When President Mr . trump signed the last-minute budget deal into law earlier this month, the news coverage emphasized how the bill boosted military funding, provided many billions in disaster aid and raised your debt ceiling.
But buried deep in the 652-page legislation was a repeal of the limit on Medicare coverage of physical and occupational therapy. It received little public attention, but towards the American Physical Therapy Association, this headline was decades in the making.
The group had spent 20 years lobbying to reverse a component of the Balanced Budget Act of 1997, which may have limited patients to $2,010 price of occupational therapy annually, and another $2,010 of physical therapy and speech-language pathology. Every time the limit involved to start working, APTA managed to postpone its implementation – sometimes for just months, sometimes for another couple of years.
Justin Moore, APTA's CEO, quit his job as a physical therapist in Missouri and gone to live in Washington, D.C., in 1999 specifically to lobby Congress full time about staving off these so-called therapy caps. He recalls recruiting a large number of physiotherapists to protest on Capitol Hill, extended hours lobbying in congressional offices and eleventh-hour victories to keep the cap from taking effect.
Just hours after Trump signed the sweeping bill, Moore joked: “I've reached figure out what to complete next,” celebrating the victory with cupcakes in his Virginia office.
It's a story of 1 long-fought battle, marked by legislative twists and convolutions, procrastination and budgeting witchcraft. But it provides a window into the bizarre realm of the way much of health care financing gets completed in Washington – being an afterthought and via backroom negotiations.
“This can be a miniature version of what we should also have as the inefficiencies of health policy and healthcare,” said Thomas Miller, a resident fellow in the conservative American Enterprise Institute, a Washington think tank. “We do a many things that burn up resources and, and we treat them like a big deal, and that tends to keep you down within the trenches, shooting at things before you and not looking at the larger picture.”
In their enthusiasm to pass a financial budget this month, Congress included permanent dissolution of the therapy caps – 277 pages into the bill. The balance contained other measures designed to placate medical constituencies by fulfilling their financial requests: for example, forestalling payment cuts to so-called Disproportionate Share Hospitals, which treat higher proportions of low-income patients, and recurring a payment bump to certain rural home health providers.
An Arbitrary Amendment
The therapy cap came being an amendment to the 1997 budget bill, part of a “big push to reform entitlements,” recalled Katherine Hayes, health policy director at the D.C.-based Bipartisan Policy Center, who worked at the time for Rhode Island Republican Sen. John Chafee, then your chair from the Senate subcommittee on healthcare.
Its inclusion was somewhat arbitrary – “an assignment – to get some savings within the health sector,” recalls Sen. Ben Cardin (D-Md.), who at that time would be a junior member of the House Ways and Means Committee, in which the proposal originated.
Others recalled some concern that Medicare was paying an excessive amount of for physical rehabilitation along with a hope that limiting coverage might help control these costs.
Since lawmakers “had to reach the prospective [for savings], it entered the package. Once it went into the package, it had been enacted and have become law,” said Cardin, that has introduced numerous bills through the years attempting to repeal the caps.
Almost immediately, backlash came from a small but impassioned therapy contingent, prepared to devote the majority of its lobbying resources for this one issue, with effect. Lawmakers on both sides from the aisle balked when it came to actually implementing the caps.
Over the years, that resistance translated into Capitol Hill rallies, starring speakers for example Maine Republican Sen. Susan Collins, who would wear and remove baseball caps – metaphorically “lifting the cap,” Moore recalled. Additionally, it meant full-court-press phone-a-thons from the nation's physical rehabilitation community, contacting Congress to increase the delay, usually by attaching legislative language to whatever must-pass spending bill or healthcare funding measure was moving with the pipeline.
The therapy lobby kept the legislative patches going, but efforts always stopped lacking a complete repeal, many recalled. This solution allowed lawmakers to have it both ways: They didn't need to take an ample popular benefit, physical rehabilitation, from voters. But they continue to support a budget amendment aimed at taming runaway spending.
“For a number of years, we thought [the cap] was not a thoughtful approach,” said Cybele Bjorklund, who worked from 1995 to 2021 like a Democratic staffer in Congress. “Many Republicans also realized pretty in early stages this was bad policy. But again – nobody wanted to then pay to get rid of it.”
And so, sidestepping imposition of the therapy cap was achieved by adding the delay right into a hodgepodge of small health initiatives, known as the “extenders,” that are addressed every few years. In 2006, Congress switched from delaying the cap to simply allowing for easy exceptions for patients who needed therapy past the stipulated limits.
On the balance sheet for the budget bill that passed this month, the nonpartisan Congressional Budget Office estimated the permanent therapy cap repeal will definitely cost a lot more than $6 billion within the next decade.
A Few Hiccups And, Ultimately, Repeal
The good and the bad from the therapy cap provision kept APTA running a business – providing fodder to mobilize their visitors and leading to increasing lawmakers' curiosity about a lasting deal, Moore said. Political gamesmanship and partisan bickering resulted in brief lapses – in late 2003, for any month in 2006 and in early 2010 – when lawmakers didn't patch together an invoice over time.
Meanwhile, the estimated price of forestalling or mitigating therapy caps grew more costly each time around.
An effort to include repeal from the caps into the 2010 Affordable Care Act failed, partially, Bjorklund recalled, because Democrats wanted the sweeping health law like a money saver. That meant every penny counted, and even a few billion dollars represented deadweight.
In 2021, a proposed Senate amendment to a larger bill on doctor payments again might have ended the treatment caps. It was ruled out of order after falling two votes short of a motion to waive concerns about its relevance.
That exhaustive 20-year effort laid the groundwork with this month's deal. When Bjorkland heard that therapy caps could be up for grabs for this year's budget bill?
“I remember saying, 'Please, just get rid of it, will you? Finish it!'” she said.