Ilisa Halpern Paul

About Ilisa Halpern Paul

Ilisa Halpern Paul leads the District Policy Group and has more than 20 years of experience in government relations, advocacy, and policymaking in non-profit, academic, federally-funded, and government settings. Ilisa’s practice centers on advising clients with respect to advancing their federal legislative, regulatory and programmatic policy agendas. Ilisa works with clients to establish and strengthen relationships with elected officials and federal agencies, develop and implement government relations and advocacy programs, craft effective grassroots campaigns, establish coalitions and third-party stakeholder partnerships, and affect the outcomes of appropriations measures, authorizing legislation and federal regulatory actions. Ilisa is particularly skilled in creating innovative messaging, tactics, and materials in support of her clients’ policy goals. She helps her clients by bringing traditional and nontraditional partners to the table in support of common goals, fostering relationships with members of Congress and their staff, and collaborating with the administration and federal agencies. Ilisa frequently speaks at meetings and briefings providing political insight and analysis to help clients navigate the current policy environment. Ilisa previously served as director of federal government relations for the American Cancer Society and as director of federal affairs with the American Public Health Association. Ilisa worked on the legislative staff for U.S. Senator Dianne Feinstein (D-CA). She earned a bachelor’s degree in English at UCLA and a master's of public policy degree from Georgetown University's Public Policy Institute. Originally from California, Ilisa planned to become a doctor, but found her health care niche after doing a policy internship in D.C. Ilisa lives with her husband, Scott, and their twin boys in Silver Spring, Maryland, where she is currently learning to play the drums.

Temporary Executive Appointments

This is the first of a three-part series on federal agency vacancies, nominations, and Senate confirmations.

Presidents maintain innumerable responsibilities and one of the most important but least-appreciated is selecting qualified people to help him run the federal government.  Many of the leadership positions are at the “political” level and require Senate confirmation.  While nominations can occur at any time when there is a vacancy to be filled, the shift between a first and second presidential term is a very common time for political appointees to step-down and for new people to be nominated to serve.  This piece focuses on how presidentially appointed, Senate-confirmed executive branch positions (PAS positions) may be filled temporarily before a permanent, confirmation occurs.  Vacancies are filled in one of three ways.

  • Under the Federal Vacancies Reform Act of 1998 (P.L. 105-277);
  • By recess appointment; or
  • Through provisions regarding position-specific temporary appointments specifically provided for by law.

It is important to note that these methods do not require the temporary appointee to undergo the usual Senate confirmation process.  The Vacancies Act allows for three ways that a vacant position may temporarily be filled:

  • The first assistant to such a position may automatically assume the functions and duties of the office;
  • The President may direct an officer who is occupying a different advice and consent position to perform these tasks; or
  • The President may select an officer or employee who is occupying a position in the same agency – such an employee must be making a salary equal to or greater than the GS-15 level and must have been with the agency for 90 days of the preceding year.

Appointees under the Vacancies Act have full authority to perform the duties and functions of the office.  However, such temporary appointments only last for 210 days after the date of the vacancy, or 210 days after the Senate reconvenes if in recess when vacancy occurs.  The 210 day time restriction may be waived if:  (1) the first or second nomination to the position is pending before the Senate; or (2) a permanent nomination has been rejected or withdrawn, the temporary appointment may be extended for an additional 210 days.

For example, in April 2010 during his first term, President Obama nominated Dr. Donald Berwick to serve as the Administrator of the Centers for Medicare & Medicaid Services (CMS) in the U.S. Department of Health and Human Services (HHS).  Berwick’s nomination faced significant opposition from Republicans in the Senate, and it was doubtful whether the Senate would vote to confirm his nomination.  Facing such opposition and the need for an Administrator as CMS was facing health care reform implementation, in July 2010, the President appointed Berwick to the top CMS post through a recess appointment.  Because Berwick had been appointed through a recess appointment, he was unable to serve his position indefinitely (as he would have had he received Senate confirmation).  Thus, on December 2, 2011, Dr. Berwick resigned as CMS Administrator because it was unlikely that the Senate would confirm his nomination.  Since then Marilyn Tavenner has served as the Acting Administrator for CMS, after having served as the CMS Principal Deputy Administrator.

Additionally, for temporary appointments filled in the first 60 days after a new President is inaugurated, the 210 restriction period does not begin until after the first 90 days following the inauguration.  So, for example, anyone the President nominates for a position between now and the end of March, the 210 day “clock” does not start until 90 dates following the inauguration.

For more information on temporary appointment procedures, see the January 2008 Congressional Research Service Report (CRS) “Temporarily Filling Presidentially Appointed, Senate-Confirmed Positions” (available through Open CRS).

On Friday, January 25, 2013, a federal appeals court ruled that President Obama’s 2012 recess appointments to the National Labor Relations Board (NLRB) were unconstitutional. The three-judge panel ruled that, as pro forma sessions were held during the “recess” that these appointments were made, the Senate remained in session and therefore these nominations violated the Constitution. The court stated that recess appointments must be made during official recess, defined as the break between sessions of Congress. It has been suggested that this ruling may limit the Presidential ability to bypass the Senate in the appointment process.

Amy Walker and Anna Howard contributed to this posting.

Dewonkify – Debt Ceiling

Word:  Debt Ceiling

Definition:  The statutory authority given by the Congress to the U.S. Treasury to borrow a certain amount of money and/or issue securities to fund the operations of the federal government.

Used in a sentence: “After the Debt-Ceiling Breach: What Day 1 in Default America Might Look Like


According to the Congressional Budget Office, Congress long has restricted the Department of Treasury’s ability to issue debt and has exercised control over the total amount of borrowing.  However, until the summer of 2011, raising the debt ceiling traditionally had been a pro forma occurrence without much policy debate or partisanship in the Congress.  The “debt ceiling crisis” that occurred in the summer of 2011 was a political debate and battle between Congressional Republicans and President Obama.  The Republicans generally were refusing to increase the federal government’s authority to borrow money without taking steps contemporaneously to decrease federal spending.  The debate resulted in enactment of the Budget Control Act of 2011, which raised the debt ceiling but also called for reductions in federal spending.  This policy debate brought the “debt ceiling” issue into the public forum and introduced the phrase into the vernacular.  Click here for more information about the Budget Control Act. (For more history on the debt ceiling, click here.)

What it Means

The U.S. government, through the Department of the Treasury, regularly borrows money to cover the cost of running the government’s operations, as well as to pay for maturing securities, such as treasury notes, bonds, and bills.  Treasury notes, bonds, and bills are issued to raise funds to support the federal government’s activities.  This borrowing of money is referred to as public debt.  The amount of money the U.S. Department of the Treasury is allowed to borrow typically has been controlled – and limited – by the Congress.  This restriction on the federal government’s borrowing authority is known as the “debt ceiling” or “debt limit.”  When borrowing approaches the authorized amount it is referred to as “hitting the debt ceiling;” the Congress then must act to increase the debt limit or else the government cannot borrow additional funds.  Without authority to borrow additional money and pay for maturing securities, the federal government could default, causing it to default on its debts and resulting in significant domestic and international economic disruption.

Entitlement Reform: Possible Changes to Medicare & Medicaid

With all the talk in Washington about deficit reduction and efforts to craft a “grand bargain,” entitlement “reform” or changes to entitlement programs, such as Medicare and Medicaid, are on the table.  Taken together, Medicare, Medicaid, and the Children’s Health Insurance Programs are an estimated 21% of the federal budget while Social Security is approximately 20%.[i]  According to the Pew Research Center, beginning January 2011 and for the next 19 years, 10,000 people a day are turning 65 – making them eligible for entitlement programs, such as Medicare and Social Security.[ii]  In turn, this demographic reality will cause those slices of the federal budget pie to grow at break-neck speed, unless the Congress does something to stem the tide.  Hence, the growing bipartisan interest in discussing entitlement reform.

So, what does that really mean?  One usual favorite for reducing entitlement spending being touted is cracking down on “fraud, waste, and abuse,” which supporters say could potentially save billions each year (though the independent Congressional Budget Office (CBO) tends to think otherwise).  In addition to that old stand-by, here is a sampling of some of the other changes to Medicare and Medicaid currently under consideration:

–     Reforming Medicare cost-sharing rules

–     Restricting first-dollar coverage in Medicare supplemental insurance (Medigap)

–     Extending Medicaid drug rebates to dual eligibles in Medicare Part D

–     Cutting Medicare payments to hospitals for bad debts

–     Accelerating Medicare home health savings in health reform

–     Eliminating state Medicaid provider tax (a mechanism used by a majority of states to increase their federal Medicaid matching funds)

–     Placing dual eligibles in Medicaid managed care

–     Block granting the Medicaid program

–     Moving some or all of Medicare into a “Premium Support” program

–     Combining Medicare Part A&B deductibles

–     Expanding use of competitive bidding under Medicare

–     Bundling Medicare payments (e.g., moving away from fee-for-service)

–     Increasing the eligibility age for Medicare

–     Increasing means-testing for high-income Medicare beneficiaries

Dewonkify – Wonk

The Word:  Wonk

The Meaning: An expert or someone steeped in the details of a particular issue area or field, e.g. policy wonk.   Sometimes used as a compliment (“She’s a real health policy wonk”) and sometimes used as an insult to suggest someone is a nerd (“I would never date such a wonk”).

Used in a Sentence: “The Bully vs. The Wonk

What it Means: Washington, DC is filled with wonks - people with deep expertise in specific policy issues, who sometimes speak in a vernacular often not understood by people outside the Beltway.  Hence, the need for this column – to “dewonkify” words!

History: According to the online Merriam-Webster dictionary the word first appeared in 1954.

Year Since the Debt Ceiling Deal: What’s Next?

Do you remember where you were when last year’s debt deal was sealed?  Few people remember the exact date of the debt ceiling deal made last summer or where they were; I happen to know the date and where I was because it was August 2nd, which is my birthday.  My husband says I get better with age – consensus is that the debt deal does not.  Nothing much usually happens in August; there are no federal holidays, lots of people go away on their summer vacations, and generally things in Washington are very quiet.  Well, last August 2nd, the nation’s – and some say the world’s – economy came to the brink and was saved (at least temporarily) due to the bipartisan deal on the debt ceiling, formally known as The Budget Control Act of 2011.

This measure was the result of months of debate, disagreement, dissent, and generally serves as a textbook illustration of the current dichotomy in political views.  The deal was like most compromises – imperfect and both sides feel they got some wins and some losses.  Members of Congress built in a fail-safe trigger – if the “supercommittee” (remember that?) couldn’t come to agreement on what to cut and how much, then automatic across-the-board reductions in spending would go into effect beginning January 1, 2013.  Now, five months away from that deadline most Members of Congress have buyer’s remorse.  The Act applies equal amounts of cuts to both defense and what those inside the Beltway call “non-defense discretionary programs,” which in English means everything that is not defense, not interest on the debt, and not entitlement programs (e.g., Medicaid, Social Security) that were carved out or whose cuts (e.g., the Medicare) were capped under the deal.  The Centers for Budget and Policy Priorities (CBPP) estimate the Budget Control Act will result in cuts of approximately $109 billion per year, or $984 billion through 2021, for both the defense and “non-defense discretionary”.

Congress just achieved bipartisan agreement on a six-month deal on regular order annual appropriations to avert a government shutdown and get us past the election and push that debate into the next session of Congress – leaving the big ticket hot potato political and budgetary issues (read: problems) for the Lame Duck session.  Somehow between the November 6th election and New Year’s Eve Congress has to tackle the impending sequestration, expiring tax cuts,  fixing the reimbursement for physicians who treat Medicare patients (aka, “the doc fix” or SGR), raising the debt ceiling, etc.  There is not much bipartisan agreement on remedies to any of these issues but there is one thing both sides can agree upon now – no one should be buying airline tickets home for the holidays quite yet.

Want Federal Funding? Don’t Forget OMB!

Most people know that the Office of Management and Budget plays a leadership role in the development of the President’s budget.  However, too often advocates solely focus their federal funding advocacy efforts on the Congress and the members of the House and Senate Appropriations Committees.  While clearly, those who control the purse-strings are essential to the federal funding process and outcomes, the staff – both political and career – at OMB maintain significant expertise in – and authority over - federal departments, agencies, and programs.  OMB maintains responsibility for five core functions, only one which relates to the development of the annual budget proposal.  It is important to note that OMB:

  • provides “oversight of agency performance, federal procurement, financial management”;
  • coordinates and reviews “all Federal regulations by executive agencies”;
  • engages in “legislative clearance and coordination (review and clearance of all agency communications with Congress, including testimony and draft bills)”; and
  • is involved in “Executive Orders and Presidential Memoranda to agency heads and officials.”

Given this significant role and associated authority, OMB and its staff are in an unique position to influence policies, programs, and funding across the entire spectrum of the federal government.  In my experience, visiting with the OMB staffer whose portfolio includes the program or agency of concern of interest will prove time well spent.

To read the 2014 Budget Guidance released by OMB on May 18th, click here.

No Matter the Outcome of the Supreme Court’s Review of Health Reform – The Health Care Community Should Consider Five Illustrations of “The New Normal”

Since last November – 365 days from the 2012 election to be exact – at the invitation of various health care providers, I have been going around the country giving a “crystal ball speech” about the future and outcomes of government spending, health reform, and the election.  Whether I speak to an audience in Chicago, San Francisco, New Orleans, or Florham Park, New Jersey, the most frequently asked questions I receive are: “What will the Supreme Court do?” and “Is there any hope that they can get something done and start to agree in Washington?”  The answer I give to the former is my favorite answer to give:  “It depends.”  The answer I offer to the latter is “I hope so – and if I didn’t think so I wouldn’t keep doing what I do.”

In all seriousness, there are four separate but related questions before the Supreme Court and a number of different combinations and permutations that can result from the court’s deliberations and determinations.  Tens of thousands if not millions of people are making their guesses and sometime in June we expect we will know who is correct.  In the meantime, I offer these five examples of the new playing field for those in health care:

1.  We are in a period of fiscal contraction – call it austerity, compression, retraction, or budget tightening – these are not times of Congress taking steps to expand programs or increase funding.  As such, it is important to recognize this fiscal and political reality and modify your expectations, requests, and approaches to policy makers accordingly.

2.  So goes the economy, so goes provider reimbursement.  The nation’s tax base is at an all-time low – meaning the available pie is shrinking – while entitlement spending grows, especially within federal health care programs (Medicare, Medicaid, VA).  Using baseline FY 2010 estimates from the Office of Management and Budget, entitlement spending is approximately 60% of the budget while non-defense discretionary funding is 15% and defense spending is 20% (remaining 5% is interest payments).  It is a basic math issue:  We cannot balance the budget only paring down the smaller, non-entitlement parts of the pie.  So, if your interests are in the entitlement slices, expect those – at some point – to shrink.

3.  Health care has become a “pay-for” for health care.  When I first arrived in Washington more than 20 years ago, most Members of Congress did not want to pit members of the same community against one another or pick among their children – hence the holistic approach to the doubling of the National Institutes of Health (NIH) budget.  Those also were much better economic times.  Now given current circumstances and the fact that health care spending is crowding out other parts of the budget, Congress is looking and finding money from within other areas of health care to pay for things like the “doc fix.” This trend likely will continue … Indefinitely.

4.  Innovation in care delivery is the key to survival.  The days of paying for volume are over.  Patients, insurers, and the government want value and quality and providers need to respond to the marketplace.  Those leading the field in innovative care delivery models and real outcomes based, patient-centered care – that measurably decrease costs – will do well from both private and public payor perspectives.

5.  Don’t necessarily fear the sequestration – some alternatives could be worse.  See items one, two, and three above.  Don’t get me wrong – it’s bad … And depending on where you reside and in which pieces of the pie, it’s really bad … for non-defense discretionary spending the estimates are 10% cuts across-the-board, and for Medicare (the reimbursement side of the equation) cuts are capped at 2%, but for many providers 2% poses a threat to their ability to maintain access to care.  But it could be – and can get – way worse.  Taking a page out of the earlier example of doubling the NIH playbook of collaborative advocacy, the health community is banding together with other communities (e.g., energy, environment, education, transportation) and those in the non-defense discretionary spending slice of the pie to work together to protect funding.

While the crystal ball remains cloudy with respect to the Supreme Court, the future of health care spending generally is pretty clear:  public and private payors will want more for less and somehow, as a nation, we have to get health care costs and spending under control.  The reality of current and long-term fiscal projections is that the intense budgetary pressures on the country will have as much – if not a greater – impact on the future of health care than anything those nine cloaked justices decide in June.

Budget Reconciliation: Coming to a House Committee Near You

The FY 13 budget and appropriations process continues in earnest this week with a number of House committees holding mark-ups to conform to reconciliation instructions included in the House-passed budget resolution, which went further than the August 2, 2011 compromise struck under the “Budget Control Act” (aka BCA or “debt deal”).   Reconciliation instructions are contained only in budget resolutions and direct one or more committees to develop and submit bills that change spending, revenues, and/or the debt-limit so they align with the budget resolution.  In total, six committees are working to identify – by April 27th – $261 billion in savings that will be spread over a ten year time frame.  This amount will result in Congress enacting both the equivalent of the first-year of sequester plus additional spending cuts beyond those of the BCA.  The last time Congress enacted a reconciliation bill was in conjunction with the passage of health care reform in 2010.

Last week, the Ways and Means Committee reported out a bill that reduces spending over ten years by $53 billion.  The cuts are comprised of: the elimination of the Social Services Block Grant; rescinding the child tax credit; and defunding the subsidies in the Patient Protection and Affordable Care Act (aka health reform).

Tuesday, the Energy and Commerce Committee began work on its measure, which will reduce spending by $98 billion over ten years.  Items expected to be on the chopping block include:  grants for state exchanges (the funds that have not yet been spent/obligated); the Public Health and Prevention Fund (it likely will be eliminated entirely); and Medicaid DSH (rebasing allotments starting in FY 22).

Once all six committees have marked-up and reported their respective bills, the House Budget Committee will weave all the proposals and cuts together and report a single measure out to the full House, which is expected to consider the omnibus spending cut package in May.  It is important to note that the Senate is unlikely to do anything similar as both Senate Democrats and Republicans have indicated their preference for sticking with the BCA numbers – at least for now.  Senate Majority Leader Reid previously announced he is not bringing a budget measure to the Senate floor because FY 13 spending caps were previously set by the BCA.  As such, there are no movements afoot in the Senate for a budget or reconciliation at this time.  Therefore the Senate has leapfrogged over the budget and moved straight to moving the FY 13 appropriations bills, which taken all 12 together fund all the activities of the government.

Last week President Obama issued a veto threat for any appropriations measures that cut funding further than BCA amounts.  While Senate Democrats are holding to the BCA numbers because they want to safeguard programs, Senate Republicans indicate they are sticking to the BCA numbers in an effort to move appropriations bills through the chamber on the front end, with the hope that they can negotiate further cuts in conference at the end of the annual process.

FY 2013 Spending Process – Off to the Races or Already Hitting Road Bumps

The FY 2013 appropriations process got underway this week in the House and elicited a veto threat from President Obama. House Budget Committee Chair Paul Ryan (R-WI) developed a budget that exceeds the cuts enacted by the Budget Control Act of 2011 (otherwise known as the “debt ceiling deal”). The Hill reports that the White House announced Wednesday that barring a change to the GOP proposed spending levels, the President will veto their funding bills.

Meanwhile, on the Senate side, Majority Leader Reid (D-NV) has indicated he does not plan to bring a budget proposal to the Senate floor for a vote as the spending caps and allocations for the 12 different appropriations measures were predetermined by the Budget Control Act.

It is expected that House and Senate Appropriations Subcommittees will begin to consider appropriations bills in short order. The Labor, Health, and Human Services (LHHS) bill will not be one of the first to be considered since it is notoriously controversial due to many competing priorities and limited funds.

The regular order budget and appropriations process first involves the development – and passage by House and Senate – of a budget proposal, which outlines overall spending by broad categories (e.g., defense, health). The Congressional budget does not require the signature of the President. Then, the 12 Appropriations Subcommittees in both the House and Senate receive their particular allocation; from there, each subcommittee decides specific line-item funding amounts for the departments, agencies, and programs under their respective jurisdiction. The bills are marked-up and passed at the subcommiittee and full committee levels and brought forward for full House/Senate consideration. Since the chambers typically pass very different bills, each of the 12 spending measures goes to a conference committeee where differences are worked out and a single, uniform measure is developed and then sent back to both the House and Senate for final passage. Once a spending bill is enacted by both chambers it is sent to the President for signature or veto. The annual appropriations process is supposed to be wrapped-up by September 30, the end of the federal fiscal year. However, Congress typically misses this deadline. Given that this is an election year, it is expected that most – if not all – 12 appropriations bills will be on the growing list of matters to be considered during the lame-duck session.

Congressional Spring Recess: A Great Time for Advocates to Connect with Elected Officials

Members of Congress will be at home in their states/districts from now until the week of April 16th.  This “spring break” presents advocates a terrific opportunity to visit with their elected officials at-home.  Most Members post their schedules on their websites or notify constituents through newsletters.  If you are not on your Members’ email/mailing lists, visit their websites ( and to sign-up.

Given that it is an election year, now – more than ever – elected officials are interested in hearing the concerns of the people they represent.  Be sure to have your voice heard and get out to town hall meetings and other forums hosted by your Members of Congress.  If you miss them in April, not to worry – Members of Congress will be at-home again the week of May 28th for the Memorial Day Recess.

For tips about how to communicate with elected officials, see the excellent post by my colleague, Hilary Hansen.