The Affordable Care Act (ACA) and the Medicare and CHIP Reauthorization Act (MACRA) provided the Centers for Medicare & Medicaid Services (CMS) and the newly created Center for Medicare and Medicaid Innovation (CMMI) tremendous authority. With Republicans set to take control of both the White House and Congress, the future of that authority is very much in question.

The ACA created CMMI to test innovative payment and service delivery models to reduce program expenditures and improve care. To carry out this goal, the ACA allows CMMI to waive any Medicare provision of the Social Security Act, as well as select Medicaid provisions, that may be necessary to carry out and evaluate demonstration policies. If the demonstrations prove effective, CMS may implement the program nationally.

Over the past few years, CMS has implemented numerous demonstration projects under CMMI’s authority. These include delivery reform demonstrations such as the Medicare Shared Savings Program and Pioneer ACO program, as well as the Financial Alignment Initiative, which integrates care for dual-eligible individuals in select states. Demonstrations such as the Medicare Advantage Value-Based Insurance Design Model have focused on encouraging the use of high-value clinical services, while others, such as the Diabetes Prevention Program, have focused on preventive service models. In July of this year, CMS proposed expanding the Diabetes Prevention Program nationally.

While there have been successes, CMS’s use of this authority has not been without controversy and criticism. In September of this year, Rep. Tom Price, along with over 150 members of Congress, sent a letter to CMS condemning CMMI’s large mandatory demonstrations, citing that “CMMI has exceeded its authority, failed to engage stakeholders, and has upset the balance of power between the legislative and executive branches.” This letter specifically attacked the Cardiac Bundled Payment Model, the Comprehensive Care Joint Replacement Model, and notably, the Part B Drug Payment model as problematic programs. Further, the House Budget Committee held a hearing criticizing the authority granted CMS and CMMI to effectively usurp the role of Congress in creating public policy. With Rep. Tom Price, current Chairman of the House Budget Committee, reportedly under consideration for HHS secretary in the Trump Administration, the future for CMMI is very much in question.

It is possible that Republicans will now move to defund or otherwise limit CMMI’s authority given their recent attacks on it. However, CMMI provides an avenue to test and garner buy-in for new models of care that otherwise did not exist. Republicans may realize the opportunity that CMMI could provide as they transition away from the Affordable Care Act. If Republicans want to maintain this authority or provide states greater authority to demonstrate coverage models, they could leverage CMMI’s authority to do so.