that a patient doesn’t need.  Waste consumes about one out of every three of the dollars the U.S. spends on health care, and drives up premiums and coinsurance for all Americans.  Therefore, it is important to find ways to maintain high quality health care for patients while drastically reducing administrative costs and unnecessary services. 

For a clinician to provide safe, effective, efficient care, he or she needs access to patients’ medical history and other records that can affect diagnoses and treatment.  This access can reduce administrative costs associated with arcane record production, as well as the high costs that stem from providing unnecessary or ineffective care.  That is why the federal government must continue to facilitate providers’ move to electronic medical records that are interoperable between health care systems and clinicians.  

Health care delivery has not systematically managed which drugs are administered to patients to optimize value, along with results.  Federal investments in outcomes research can help determine whether less expensive medications and treatment options can produce similar results. 

Administrative costs account for eight percent of all health care spending in the U.S. and tend to be much higher than in other countries, largely the result of the costs of compliance with federal and state regulations and insurance billing requirements.  By eliminating half of the administrative cost burdens of billing and insurance, medical spending in the U.S. can be reduced by up to 15 percent.

While categorizing waste may help identify and measure general types and sources of waste, successful reduction strategies must integrate the administrative, operational, and clinical components of care, and proceed by identifying goals, changing systemic incentives, and making specific process improvements.  Unfortunately, instead of trying to resolve the problem of waste in health care spending, some proposals under consideration threaten to make it worse by allowing insurance companies to offer junk plans that impose strict coverage limits, leave people with preexisting conditions unprotected, and otherwise diminish quality of care. . 

A possible solution to reduce costs in the American health care system would be to make data trans-parent to the public while providers compete on their ability to successfully help their patients get the care that they need.  Purchasers and individuals must be able to choose their treatments and their providers based on useful information about outcomes and cost.  Therefore, there needs to be better aligning and applying regulatory requirements within and across federal agencies and programs.

Even if the United States implemented all the approaches to waste reduction whose effectiveness has been measured, only 40 percent of the estimated $1 trillion of wasteful spending would be curtailed.  While the scale of the issue is massive, effective means to address it offer a huge opportunity to both improve care and reduce the cost of health care. 

CRD’s Holubowich Selected for Prestigious Leadership Fairfax Institute

Emily Holubowich, Senior Vice President at CRD Associates, has been selected for the Leadership Fairfax Institute—a 10-month program that provides a forum for senior leaders in the business, nonprofit, and public sectors to strengthen themselves as a professional and a community leader. Participants are selected based on their demonstrated capacity for leadership and record of volunteer service in Fairfax County, Virginia. In September, Emily will join established leaders of large and small businesses, educators, government officials, and nonprofit executives in expanding her commitment to voluntary civic responsibility and deepening her understanding of the major issues facing Fairfax County.


In The Hot Seat: Tips for Nailing Your Congressional Testimony

Emily J. Holubowich, MPP, Senior Vice President

I have prepped many a congressional hearing witness over the last 20 years. Last week, I had my first opportunity to be a witness when I testified before the Joint Select Committee on Budget and Appropriations Process Reform on behalf of the Convergence Building a Better Budget Process Project (video here).

Let’s just say I have a whole new perspective on the experience. For example, I will never again tell a witness, “Don’t be nervous, you’ll be great!”

(But what if I’m NOT? EEEK!)

Sure. No pressure.

Testifying before Congress is intimidating. Nerves are inevitable, and natural. Beyond taking a page from Amy Cuddy’s TED Talk about striking the “Super Man” pose, there’s not much many of us can do to completely turn off that “flight” response. What you can do is prepare. The more prepared you are, the more comfortable and effective you will be during the hearing. Here are some tips based on my experience—as both prepper and preppee—to help you nail your congressional testimony.

Clear Your Calendar. You’ve been invited to testify before a committee, and given five minutes to deliver your remarks. How much time could you possibly need to prepare for five minutes? A lot more than you think.  In a nutshell:

  • Write your written statement for the Congressional Record, and have someone review it before submitting it to the committee;
  • Pare that written statement down into your five-minute oral statement;
  • Think through how you’ll answer likely questions from the lawmakers and reporters;
  • Learn more about those lawmakers, your fellow panelists, and reporters who cover that beat;
  • Practice (yes, read your statement out loud, preferably to someone else);
  • Work with your organization or institution on the media outreach and interactions;
  • Promote your appearance through your social media networks;
  • Be prepared to submit written responses to questions for the record; and
  • Promote your appearance after the fact.

And don’t forget to send those thank you notes!

I delve into this more below but the bottom line is: all of this takes time—and lots of it. If you’re lucky you’ll have a week to prepare, at most, so clear your calendar and give yourself plenty of time to focus on the tasks at hand.

Do Your Homework. Rule #1 in communications is “know your audience.” Take time to learn everything you can about the committee, the lawmakers on the committee, their positions on the hearing topic, and how the committee and previous hearings have been run. You will find answers to all of these questions and more online. Information about lawmakers—bios, interests, committee assignments, bills sponsored—is publicly available on their websites, and the committee’s website will have recordings of past hearings to better understand the committee’s culture and the interactions between members.

In doing your homework, don’t forget to learn more about the other witnesses on the panel and reading anything they’ve published on the topic, and connecting with them on LinkedIn and Twitter. Don’t be shy about introducing yourself via email, asking them (or the committee staff) for copies of their written statements in advance of the hearing, and sharing yours. You don’t want to be caught off guard during the hearing, so do your best to find out what they’re going to say in advance.

Refine Your Message. Writing your testimony and then reading your oral statement are actually the easiest part of the experience. It’s the Q&A portion of the hearing that is most intimidating—at least, it was for me. Part of that fear is not knowing what you’ll be asked. That’s where doing your homework about the committee, the lawmakers, and the witnesses can really help you be ready for anything. But you should also think of the Q&A as an opportunity to hammer home your message, repeat your key points, and if necessary, cover material that may not fit in your five minute statement.  

Practice, Practice, Practice. And when you think you can’t stand another minute of practice, practice some more. Invite one or two trusted colleagues/friends to be there with you and coach you through it. Read your oral statement aloud to ensure the statement flows, and have your coaches time you to ensure you stay within the designated time limit. Draft some questions you think you may be asked and have your coaches grill you, and time your responses. Ask your coaches to give critical feedback about your cadence, body language, facial expressions, eye contact, and responses to the sample questions. If their only feedback is, “You’re GREAT,” find some new coaches who can give it to you straight.

Treat this practice session as a true “dress rehearsal” and set the stage accordingly: wear a suit, sit at a conference table with your coaches across from you, even set up a tent card with your name. It may feel goofy, but setting the stage for your dry run will make you feel more comfortable the day of.

Say “I Don’t Know.” The Senator has asked you a question that is out of left field. What now? It is perfectly appropriate to say, “That is an excellent question, Senator. I don’t know the answer, but I’d be happy to respond to your question in writing for the record.” Don’t think of “I don’t know” as a personal failing, but a useful tool to buy some time. You can use it when you truly don’t know, and when you do know but you’re not sure if/how you want to respond in that moment. “I don’t know” also provides a great opportunity to keep the conversation going with Members of Congress and their staff after the hearing.

Be Yourself. Lawmakers know a lot about a lot of things, but they don’t know everything. They’ve invited you to testify because you are the expert on this topic and they value your perspective and expertise. Be confident in what you know, and let it show. At the same time, always be respectful in your tone and demeanor—even if the lawmakers don’t afford you the same respect. Smile. Thank. Listen. Being authentic will help you connect with lawmakers, and make them want to come back to you as a trusted expert on this issue and others in the future.

Get Help. Preparing for a congressional testimony is a lot of work, especially when you have a day job. You don’t have to go it alone. The government relations and strategic communications professionals at CRD Associates are well-equipped to help you in all aspects of your hearing prep—research, drafting, coaching—and thinking through how to promote you, before and after the fact.

When you get that call, let us know how we can help!

Rescissions would have severe costs

By Matt Dennis, Senior Vice President

If one were to design in a laboratory specific legislation intended to encumber stable governing and inhibit responsible, bipartisan legislating, it would be hard to develop one as noxious as a rescissions package clawing back budget authority appropriated in the recently-enacted Omnibus Appropriations bill.

Such a gambit would pull the rug out from federal, state and local agencies, which are – quite reasonably – planning budgets based on the enacted law.  How can any agency function with stability when it is whipsawed over the course of a year between budget cuts, two government shutdowns, a budget increase, and then the possibility of an unexpected reduction or elimination?

Even the introduction or debate about a rescissions package would force agencies to put on hold grants, contracts, hiring, capital investments, and other routine actions of a functional government. Whether Americans want a big government or small government, all Americans have an interest in an efficient government.  Advancing a rescissions package would introduce new inefficiencies for purely political reasons.

This budget uncertainty at the federal, state and local level would also trickle down and have negative consequences for organizations that partner with government at all levels, as well as their employees and the populations they serve.

Corporations that depend on government contracts would be unable to hire and retain employees or invest in new services, equipment, or facilities while agencies’ budgets are on hold.  Nonprofit organizations that rely on public grants to provide health care services, improve schools, and develop communities would be paralyzed, taking the hardest toll on those most in need of services.

Congress and the White House should be working to minimize uncertainty and support contractors and grantees, but advancing a rescissions package would do the exact opposite.

Beyond the substance, reneging on the Omnibus – which was enacted with an overwhelming bipartisan majority of Congress and the president’s signature – would have severe political consequences as well.

Given the near certainty that a rescissions package would target non-defense discretionary investments important to Democrats, it would render bipartisan deals in the future impossible – not just on appropriations, but on anything.

For example, why would any party in the minority consider earnest, bipartisan work on a farm bill, surface transportation reauthorization, or telecommunications reform when evidence suggests that as soon as the bill is enacted into law, the majority might attempt to reverse the agreements already made by both parties in Congress and the White House.

Advancing a rescissions package would cause further postponement of the 2019 appropriations process, which is already significantly late as a result of the six-month delay in enacting the 2018 Omnibus. Such a delay increases the likelihood of long-term Continuing Resolutions and brinkmanship over unrelated issues.

Republican appropriators in the House and Senate are largely cool to the idea because they understand that your word is your bond. They also know that if Democrats win the majority in the House and/or Senate in the upcoming election, the actions they take today could have serious repercussions tomorrow.

The 2018 Omnibus provided reason for guarded optimism that Congress and the White House are still capable of enacting responsible, bipartisan legislation that improves Americans’ lives. Advancing a substantively harmful and politically damaging rescissions package would be a counterpoint showing that optimism may have been misplaced.

Matt Dennis is a Senior Vice President at CRD Associates and former Appropriations Committee staff.

Opioid Legislation and the Cost of Treating Addiction

By Nick Cavarocchi, Jr., Vice President

The ongoing opioid crisis is unquestionably a major public health challenge. Since the mid-2000s, the annual cost of treating opioid addiction and treating patients who overdose on opioids has drastically increased. Opioid-related deaths have risen over the last three years – up by 28 percent in 2016 alone. The Food and Drug Administration (FDA) is looking closely at certain opioids that may have a higher abuse potential, with a view to making sure patients are prescribed opioids only when medically indicated. 

According to a recent analysis done by The Kaiser Family Foundation, in 2016, people that got their health coverage through their employer received $2.6 billion in opioid treatment services, compared to $273 million in 2004. 

On April 24, Senate Health, Education, Labor, and Pension (HELP) Committee Chairman Lamar Alexander (R-TN) plans to mark up the Opioid Crisis Response Act, a bill intended to combat the opioid epidemic by making it easier to prescribe smaller packs of opioids for shorter periods; develop non-addictive painkillers; and detect illegal drugs coming across the border. This legislation updates how certain opioid treatment and prevention grants are allocated to states, with states more severely affected by the epidemic receiving more funding. 

Some specific populations face particularly acute risk.  Nearly one infant is born every fifteen minutes with signs of drug withdrawal, and babies born to mothers using opioids are at risk for neonatal abstinence syndrome (NAS) along with other health problems.  States and local communities are making every effort to help children and families affected by opioid abuse and ensuring that newborns and children affected by drug abuse get the care they need. Congress also must do its part by supporting these local efforts.   That is why Sen. Alexander’s bill provides further funding and support to states to strengthen their health care workforce to increase access to substance use disorder treatment, including medication-assisted treatment, and access to mental health services in schools.  This legislation will also provide grants to states to improve data collection.

The cost of treatment for opioid dependency presents a serious hurdle to recovery.  Private insurance and Medicaid coverage of outpatient methadone treatment, including medication and integrated support services, varies across states and can still entail daily out-of-pocket costs for a population that may be unable to afford it.  For the uninsured, costs of daily treatment can reach several hundred dollars per month. 

As with every public health crisis, the costs of inaction are severe, in the form of costs associated with criminal justice justice, treating babies born with dependence on opioids, greater transmission of infectious diseases, and treating overdoses.