ANCOR's Government Relations staff distributes stories in the Washington Insiders Club (WICS) – a weekly round-up of top stories and headlines – to ANCOR Members to keep them up to date on policy and political developments of note to the disability community. The following entries highlight the most significant reports of the last two months.
April 3, 2017 – In the wake of the American Health Care Act (AHCA) being pulled twice by House Speaker Paul Ryan (R-WI) for failing to gain sufficient support to pass, Washington insiders have been sending mixed messages about where to go from here. (See WICs article, "ACA Remains Law for "Foreseeable Future" as Repeal Efforts Implode," March 27, 2017.) President Trump initially said he would welcome working with Democrats on future health care reform efforts, appearing to recognize that given the deep fissures in the Republican party, bipartisanship would be necessary to move any effort forward. Speaker Ryan, just days after proclaiming that "Obamacare remains the law of the land" for the "foreseeable future", again vowed to repeal the Affordable Care Act (ACA). However, others in the Republican party remain unmoved, with some members questioning what Ryan thinks has changed since the demise of the AHCA that would bring those opposed to the bill to the table.
As Congress moves into recess prior to the Easter holiday, it's expected that health care will remain front and center for constituents engaging in advocacy at the local level, including likely more contentious town hall events with constituents promising to hold responsible any lawmaker who works to take away health coverage from people who gained it under the ACA. Some states that had previously opted not to expand Medicaid are now exploring the possibility after the AHCA failed. This could cause an uptick in coverage, and costs, which could complicate future efforts to unwind the law.
Democrats are seizing on the failure of the AHCA as an opportunity to position themselves as reasonable partners in a real conversation about health care reform. Last week, 44 out of 48 Senators sent a letter to Trump offering to work on improvements to the ACA so long as repeal was off the table.
It remains to be seen whether the closed-door conversations happening now in Washington will result in a viable health care reform package, or whether the administration and Congress will move on to tax reform, which appeared at the end of last week to be the most likely course of action.
April 3, 2017 – The Centers for Medicare and Medicaid Services (CMS) has published the comments received in response to the Request for Information (RFI) published on December 23, 2016. The RFI sought comment on potential elements to be included in a five-year PACE-like model test for individuals dually eligible for Medicare and Medcaid, age 21 and older, with disabilities that impair their mobility and who are assessed as requiring a nursing home level of care. (The Programs of All-Inclusive Care for the Elderly [PACE] currently serve seniors with specific supports, but a law in 2015 has expanded the authority to serve individuals under age 55 with disabilities as well.) (See WICs article, "PACE Demonstration Legislation Signed into Law," November 23, 2015.)
Zip files containing RFI comments are available to download at the bottom of this page. ANCOR submitted comments which are attached below.
March 31, 2017 – Following last week’s cancellation of a House vote on the American Health Care Act (AHCA), Congress and the Trump Administration are still showing a commitment to working on healthcare issues in 2017. In a letter to President Trump just before a reception for Senators at the White House, 44 Senate Democrats expressed that they would be willing to work on healthcare improvements and solutions with the President if he moved away from the repeal of the Affordable Care Act. Meanwhile two leading Senate Republicans, Senators Lamar Alexander (R-TN) and Bob Corker (R-TN), introduced a bill to address issues with the Affordable Care Act around the value of subsidies with a deficit of insurance providers.
In the House, Health and Human Services Secretary Tom Price made an appearance in a Appropriations Subcommittee to address the White House’s FY 2018 budget proposal, but provided responses about the Affordable Care Act, the current intention to implement it, and intention to impact regulations to improve access to care. Read more about these stories below.
March 27, 2017 – On March 24, Speaker of the House Paul Ryan (R-WI) pulled the American Health Care Act (AHCA) for a second time as it became clear that the Affordable Care Act (ACA) repeal bill did not have sufficient Republican support to pass. (See WICs article, "ACA Repeal Vote Postponed, Rescheduled Amid Republican Dissent," March 24, 2017.) In a statement to the press, Ryan said, "Moving from an opposition party to a governing party comes with growing pains...We came really close today but we came up short." He also acknowledged that the ACA is the "law of the land" for the "foreseeable future", and will remain so until it is repealed. A number of factors went into the bill's failure to pass, including dismally-low public approval (measured on Thursday as being only 17%), deep fissures between House Republicans, and what was seen as tepid support from the President in the initial stages.
As Friday progressed, it became clear that if the AHCA was put up for a vote, it would fall well short of votes needed. President Trump convened a meeting with Republican members of the conservative Freedom Caucus on Friday morning to make a final pitch to garner support. Members were unmoved, saying that the AHCA did not go far enough to repeal the ACA, and that even with last-minute amendments, did not sufficiently alter what was viewed as the creation of a new entitlement in the form of new tax credits. As the changes moved the bill further right, more moderate Republicans also dropped support. The professed "no" votes increased, signaling that failure of the bill was inevitable. Rather than forcing a vote that would defeat the bill, Ryan and Trump agreed to pull the bill Friday afternoon.
President Trump was not critical of Speaker Ryan in the moments following the bill's failure, instead saying that the lack of Democratic support was to blame. (No Democrats supported the AHCA). Trump said, "With no Democrat support we couldn't quite get there." He also said that if Democrats "got together with us and got a real health care bill, I'd be totally open to it...I think the losers are [House Minority Leader] Nancy Pelosi and [Senate Minority Leader] Chuck Schumer, because now they own Obamacare." Democrats were vocally critical of Republicans throughout the 17-day lifecycle of the legislation, repeatedly blasting Republicans for not inviting a bipartisan process. Fellow Republicans were critical of the lack of transparency during the process, including Senator Rand Paul (R-KY) who attracted press attention by attempting to view a draft version of the bill that was under guard in the basement of the Capitol.
President Trump, Speaker Ryan, and other members of the Republican party have indicated they will move on from health reform, and that the next major policy initiative on deck will be tax reform. Though many disability, aging, and Medicaid advocates are relieved that the significant restructuring of the Medicaid system that was included in the AHCA has been given a temporary reprieve, there is still great concern that similar proposals to impose block grants or per capita caps will emerge as a way to offset the costs that will inevitably come with any tax reform package. For now, all eyes turn back to the House, which will need to coalesce around budget legislation, increase the debt ceiling, and ensure that the government does not shut down when the funding included in the current continuing resolution expires.
March 27, 2017 – On March 16, the Office of Management and Budget (OMB) issued, "America First: A Budget Blueprint to Make America Great Again," President Donald Trump's budget proposal for FY 2018. Overall, the budget proposes deep cuts for many executive agencies, as well as a $54 billion increase in defense spending. The departments of Agriculture, Labor and State would see reductions of more than 20 percent while the Environmental Protection Agency(EPA) would face a 30 percent cut in funding. Spending would also be cut at Commerce, Education, Health and Human Services, Housing and Urban Development, and Transportation, among others. The budget seeks $1.7 billion in funding in 2017 to begin construction on a U.S.-Mexico border wall, and another $2.6 billion in 2018.
Of particular interest to providers are the following items:
DOL Funding - The President’s 2018 Budget requests $9.6 billion for the Department of Labor, a $2.5 billion or 21 percent decrease from the 2017 annualized CR level.
ODEP - Refocuses the Office of Disability Employment Policy, eliminating less critical technical assistance grants and launching an early intervention demonstration project to allow States to test and evaluate methods that help individuals with disabilities remain attached to or reconnect to the labor market.
DOED Funding -The President’s 2018 Budget provides $59 billion in discretionary funding for the Department of Education, a $9 billion or 13 percent reduction below the 2017 annualized CR level.
IDEA Funding - Maintains approximately $13 billion in funding for IDEA programs to support students with special education needs. This funding provides States, school districts, and other grantees with the resources needed to provide high quality special education and related services to students and young adults with disabilities.
The President's proposal is a blueprint indicating his policy priorities, but the budget must actually be constructed and passed by Congress. This means that President Trump will have to persuade Congress of his vision in order to appropriate funds in the way he wants. Some lawmakers are already pushing back on the budget. Senator Marco Rubio (R-FL) said, "The administration's budget isn't going to be the budget. We do the budget here. The administration makes recommendations, but Congress does budgets."
March 19, 2017 – On March 14, Secretary of Health and Human Services (HHS) Tom Price and the newly-confirmed Administrator of the Centers for Medicare and Medicaid Services (CMS) Seema Verma sent a letter to state governors suggesting that states should focus on ways to ensure that Medicaid "operates in a way that best serves the most vulnerable populations." The letter starts by characterizing the current Medicaid program as "outdated", "rigid", and full of federal rules that have been implemented and interpreted in way that hinder states from ensuring that Medicaid achieves positive health outcomes for vulnerable individuals and families. One of these hindrances, according to the letter, is the expansion of Medicaid to non-disabled, working age adults contained within the Affordable Care Act (ACA).
The letter then sets forth several keys areas that HHS plans to improve collaboration with states on. It starts by pledging that CMS will engage in a more transparent and efficient State Plan Amendment approval process. Part of this process will be to conduct a full review of managed care regulations, in order to prioritize beneficiary outcomes and state priorities. The letter also reaffirms HHS' commitment to assist states in programs that "have demonstrated success" in empowering low-income Americans with skills and employment by approving section 1115 demonstrations that innovate around training, employment and independence.
The letter then discusses state-led reforms to Medicaid design and benefit structure that could align them with commercial insurance, including cost-sharing, programs similar to Health Savings Accounts (HSAs), premium payments, and waiving non-emergency transportation benefit requirements. It also mentions the used of emergency room copayments to encourage the use of non-emergency providers. Finally, it notes that states should consider waivers of enrollment and eligibility procedures that do not promote continuous coverage, such as presumptive eligibility and retroactive coverage.
Of particular interest to ANCOR members is a section of the letter discussing the timeline for the HCBS rule. The letter notes that CMS has worked with states and other stakeholders to implement the HCBS final rule. The letter then says, "In recognition of the significance of the reform efforts underway, CMS will work toward providing additional time for states to comply with the [rule]." This is significant for several reasons. First, it does not actually extend the implementation date set in the rule of March 17, 2019. Second, it doesn't include another target date or provide any indication if or when a different implementation date may be set. This could mean that implementation may be extended on a case by case basis rather than as a blanket extension that would cover all states. It could also mean a different timeline for different states. Finally, it is notable because it does not indicate that the rule itself will be rolled back or significantly changed, only that the implementation timeframe may change. Both Price and Verma discussed the rule in their confirmation hearings and did not indicate that the rule would be repealed. The next sentence in the letter reads, "Additionally, we will be examining ways in which we can improve our engagement with states on the implementation of the HCBS rule, including greater state involvement in the process of assessing compliance of specific settings." This final sentence on HCBS signals that there may be additional guidance forthcoming regarding the heightened scrutiny piece of the settings rule, potentially by providing states more flexibility to determine whether a setting meets the criteria to undergo heightened scrutiny.
March 19, 2017 – On March 13, Seema Verma was confirmed (55 to 43) by the Senate to lead the Centers for Medicare and Medicaid Services (CMS). Verma was previously in private practice as a health care consultant who assisted Indiana and other states in designing their Medicaid systems. Unlike recent past CMS administrators, Verma has significant experience in the Medicaid field. (For more information, see WICs article, "Verma Inches Closer to Confirmation as CMS Administrator," March 3, 2017.)
House Ways and Means Committee Chairman Kevin Brady (R-TX) released a statement after the confirmation, saying, “Congratulations to Seema Verma on being confirmed to lead CMS—she’s the perfect person for this job. Seema has more than two decades of hands-on health care experience—including leading Indiana’s work to modernize its Medicaid program. I look forward to working with her to return control of health care back to states and give patients across America more control over their own care. President Trump has clearly put together a talented leadership team of health care advisors, and I’m confident that together we can deliver on our promise of lower costs, more choices, and greater access for individuals and families.”
March 11, 2017 – On March 6, the acting administrator of the White House Office of Information and Regulatory Affairs (OIRA) sent guidance to agencies telling them to pay close attention to the executive order signed by President Trump in January directing agencies to eliminate two existing rules for each new rule put in place. (See WICs article, "Trump Directs Agencies to Roll Back Two Regulations for Every One Issued," February 6, 2017.) Agencies are required to submit plans to be included in the semi-annual regulatory agenda later this month. The expectation is that the net incremental cost for FY2017 should be "no greater than zero", in addition to eliminating regulations.
Office of Management and Budget (OMB) Director Mick Mulvaney said in an interview that the OMB is prepared to "push the limit" with the Congressional Review Act CRA), which permits Congress to roll back rules passed shortly before a new administration. The CRA allows Congress a 60-legislative-day "look back" period during which they can repeal a regulation. Typically, the CRA will not come into play except when an administration changes, as the Congressional action is subject to a presidential veto. Under the current circumstances, the Republican-controlled Congress sees the CRA as an effective tool for rolling back some of the Obama administration's more recent regulatory actions.
Source: The Hill
March 3, 2017 – On March 3, ANCOR joined with dozens of other national health and disability organizations in sending a letter (attached below) supporting the preservation of the essential health benefit (EHB) category of “rehabilitative and habilitative services and devices” in any reform of the Affordable Care Act (ACA). Recent draft proposals have recommended eliminating or scaling back EHBs, which are minimum requirements for services that must be covered in insurance plans. The letter was sent to all Congressional offices, as well as to Health and Human Services Secretary Tom Price.
March 3, 2017 – On February 17, the Centers for Medicare and Medicaid Services (CMS) issued proposed rule RIN 0938-AT14, which seeks to stabilize the health insurance market for individual and small group health plans. The rule would make changes to special enrollment periods, the annual open enrollment period, guaranteed availability, network adequacy rules, essential community providers, and actuarial value requirements. It also announces upcoming changes to the qualified health plan certification timeline.
The rule proposes a variety of policy and operational changes to stabilize the Marketplace, including:
Special Enrollment Period Pre-Enrollment Verification: The rule proposes to expand pre-enrollment verification of eligibility to individuals who newly enroll through special enrollment periods in Marketplaces using the HealthCare.gov platform. This proposed change would help make sure that special enrollment periods are available to all who are eligible for them, but will require individuals to submit supporting documentation, a common practice in the employer health insurance market. This will help place downward pressure on premiums, curb abuses, and encourage year-round enrollment.
Guaranteed Availability: The rule proposes to address potential abuses by allowing an issuer to collect premiums for prior unpaid coverage, before enrolling a patient in the next year’s plan with the same issuer. This will incentivize patients to avoid coverage lapses.
Determining the Level of Coverage: The rule proposes to make adjustments to the de minimis range used for determining the level of coverage by providing greater flexibility to issuers to provide patients with more coverage options.
Network Adequacy: The proposed rule takes an important step in reaffirming the traditional role of states to serve their populations. In the review of qualified health plans, CMS proposes to defer to the states’ reviews in states with the authority and means to assess issuer network adequacy. States are best positioned to ensure their residents have access to high quality care networks.
Qualified Health Plan (QHP) Certification Calendar: In the rule, CMS announces its intention to release a revised proposed timeline for the QHP certification and rate review process for plan year 2018. The revised timeline would provide issuers with additional time to implement proposed changes that are finalized prior to the 2018 coverage year. These changes will give issuers flexibility to incorporate benefit changes and maximize the number of coverage options available to patients.
Open Enrollment Period: The rule also proposes to shorten the upcoming annual open enrollment period for the individual market. For the 2018 coverage year, we propose an open enrollment period of November 1, 2017, to December 15, 2017. This proposed change will align the Marketplaces with the Employer-Sponsored Insurance Market and Medicare, and help lower prices for Americans by reducing adverse selection.
The press release issued by CMS announcing the proposed rule is available here.