House Democrats secured a temporary truce last month in their internal dispute over economic priorities, but the solution to their standoff all but guarantees another clash by the end of September.
The disagreement between the party’s moderate and progressive wings is ostensibly over the sequencing of two big bills that make up the bulk of President Joe Biden’s economic agenda. A Senate-passed bipartisan infrastructure bill would provide $550 billion in new spending on roads, bridges, transit, broadband and water projects, and a mostly unwritten partisan budget reconciliation package could add another $3.5 trillion on “human” infrastructure, including subsidies for child care, education, paid leave, health care, clean energy programs and more.
The crux of the dispute, however, is about which faction would have the most leverage over the reconciliation package, which House committees are putting together in markups that began last week. The filibuster-proof reconciliation process allows Democrats to pass their economic priorities without Republican support, but they must be unified since they can’t lose a single vote in the Senate or more than three in the House.
Progressives want the infrastructure and reconciliation bills linked to ensure moderates don’t sink or water down the latter. Speaker Nancy Pelosi, D-Calif., embraced the strategy, repeatedly promising the House would not take up the infrastructure bill until the Senate passed the reconciliation package. But moderates balked, saying Democrats should claim the win from the infrastructure bill and then have a debate about the size and scope of the reconciliation package.
The tensions came to a head in late August as the House considered the fiscal 2022 budget resolution containing instructions for the reconciliation bill. Ten moderates publicly threatened to vote against the budget without the House voting first on the infrastructure bill, the same order that occurred in the Senate.
The moderates relented after securing language ensuring the House will consider the infrastructure bill by Sept. 27. They also received a separate commitment from leadership that the House will “pre-conference” the reconciliation package with the Senate.
The initial group of nine moderates who threatened to vote against the budget — Reps. Josh Gottheimer of New Jersey, Ed Case of Hawaii, Kurt Schrader of Oregon, Carolyn Bourdeaux of Georgia, Jared Golden of Maine, Jim Costa of California and Texans Filemon Vela, Henry Cuellar and Vicente Gonzalez — issued a statement claiming their strategy succeeded.
“This agreement does what we set out to do: secure a standalone vote for the bipartisan infrastructure bill, send it to the president’s desk, and then separately consider the reconciliation package,” they said. “It will receive standalone consideration, fully delinked, and on its own merits.”
But progressives didn’t see it that way.
“Our position remains unchanged: we will work to first pass the … reconciliation bill so we can deliver these once-in-a-generation, popular, and urgently needed investments to poor and working families, and then pass the infrastructure bill to invest in our roads, bridges, and waterways,” Congressional Progressive Caucus Chair Pramila Jayapal, D-Wash., said in a statement. “The two are integrally tied together, and we will only vote for the infrastructure bill after passing the reconciliation bill.”
Both sides believe they’ve got the leverage needed to execute their dueling strategies.
“What this little ‘private equity caucus’ has shown is that they’re erratic,” Rep. Alexandria Ocasio-Cortez, D-N.Y., said of the moderate rebels, in an apparent dig at some members’ ties to financial services and investment firms. “And there’s not much you can do with kind of an erratic group like that, aside from keep a steady course.”
Progressives say a majority of their 96-member caucus is willing to vote against the infrastructure bill unless the Senate first passes a reconciliation package that fulfills their top priorities — such as affordable housing and climate programs, lowering prescription drug costs and expanding Medicare and providing a path to citizenship for certain categories of undocumented immigrants.
“The commitment on this strategy to move both of these pieces simultaneously still remains,” Rep. Ilhan Omar, D-Minn., the Progressive Caucus whip, said.
The only thing that would take away progressives’ leverage is if enough House Republicans support the infrastructure bill to offset their opposition.
If the infrastructure bill had been brought up for a vote last month as moderates initially demanded, there would have been “a significant number” of Republicans supporting it, “potentially” more than 40, according to Rep. Brian Fitzpatrick, R-Pa. But now he’s not sure if those numbers will hold.
“A lot of them, their support was contingent upon it not being in any way, shape or form tied to reconciliation. Now, many of them are going to view this as being tied,” Fitzpatrick said. “Some of them will view it as not being tied. And that’s what I need to find out.”
Fitzpatrick, who co-chairs the Problem Solvers Caucus with Gottheimer, said his Democratic colleagues in the caucus made a deal they felt was necessary but it’s “certainly not the way I would have played my hand.”
Democratic leaders are trying to avoid those obstacles to the infrastructure bill by getting the reconciliation bill done first. Although they’ve not officially made any scheduling decisions, leaders indicated they want to bring the reconciliation package to the floor the week of Sept. 20.
“That is ambitious given the amount of conversations that need to be had between the two chambers,” Rep. Stephanie Murphy said. The Florida Democrat became the 10th moderate to publicly threaten to oppose the budget after leadership rebuffed her efforts to negotiate privately on scheduling the infrastructure vote and de-linking it from reconciliation.
One of the things Murphy and others successfully pushed for is to have the House pre-conference the reconciliation package with the Senate. The moderates want to ensure whatever the House passes can get the support of all 50 Senate Democrats, with Vice President Kamala Harris able to break a tie.
“We’re not going to vote on a measure that doesn’t have 51 votes in the Senate,” Costa said.
The reconciliation package won’t be ready to assemble until the House committees finish their individual markups, the last of which are expected to wrap up by the nonbinding Sept. 15 deadline written into the budget resolution. It’s likely to take more than a week to get Democrats in both chambers to unify around a final product, especially with Sen. Joe Manchin III, D-W.Va., calling to “hit the pause button” on the measure given a variety of economic unknowns.
One thing that could take some time is getting the Senate parliamentarian to issue opinions on which provisions comply with the Byrd rule, named for its author, former Sen. Robert C. Byrd, D-W.Va. The rule requires policies included in reconciliation to have a budget impact that is not just “merely incidental,” among other stipulations.
There are several policies Democrats want to include that Republicans are likely to challenge under the Byrd rule, like providing a path to citizenship for millions of undocumented immigrants, extending Medicare-negotiated prescription drug price limits to private insurers and taxing carbon-intensive imports.
Moderates want any language that doesn’t comply with the Senate rules removed before the House votes on it, unlike in March when the House passed a coronavirus relief measure including a provision to raise the minimum wage that was stripped in the Senate after the parliamentarian deemed it merely incidental.
The group of 10 moderates, plus allies who never took their concerns public in the budget fight, are also planning to make sure the House doesn’t assemble a package that’s too big to get through the Senate. Manchin and fellow moderates Sen. Kyrsten Sinema of Arizona have said they won’t support the $3.5 trillion topline leadership and the White House have set.
The House centrists are working with their Senate counterparts to identify “what revenues are acceptable and where spending should be,” Murphy said. “We are having these conversations, irrespective of what our committees and the committee staff are doing.”
But Murphy, the only member of the moderate group who serves on the tax-writing Ways and Means panel, communicates regularly with committee staff and leadership about what policies are unlikely to get enough moderate votes. “I think it’s my responsibility to send up an early signal,” she said.
If moderates’ input isn’t incorporated in committee markups, they will have leverage to influence the final product before it reaches the floor. They’re prepared to reluctantly oppose the reconciliation package or the House rule that will be needed to bring it to the floor as a last resort.
“My hope is that leadership is open to all the voices within their caucus, so that we can avoid any last-minute scrambles,” Murphy said.
Progressives want infrastructure and reconciliation bills linked so moderates can’t sink or water down the latter.
Democrats are staring down a nightmare September, a month jam-packed with deadlines and bruising fights over their top priorities.
The numerous legislative challenges in a condensed timeline will test Democratic unity and provide plenty of opportunities for Republicans to lay political traps just a year out from the 2022 midterm elections, where they are feeling increasingly bullish about their chances.
When lawmakers return to Washington, they’ll have to juggle averting a government shutdown in a matter of days with Democrats’ self-imposed deadline for advancing an infrastructure and spending package that is at the center of President Biden’s economic and legislative agenda and sparking high-profile divisions.
That’s on top of a looming decision about the debt ceiling, a voting rights clash set to come to the Senate floor in mid-September, lingering Afghanistan fallout and, in the wake of a controversial Supreme Court decision, a heated fight over abortion.
“I think it’s a full agenda,” Sen. Dick Durbin (D-Ill.) told The Hill.
Sen. Tim Kaine (D-Va.) added that the Senate’s schedule would be “crowded” but that they were “getting used to working weekends and we’re going to continue to.”
Senators are scheduled to return to Washington on Monday, though they’ll only be in for three days that week because of Yom Kippur, the Jewish holiday. The House is set to return on Sept. 20.
That leaves Democrats little time to finalize a massive $3.5 trillion spending package before key deadlines set by leadership in both chambers.
Senate Majority Leader Charles Schumer (D-N.Y.) has given his committees until Sept. 15 to finalize their parts of the spending package so that Democrats can then start negotiating the bill within the 50-member caucus.
And, as part of a days-long standoff, House moderates got a commitment to bring up the other piece of Biden’s package, a roughly $1 trillion Senate-passed infrastructure bill, for a vote by Sept. 27, just days after they return from a weeks-long summer break.
But Democrats are still trying to lock down how to pay for the package, bridge divisions on shoring up the Affordable Care Act and expanding Medicare, draft immigration reform language and iron out sections on climate change.
There are already high-profile warning signs amid simmering tensions between moderates and progressives — neither of whom Schumer or Speaker Nancy Pelosi (D-Calif.) can afford to lose if they are going to get the two bills to Biden’s desk.
Sen. Joe Manchin (D-W.Va.) threw the latest wrench into the $3.5 trillion package when he called for a “pause” on the bill last week and warned that he likely couldn’t support the price tag. In a 50-50 Senate, and Republicans unified in opposition, Democrats can’t afford to lose Manchin.
“Let’s sit back. Let’s see what happens. We have so much on our plate. We really have an awful lot. I think that would be the prudent, wise thing to do,” Manchin said at a West Virginia Chamber of Commerce event on Wednesday.
“I know they’re going to go nuts right now … because what I said is going to all my caucus in Washington,” Manchin added, referring to his Democratic colleagues. “But I’m thinking of it from the standpoint of where we are as a nation today.”
Sen. Kyrsten Sinema (D-Ariz.) has also warned repeatedly that she doesn’t support a $3.5 trillion top-line figure.
Both Sinema and Manchin have urged the House to move the $1 trillion bipartisan bill separately.
But any push to go below $3.5 trillion, or delay the timeline for passing the bill, is a nonstarter for progressives, who quickly rejected Manchin’s suggestion.
Senate Budget Committee Chairman Bernie Sanders (I-Vt.) called rebuilding the country’s physical infrastructure “important” but said making improvements to health care, education and combating climate change was “more important.”
“No infrastructure bill without the $3.5 trillion reconciliation bill,” he said.
Outside groups are also urging activists and progressive lawmakers to steel themselves for a heated fight with their own party over the $3.5 trillion package.
“We are in a powerful, but precarious place—we passed the budget resolution with all our progressive priorities still on the table, but still have a race to the finish line as major corporations invest millions in a major lobbying blitz,” the progressive groups wrote in a memo.
The Democratic deadlines over voting on the infrastructure package are set to collide with an end-of-the-month deadline to fund the government.
Congress has until Oct. 1 to pass government funding bills to prevent a shutdown. While the House has passed nine of the fiscal 2022 government funding bills, the Senate has passed none. Senate Republicans have warned they won’t help pass the full-year bills without a deal on top-line spending numbers, an equal increase in defense and nondefense funding and an agreement to avoid politically controversial policy riders.
Instead, lawmakers are likely to use a continuing resolution, a short-term bill that continues current funding levels, into late November or December to keep the government running.
The continuing resolution could also be an attempted vehicle for raising the debt ceiling, which would effectively dare Republicans to either support a debt hike or risk a government shutdown. The Treasury Department is currently using so-called extraordinary measures to keep the country solvent but is expected to hit a wall sometime this fall.
Republicans have warned that they won’t help raise the debt ceiling, either on its own or if it’s attached to something, because Democrats are planning to sidestep them to try to pass their $3.5 trillion plan.
Democrats need at least 10 GOP votes in order to increase the nation’s borrowing limit. But 46 GOP senators signed a letter late last month vowing to oppose it, writing that “this is a problem created by Democrat spending. Democrats will have to accept sole responsibility for facilitating it.”
Democrats could raise the debt ceiling on their own as part of the $3.5 trillion spending package. But they left it out of their budget instructions, arguing that it should be bipartisan.
“The White House and Janet Yellen preferred it be done outside of reconciliation, to keep it bipartisan, stop making this a partisan issue because it’s fraught with peril. Mitch McConnell seems to want to do that. I don’t think he’ll succeed,” Schumer told reporters last month, referring to the Senate Republican leader.
Amid the spending fights, Schumer has also teed up a voting rights brawl that Democrats are hoping will move their holdouts on changing the chamber’s legislative filibuster.
Republicans previously blocked the For the People Act, a sweeping bill to overhaul federal elections, from getting the 60 votes needed to start debate.
Democrats are hoping that they’ll have a voting rights bill ready by the time they return that could unite all 50 Democrats. But even if they did, they don’t have the 50 votes needed to nix or pare back the legislative filibuster.
Schumer hasn’t taken a public stance on filibuster reform but argued that his caucus shouldn’t let Republicans prevent them from acting.
“Republicans refusing to support anything on voting rights is not an excuse for Democrats to do nothing,” Schumer said after Republicans blocked a quick start to the voting rights debate as senators bolted from the Capitol for the recess.
Congress’s long to-do list has only expanded over the break following the botched Afghanistan withdrawal and a Supreme Court decision allowing a Texas law that bans abortions after six weeks to remain in place.
Lawmakers, including Democrats, are vowing to grill administration officials over the Afghanistan exit, where the administration was caught off guard by the Taliban’s quick rise and overestimated both the Afghan government and military.
Though Democrats largely agree with Biden’s ultimate endgame, withdrawing U.S. military forces, the president has found little cover from Democratic lawmakers over his handling of the exit.
“The U.S. Senate Armed Services Committee should quickly begin investigating the rapid collapse of the Afghan government and forces after two decades of American investment of resources and troops, and why we were unable to better anticipate it,” Sen. Tammy Duckworth (D-Ill.) said in a statement.
Pelosi, meanwhile, added the abortion fight to the House agenda after the Supreme Court decision.
“Upon our return, the House will bring up Congresswoman Judy Chu’s Women’s Health Protection Act to enshrine into law reproductive health care for all women across America,” Pelosi said, referring to legislation that would codify Roe v. Wade.
The Senate Judiciary Committee has also vowed that it will hold a hearing on the Supreme Court’s “shadow docket,” which the justices have increasingly used to issue decisions on weighty cases on an emergency basis.
But the fight could also reignite Democratic tensions. The same bill has only 48 Democratic supporters in the Senate, where progressives are renewing their calls to nix the filibuster and expand the Supreme Court.
Sen. Tina Smith (D-Minn.), while saying she agrees with those goals, warned that both would fall short among Democrats in the Senate.
“The reality is that if a vote was brought up tomorrow to change or eliminate the filibuster or reform or add seats to the Supreme Court, it would fail,” Smith wrote in a string of tweets. “I wish it were different. We don’t have the numbers and that’s what we have to focus on changing.”
The Covid-19 pandemic is the nudge the Medicare and Medicaid agency needed to rethink what quality measures it asks providers to report, health policy experts said.
The industry is questioning the utility of having so many quality measures at a moment when doctors and resources are stretched thin. Providers said the measures can be easy to game and arduous to report, and they’re expensive for themselves and the government. Studies have shown some measures may not lead to higher quality care.
The Centers for Medicare & Medicaid Services spent more than $1.3 billion on quality measure development between 2008 and 2018, according to a 2020 study published in the JAMA Network Open. The measures translate to more than $15.4 billion in spending for physicians, with providers in common specialties spending more than 15 hours per physician per week on quality reporting, according to a 2016 study published by Health Affairs.
“There’s an emerging medical term called ‘pajama time,’” said Richard Dutton, chief quality officer for U.S. Anesthesia Partners. “You take care of patients all day, but then, when you go home, you have to spend a couple of hours in front of the computer in your pajamas doing all the documentation,” Dutton said. Reporting these measures is “very redundant, very bureaucratic, and not really helping patient care.”
Providers paid by the CMS are incentivized to report certain metrics about the quality of care they deliver, which determines whether they gain or lose funding. The 729 measures that providers must report back to the agency as part of quality programs reflect the health-care industry’s shifting focus from payment for quantity of services to value-based payment for quality of services.
“Now we have the right constellation of historical moment and circumstance” to allow the CMS to engage in quality measurement reform, said Kedar Mate, president and CEO of the Institute for Healthcare Improvement.
“We don’t have a whole lot of time, or energy, or money to waste,” Mate said, so the CMS needs to focus on “capturing measures that really matter to people.”
More useful measures tend focus on patient outcomes, Mate said, such as the percentage of patients who die 30 days after being admitted for a heart attack. Measures reported by patients are also valuable—for example, a patient’s functional status after a hip replacement. By contrast, process-oriented measures, such as whether a patient was discharged on a cholesterol-lowering drug, are less helpful, Mate said.
The CMS is developing an initiative that builds on previous efforts to curb the number of measures providers must report. The initiative will focus on prioritizing patient outcomes and making measures totally digital by 2025, according to the agency.
“CMS continues to evaluate its quality measurement strategy incorporating lessons learned from the COVID-19 pandemic,” a CMS spokesperson said.
Improving outcomes for patients lies at the heart of any quality measure, said Tricia Elliott, senior managing director of National Quality Forum, an organization that evaluates and endorses some CMS quality measures.
Such measures can be reported to the public, allowing patients, caregivers, and even clinicians to make better-informed decisions, said Laura Smith, senior research public health analyst for the Quality Measurement and Health Policy Program at research firm RTI International.
About 97% of eligible doctors participated in the CMS’ Merit-Based Incentive Payment System in 2019, according to a 2020 report. The MIPS program, one of the CMS’ central quality payment programs, rewards doctors who provide high-quality care and penalizes those who don’t. Participation in the program has beaten the CMS’ expectations, leading to modest payouts for doctors.
Measuring quality of care is in line with the Biden administration’s priority to close health equity gaps. It also infuses clinicians and health system leaders with “more vigor” to try and tackle injustices in the health-care system, Mate said.
The CMS recently solicited feedback on several quality measures that would close equity gaps related to race, ethnicity, and other factors. “In general, health-care facilities are very supportive of measures and programs to advance equity,” a CMS spokesperson said.
Providers said that while some measures inform their practice and leave patients better off, others are an exercise in box-checking.
A recent study, also published in the Journal of the American Medical Association, found that physician MIPS scores using self-selected quality measures are “at best, only weakly associated with hospital performance.”
Tying financial incentives to quality improvement can inspire gamesmanship. “People are going to choose the measures that they’re already doing well in to get credit, even though what they really should do is focus on what they’re not doing well at,” said Kerin Adelson, chief quality officer and deputy chief medical officer at the Yale Cancer Center and Smilow Cancer Hospital.
Some measures get topped out, with median performances at over 95%, the CMS said. “If everybody’s above average, it’s impossible to use the measure to sort out good doctors and bad doctors,” Dutton said.
Giving providers a “supportive learning environment” before incentivizing them with payment could promote better outcomes. Most clinicians are “driven largely by intrinsic desire to get better,” Mate said.
The CMS regularly solicits feedback from stakeholders on how quality reporting is working for them. The agency also evaluates measures annually to determine if they should be phased out using eight metrics, including whether a measure is topped out, if it improves outcomes, and if the cost of collection outweighs the benefits, a CMS spokesperson said.
The CMS has cut the number of quality measures by 18% since it launched a 2017 initiative under the Trump administration to reduce the number of quality measures, projecting a savings of $128 million.
The initiative’s next phase will “shape the entire ecosystem of quality measures that drive value-based care,” by addressing gaps in health care and creating measures that “reflect social and economic determinants,” the agency said. The CMS is soliciting feedback on the initiative, which has not been finalized.
The CMS made most quality measure reporting optional for the first half of 2020, as Covid-19 cases and deaths climbed, “to allow providers to focus on patient care,” a CMS spokesperson said.
Hospital staff that help with measurement reporting were often pulled to other tasks that more directly supported caring for Covid-19 patients, Elliott said. “It was appropriate for the quality measurement to kind of take a step back, a pause, so that the industry could really adjust to this new situation,” Elliott said.
The agency brought back most of the requirements in the latter half of the year with some flexibilities to support providers. The CMS also “finalized multiple rules around measure suppression for payment purposes if data demonstrated a significant impact from Covid-19,” a CMS spokesperson said.
The industry still doesn’t know what the impact of this period of missing data will be, Smith said, so the CMS should not rush to throw out measures that took many years to “identify, design, and implement.”
The pandemic has accelerated the development of electronic health records, Elliott said, and showcased “the need for some real-time information” about treatment quality. Measures are also “becoming more robust” as they digitize, representing entire populations rather than individual physicians, which reduces the burden on providers and makes them more difficult to game, Elliott said.
The CMS will continue working with stakeholders to “identify measures that are meaningful to providers, reduce reporting burden, enhance transparency and data sharing, and empower beneficiaries and their families to make informed decisions about their health care,” a CMS spokesperson said.
Mate said he hopes this period of innovation driven by the pandemic and racial justice advocacy “is not a blip” and that the industry doesn’t “go back to doing things the way we’ve always done them.”
“This is a different time, a different moment,” Mate said, and the industry now has the opportunity to “focus on what really matters.”
The industry is questioning the utility of having so many quality measures at a moment when doctors and resources are stretched thin.
Slide Deck: Drug Pricing Bills
Allowing Medicare to directly negotiate the price of prescription drugs is a top priority for Democrats as lawmakers craft their budget reconciliation bill, though the details are still undetermined.
The House Energy and Commerce Committee held a hearing on drug pricing bills in May, including H.R. 3, a similar Medicare price negotiation bill to one the chamber passed in 2019, largely along party lines.
The previously passed price negotiation bill was estimated to save $456 billion over a decade, and Democrats want use these savings for their other health-care priorities, such as expanding Medicare coverage. The reconciliation process allows Democrats to pass legislation without Republican support, though there are limits on the types of provisions that can be included.
House and Senate committees have also considered more bipartisan efforts aimed at lowering drug prices by easing market entry for generic drugs, including a Senate Judiciary Committee mark up in July.
The attached presentation reviews bills related to Medicare price negotiations and generic drugs, as well as potential next steps in Congress.
Health care stakeholders are divided on whether CMS can stand up a new Medicare Part B dental benefit in less than three to five years, but say a variety of interim measures could help provide coverage if doing so takes time. Meanwhile, dental plan and dentist associations are pushing instead for a stand-alone, opt-in Medicare dental benefit they say could be created in roughly two years.
Democratic lawmakers are angling to add comprehensive dental benefits to Medicare Part B through the $3.5 trillion budget reconciliation package likely to be voted on later this year. The lawmakers also want to add hearing and vision coverage to Part B.
Adding these benefits is extremely popular with voters across party lines, and getting coverage passed and implemented could be an important political talking point for Democrats going into the 2022 midterms and 2024 presidential election.
But most dental providers aren’t enrolled in Part B right now, and dental care would require an entirely different set of codes. CMS believes enrolling providers and figuring out the rest of the administrative details would take between three and five years, stakeholders told the Washington Post Thursday (Sept. 2). CMS did not respond to Inside Health Policy’s inquiry in the issue.
Melissa Burroughs, associate director for strategic partnerships at Families USA, said she’d give the same timeframe if she were CMS administrator.
But realistically, she believes a Medicare dental benefit could be set up faster. The technical considerations might not take as long as CMS estimates, but that also depends on how Congress decides to phase in the benefit, she said.
Some people on Capitol Hill have discussed phasing in a preventative benefit first, Burroughs said. If the benefit is straightforward and robust, lawmakers could structure the rollout so only part of the benefit needs to be up and running at first, and more can be added on later. That’s the strategy Families USA is hoping Congress will take, she added.
Additional options on the table for phasing in a dental benefit include starting the benefit at only covering 10% of all services and gradually increasing that coverage, as well as offering vouchers for Medicare beneficiaries to purchase private coverage as the Medicare program is set up, Burroughs said.
Others are less optimistic CMS could stand up the benefit in less than three to five years.
One health lawyer said he doesn’t see how it’s possible to cut that time down, given all the moving parts CMS would need to work out in order to operationalize the benefit.
Offering beneficiaries vouchers for private dental insurance would be a great way to provide coverage in the meantime before the next election cycle, the lawyer said.
Wey-Wey Kwok, senior attorney at the Center for Medicare Advocacy, said she couldn’t speculate about whether CMS could get a dental benefit ready faster but said it will take considerable time to prepare a comprehensive benefit that works for beneficiaries. CMA wants to see Medicare cover more medically necessary coverage in the meantime, Kwok said.
Sen. Ben Cardin (D-MD), one of the lawmakers leading the push for Medicare dental benefits, also continues to urge the Biden administration to administratively expand Medicare’s definition of medically necessary dental coverage, he said in a statement to Inside Health Policy. Congress could theoretically bring down the price tag of adding a Part B dental benefit by broadening medically necessary coverage.
Meanwhile, the American Dental Association and the National Association of Dental Plans are both lobbying Congress for an alternative Medicare dental benefit, dubbed Part T, that beneficiaries could opt into. They say a Part B benefit would restrict private market offerings and be generally difficult to implement.
The Part T benefit would be structured similar to Part D coverage. The ADA would like to see this benefit available only to lower-income Medicare enrollees, though NADP says it should be open to any beneficiary.
NADP staff said during a recent presentation on its Part T proposal to insurance stakeholders that setting up Part T would be faster and potentially cheaper than a Part B dental benefit.
Based on the experience plans already have in developing networks, recruiting providers and clearing administrative hurdles around setting up dental benefits, NADP thinks a Part T benefit could be rolled out in about two years, a staff member said.
However, Burroughs and other stakeholders say lawmakers aren’t seriously considering adopting a Part T model at this time. NADP staff also said folks on Capitol Hill seem to be focused on crafting a Part B benefit, though some lawmakers are concerned about how to deal with people who already have private coverage and the effect such a policy could have on Medicare Advantage plans.
White House science advisers on Friday called for the creation of a $65.3 billion overhaul of the nation’s pandemic preparedness infrastructure to protect against the “reasonable likelihood” of another serious pandemic in the years ahead.
“The next pandemic will very likely be substantially different than Covid-19, so we must be prepared to deal with any type of viral threat,” Eric Lander, director of the White House Office of Science and Technology Policy, told reporters.
The details: The new plan calls for having the capability to do routine genomic sequencing of samples from patients with an unexplainable fever or respiratory disease to more quickly detect emerging threats, and creating data systems that share real-time information. Other cornerstones of the effort include strengthening global R&D standards for “potentially dangerous biological agents” and deterring the development of bioweapons.
In the event of an emerging pandemic, officials want the U.S. to be able to develop and deploy daily at-home diagnostic tests within weeks and design, test and review candidate vaccines within 100 days. Funding would be directed toward researching therapeutics that can be used to target any family of viruses and bolster the nation’s ability to rapidly manufacture monoclonal antibodies at scale.
Other priorities include refilling stockpiles, building “onshore and near-shore” manufacturing facilities for essential medical supplies and establishing the ability to surge production of personal protective gear.
The effort would resemble the Apollo space program, with a centralized “Mission Control” housed at the Department of Health and Human Services tasked with overseeing funds, developing program goals and coordinating efforts across government, academia, philanthropy and the private sector. The command hub would draw on experts from the National Institutes of Health, Centers for Disease Control and Prevention, Food and Drug Administration, Centers for Medicare and Medicaid Services, Biomedical Advanced Research and Development Authority and other agencies.
Funding considerations: The Biden administration is in discussions with congressional leaders to include $15 billion dollars for the overhaul in the forthcoming reconciliation bill, according to Lander. Additional appropriations would be sought in the future to fund the total cost of the decade-long plan.
The new proposal is a “central piece” of the Biden administration’s vision for building better biological preparedness and builds on efforts like the establishment of a Center for Forecasting and Outbreak Analytics at CDC, according to Beth Cameron, the White House National Security Council senior director for global health security and biodefense.
CMS’ incomplete, inaccurate data on COVID-19 cases, deaths and availability of personal protective equipment in nursing homes could hinder the government’s response to hot spots, HHS Office of Inspector General found in a report released Friday (Sept. 3). Nursing homes and resident advocates support the OIG’s suggestions that CMS improve the quality of data and align that data with state data, but CMS says it doesn’t have the authority to standardize data with the states.
CMS in April of 2020 required nursing home facilities to weekly report COVID-19 data to the Centers for Disease Control and Prevention. CMS publishes that information online, including case counts, deaths of residents and staff, and supplies of protective equipment and ventilators.
But a House Ways & Means investigation found large gaps in CMS’ COVID-19 data, making it difficult to assess death rates and staffing needs and to allocate provider relief funds. An independent commission said it’s not worth the effort to report data if it isn’t being used to fix problems such as protective equipment shortages.
The OIG report released Friday found about 5% of the 15,388 nursing homes had incomplete or inaccurate data on COVID-19 cases after CMS performed its quality assurance checks. These checks are meant to reduce misrepresentation and inaccuracies in the data, but OIG staff found they didn’t always catch errors.
“When CMS’s COVID-19 data are complete and accurate, Federal and State officials and other stakeholders may be able to more effectively monitor trends in infection rates and develop public health policies when making decisions about how to ensure the health and safety of nursing home residents and staff,” OIG’s report says. “Incomplete or inaccurate data could delay CMS’s ability to detect and respond to an emerging COVID-19 hotspot, such as a surge or resurgence of COVID-19 cases in a community.”
The OIG report also shows CMS does not contact all nursing homes that failed quality assurance checks, so some facilities might not know they may need to verify and revise their reported data. CMS didn’t set up processes to identify which nursing homes submitted partial data and didn’t create a protocol to reach out to nursing homes to ask them to send CMS the complete information.
OIG recommends CMS provide technical assistance to nursing homes that fail quality assurance checks and suggests the agency collect the same data that states collect.
Standardized reports might improve stakeholder trust in the information. Differences in CMS’ and states’ COVID-19 data can make it confusing to lawmakers and advocates who then have to figure out which set of data they should rely on.
The American Health Care Association/National Center for Assisted Living agrees streamlined collection of standardized data would improve the value of the information.
“Our nursing home staff need to be focused on taking care of their residents,” AHCA said in an email. “We must also focus on using this data to help direct resources to nursing homes in need.”
CMS agrees with half of OIG’s six recommendations. It disagrees with the standardizing data recommendation.
“We understand that CMS does not have the authority to mandate that States align COVID-19 data elements in their own reporting systems with Federal reporting requirements,” the OIG said. “However, CMS, CDC, and State health departments may be able to work together, to the extent possible, to use comparable data elements and monitor substantial differences in CMS’s COVID-19 data and States’ data.”
CMS asked OIG to remove the last two recommendations, saying the CDC corrected errors the OIG identified with the death rates and suspected COVID-19 case counts.
While this corrects the future information, the OIG said CMS needs to verify previously reported data on deaths and case counts.
The OIG found in June about 40% of Medicare beneficiaries in nursing homes had, or probably had, COVID-19 — dually eligible residents and Black, Hispanic and Asian beneficiaries had higher infection rates than whites.
As Congress’s self-imposed Sept. 15 deadline to ready a massive reconciliation package approaches, several health care stakeholders, including hospital associations and the American Heart Association, have sent priority lists to Congressional leadership, and lobbyists expect more to come next week. Sources have also heard that the House Ways & Means committee will mark up its piece of the bill on Sept. 9 and Energy & Commerce will do the same on Sep. 13, however, one source says the dates are placeholders and neither committee could confirm by press time.
Sources also see the Sept. 15 deadline included in the budget resolution as relatively soft, and would not be surprised to see the final language or a vote held until later this year. In addition to writing the specific language, Democratic leadership must also nail down the cost of the bill, which has a $3.5 trillion limit on paper. Several moderates, including West Virginia Democratic Sen. Joe Manchin, have already made clear they will not support that much spending, and final number could fall into the $2 trillion range, say sources tracking the talks
Already, Democratic staff have said conceded that the $400 billion investment in home-and-community based care will fall to $250 billion. Staff are also working to find a less expensive way to include dental, vision and hearing coverage in Medicare — which could mean a later start date for the benefits. The package is also expected to include an extension of the increased Affordable Care Act tax credits enacted under the American Rescue Plan, but how long is unclear. It will likely also include a mechanism for closing the Medicaid gap, either by extending subsidies to the population that earns less than 100% of poverty, creating a federally backed Medicaid program, or a combination of the two. Health care stakeholders are also pushing for Medicaid policy changes like increased post-partum coverage, allowing continuous enrollment in Medicaid and more. Additionally, stakeholders say Congress should use the opportunity to support the health care workforce and lay the groundwork for better pandemic preparedness. Stakeholders also want lawmakers to tackle prescription drug costs. The hospitals further urge Congress to avoid taking money from their industry.
In its letter, the American Heart Association stressed the need to maintain the increased ACA tax credits beyond the 2022 end date to prevent consumers from facing sudden price increases. The lobby says the policy — which increased credits for existing consumers and extends them to people earning more than 400% of poverty — should be made permanent. The American Heart Association also asks Congress to fix the glitch that blocks families from accessing subsidies if a worker is offered a plan that is affordable, even though the affordability threshold is based on self-only coverage.
The lobby calls on lawmakers to encourage all states to expand Medicaid by providing 100% federal funding for the first three years for any states that choose to expand. The American Heart Association strongly supports expanding Medicare to include dental, vision and hearing, saying it is a critical step to achieving health care equity. “Oral health care is a key determinant of economic stability, continued employment opportunities, improved social connectedness, and overall health and wellness,” the group writes. The lobby also urges Congress to tackle the high costs of prescription drugs.
The American Hospital Association also wants the ACA tax credits extended and for health care to be provided for everyone in the non-Medicaid expansion states. AHA does not specifically ask Congress to extend ACA subsides to that population, rather than create a federal Medicaid program, which the Federation of American Hospitals does. AHA’s letter also avoids any mention of extending Medicare benefits.
AHA also sidesteps any talk of allowing Medicare to negotiate prescription drug prices, but stresses that the drug costs are a major concern as they disrupt care and strain hospital budgets. “The AHA is committed to working for action on policies that foster transparency, competition and value while preserving innovation,” they lobby writes.
AHA further calls for temporary relief for any 340B hospital that had to leave the program due to changes in patient mix caused by the pandemic.
AHA calls on Congress to prioritize cybersecurity and telehealth, encourage delivery system reforms, secure the health care supply chain and help prepare for future crisis.
Finally, the hospitals say that “as Congress looks for offsets for important reconciliation policies, the AHA urges Congress to avoid consideration of any provider reimbursement cuts that would further strain financial resources for hospitals and health systems.”
“America’s hospitals and health systems are providing essential services to their patients and communities during this pandemic, all while facing their greatest financial crisis,” AHA says. “COVID-19-related expenses are skyrocketing, including for personal protective equipment, pharmaceuticals and safety equipment, maintaining testing and additional screening for every hospital patient.”
Staffing shortages are also acute which is driving up costs, AHA says.
America’s Essential Hospitals, which represents the country’s safety-net hospitals, includes help for staffing shortages as a top legislative priority. In the letter to Congress that includes its wish list for the reconciliation package and other vehicles moving this fall, the lobby asks lawmakers to consider emergency funding to support the essential workforce.
The hospitals also support measures to lower drug pricing, but they urge Congress to consider how any changes would affect the 340B program.
“Drug pricing reform must recognize potential ramifications on existing safety net supports for essential hospitals,” the group says.
“Lawmakers must consider how proposed drug pricing policies would interact with the 340B program and ensure those policies would not undermine the benefit of this critical lifeline, especially as essential hospitals continue to respond to the challenges presented by COVID-19. We ask Congress to reject policies that would require Medicaid managed care plans to pay for outpatient drugs at actual acquisition cost. Such a policy would drastically reduce 340B savings for some providers in the program. If, however, drug pricing reforms ultimately do reduce the value of the 340B savings to essential hospitals, it will be critical to issue another form of funding to ensure our members can continue to innovate and respond to the unique care challenges and needs of marginalized populations,” it adds.
The lobby also urges Congress to include in any legislative vehicle a technical fix that ensures the new definition of Medicaid shortfall does not disadvantage safety net hospitals.
The Biden administration unveiled a $65.3 billion plan to prepare for future pandemics threats, likening the ambitious proposal to the Apollo mission to the moon.
The proposal announced Friday by the White House Office of Science and Technology Policy and National Security Council focuses on protecting the U.S. against potentially catastrophic biological threats, including those that are naturally occurring, accidental or deliberately set in motion by bad actors.
“There’s a reasonable likelihood that another serious pandemic that could be worse than Covid-19 will occur soon, and possibly even within the next decade,” Eric Lander, director of the Office of Science and Technology Policy, said in a briefing with reporters. “For the first time in the nation’s history, we have the opportunity — due to these kinds of advances in science and technology — not just to refill stockpiles, but transform our capabilities.”
White House Taps Vaccine Leader in Pandemic Preparedness Push
Given the toll the Covid-19 pandemic has taken on American lives and the U.S. economy, Lander added, “We really need to start preparing now.” The proposal also points to the quickening pace of the emergence of new infectious diseases due to population growth, climate change and habitat loss as a reason to launch the effort now.
The White House’s move underscores the contrast with the administration of former President Donald Trump, whose National Security Council in 2018 eliminated a unit that oversaw planning for future pandemics.
The Biden administration said the funds should be “appropriated to a single, unified ‘Mission Control’ office” at the Department of Health and Human Services over the course of seven to 10 years, according to the strategy document, which was released Friday afternoon. The office is intended to emulate other efforts that have drawn expertise from multiple government agencies, including President John F. Kennedy’s Apollo program, which landed the first humans on the moon in 1969.
“Like any ambitious endeavor, whether it’s going to the moon with the Apollo mission or cracking the human DNA with the Human Genome Project, an effort like this will take serious sustained commitment and accountability,” Lander said.
Any funding would need to be appropriated by Congress. The plan, called “American Pandemic Preparedness: Transforming Our Capabilities,” recommends:
“It’s vital that we start with an initial outlay of $15-to-$20 billion to jump-start these efforts,” Lander said. “We’re proposing the current budget reconciliation provide at least $15 billion toward this goal.”
The Biden administration calls the investment a drop in the bucket. The U.S. spends $170 billion per year on preventing terrorism, according the proposal, which suggests that “it’s hard to imagine a higher economic — or human — return on national investment” than such a preparedness plan.
Bloomberg first reported on Friday morning that the OSTP would lead efforts to create a new pandemic preparedness office.
As a part of that new venture, the White House tapped Matthew Hepburn, the director of Covid vaccine development for the Countermeasures Acceleration Group, formerly known as Operation Warp Speed, according to people familiar with the matter.
Starting Oct. 1, Hepburn will begin serving as a direct-report to Lander, building out the U.S. government’s vaccine, therapeutic and diagnostic capabilities, among other objectives outlined in the proposal.
The people, who asked not to be named as all the details of the plan aren’t yet public, said the OSTP would provide oversight of the dispersed biodefense funding. Hepburn’s full-time position will focus on managing the “American Pandemic Preparedness” agenda across HHS’s various agencies.
The Covid-19 pandemic has made it apparent that the nation’s medical supply chains are in need of an overhaul and additional funding. Health workers were unable to get enough personal protective equipment for much of the pandemic and hospitals are still struggling to get enough oxygen.
The proposal reflects on those shortcomings and outlines five areas of “urgent need” of investment, including expanding the arsenal of pharmaceutical and diagnostic products, bolstering monitoring of infectious disease threats, improving emergency-response, replenishing protective equipment and managing the multipronged biodefense effort.
Through the plan, the Biden administration would aim to develop a successful vaccine for “any human virus” within 100 days in which a pandemic threat is identified, and produce enough supply for all the U.S. within 130 days.
The proposed office would also be tasked with securing simple, inexpensive diagnostic tests that can be deployed at large scale within weeks of a viral threat being detected. It will also develop those detection and monitoring capabilities, according to the plan.
Finally, the office will refill stockpiles that have been depleted by the Covid-19 pandemic, as well as create secure supply chains by having more U.S.-based manufacturing capacity. To address the PPE shortages, the office would work to develop new types of masks, gowns and other supplies.
The office’s purpose would be mainly focused on domestic preparedness improvements but would involve working globally to prevent laboratory accidents, a topic that has received renewed focus because of the uncertainty over how Covid-19 started.
Home health provider associations are worried that CMS’ proposed way of analyzing home health behavioral adjustments, aimed at keeping the revamped pay system budget neutral, could lead to big cuts down the road even though CMS is suggesting no new cuts to payment for 2022. The providers say CMS’ proposed method is contrary to Medicare law, but they aren’t yet considering legal action.
CMS in 2020 began paying home health agencies through a new system known as the patient-driven groupings model (PDGM), which aims to cut down on unnecessary therapies and focus more on patient clinical characteristics. The model also changed to reimbursing agencies based on 30-day periods of care and created 432 case mix payment groups, different multipliers that get applied to base pay rates according to a patient’s circumstances.
The new payment model needs to be implemented without impacting the overall budget. CMS assumes PDGM will make home health providers change coding practices to log the highest-paying code, adjust payments based on patients’ secondary diagnoses, and visit a patient more than might be necessary so they can get full payment for an episode of care.
The agency can adjust base payment based on these behavioral assumptions to keep the program budget neutral. This led to a 4.36% cut to home health providers’ base pay in the 2020 rule to offset assumed spending increases by home health providers.
CMS in the 2022 proposed rule says it would like to keep this 4.36% cut in place for another year but presents an analysis of the first year of PDGM data and asks for feedback.
CMS’ analysis was based on using data from 30-day periods during 2020 to simulate 60-day episodes, and then figuring out what 2020 payments would have looked like under the pre-PDGM pay model.
This analysis led to the conclusion that base payment for home health agencies was 6% higher than it should have been in 2020.
The National Association of Home Care & Hospice said in comments on the proposed rule that the way CMS came to this conclusion is flawed. The stakes are high for home health agencies because if CMS continues to use this model, the overpayment percentage would just continue to rise, leading to steep cuts down the line, NAHC President Bill Dombi said.
NAHC said the method for determining base pay adjustment to keep the program budget neutral needs to be based on behavioral changes triggered by switching from the old payment model to PDGM — and NAHC feels CMS doesn’t incorporate that in the proposed rule. The methodology outlined in the proposed rule doesn’t evaluate how accurate CMS’ 2020 behavioral assumptions were, doesn’t look into the difference between real and nominal changes in case mix and fails to compare how much CMS spent under PDGM with what it would have spent in 2020 without PDGM, NAHC said.
“What’s ironic about it is if a new payment model is expected to change behavior, the existing model is also expected to affect behavior, and that’s what they missed in their methodology,” Dombi said, adding that 2020 behavior shouldn’t be applied to an old payment model because the new model would have materially changed provider actions when it comes to things like therapy visits.
NAHC believes CMS’ proposed method for figuring out whether PDGM spending is budget neutral goes against Medicare law because it is tied to changes in case mix weight, rather than assumed behavior changes.
“We just see their methodology as really off base,” Dombi said. “In fact, it doesn’t come close to what the law requires them to do.”
The Partnership for Quality Home Healthcare also thinks CMS’ approach is incorrect. CMS can’t just slot claims billed under a previous system into PDGM, the organization said in its comment letter. PQHH suggests CMS instead use 2018 60-day episode data, broken down into 30-day episodes. This gets rid of the need to incorporate changes due to implementing the PDGM and prevents having to get at the impact of COVID-19 on therapy utilization, the group said.
But Dombi said it’s too soon to threaten a lawsuit, and doing so likely wouldn’t make a difference to CMS. Joanne Cunningham, executive director of PQHH, said her organization hasn’t talked about levying a lawsuit against CMS, either.
PQHH also said CMS should take the 4.36% cut out of the final pay rule. The group commissioned its own analysis of all 2020 Medicare claims data for home health agencies, which found that home health providers aren’t actually acting in the way CMS has assumed they would respond to PDGM. Medicare payments are 5.76% lower than budget neutrality would dictate, according to the PQHH-sponsored analysis. Because of this, even the 4.36% behavioral adjustment isn’t justified, PQHH said.
“CMS’ authority to make and adjust for assumptions about provider behavior does not include using this mechanism to generate program savings, which appears to be the effect of the proposed rule,” PQHH said in its comment letter.
The one change to the PDGM that CMS does suggest for 2022 is recalibrating case mix weights based on 2020 data. CMS said this would better reflect PDGM utilization than the current weights, which were set using claims data from the old system.
But NAHC and PQHH are adamant that CMS should not make this change, since utilization data from the beginning of the COVID-19 pandemic likely won’t be comparable to how home health is used in 2022.
The Medicare Payment Advisory Commission could recommend that Congress provide immediate one-time or temporary payment rate increases to providers that suffered financially during the pandemic.
In the panel’s first meeting of its 2021-2022 cycle on Thursday, commission member Paul Ginsburg called for the recommendation and said it should be made along with the commission’s annual recommendations about Medicare payment updates.
“I think we’ll need to do both,” Ginsburg said, “because the pandemic’s effects have really been profound.” He said if the commission makes such a recommendation, it should be “implemented as soon as Congress can work them through.”
“I think we can accomplish more of value to the Congress by talking about what types of one-time adjustments appear to be justified by the data,” Ginsburg added. Commission members Amol Navathe and Stacie Dusetzina supported Ginsburg’s proposal.
The commission advises Congress on issues dealing with cost and quality in the Medicare program. Their recommendations are nonbinding, but Congress relies heavily on the panel’s expertise when making funding decisions.
Any commission recommendation for one-time payment hikes would follow billions of dollars in pandemic financial relief that physicians and clinicians have already received through the federal Provider Relief Fund, advance payment of Medicare billings, and the Paycheck Protection Program.
Ginsburg and commission Chairman Michael Chernew said any additional payment increases that Congress might approve would not be factored into data used to set subsequent provider payment rates.
Ginsburg made the proposal after commission staff discussed the difficulty the panel will face in making their annual payment update for 2023 based on program data from 2020—when Covid-19 drastically affected the type and amount of care sought by Medicare beneficiaries.
In 2020, Covid-19 impacted beneficiary mortality rates, caused a decline in volume of care sought by beneficiaries, created an increase in sicker, more acute patients, and created rising costs for providers, the staff said.
Commission Deputy Director James Mathews said there’s precedent for Congress to approve such a recommendation. In order to offset changes to billing codes, Mathews said Congress previously authorized a “separate bucket of dollars” that were allocated to physicians over three years that did not get figured into the determination of subsequent rate updates.
“This would definitely be atypical for us, no doubt about it,” Mathews said. “But we will keep it in mind as we start digging deeper into the data that we use for our assessment of payment adequacy.”
“There’s nothing we’re going to do that’s not going to be atypical,” Chernew said of the new cycle.
Tens of billions of dollars designated by Congress to help hospitals, nursing homes and other health-care providers stave off financial hardship in the coronavirus pandemic are sitting unused because the Biden administration has not released the money.
As many hospitals bulge again with covid-19 patients, a wide swath of the health-care industry is exasperated that federal health officials have not made available any more of the aid since President Biden took office. About $44 billion from a Provider Relief Fund created last year remains unspent, along with $8.5 billion Congress allotted in March for medical care in rural areas.
With the coronavirus’s delta variant fueling a fourth pandemic surge, health-care institutions, lobbyists and lawmakers have ratcheted up complaints to senior Biden administration health officials, imploring them to decide how the money will be divided and when it will be distributed.
“There’s just no good reason for the administration to be sitting on these funds,” said Mark Parkinson, president and chief executive of the American Health Care Association, a trade group that represents nursing homes and assisted-living facilities. Many are running short on money, he said, because the virus’s heavy concentration in long-term-care centers early in the pandemic is still causing potential patients and residents to stay away.
Parkinson said he has had four conversations since February with the agency in the Department of Health and Human Services that is in charge of the money, and one last month with senior aides to HHS Secretary Xavier Becerra.
“Each conversation, we came away with the feeling it would be that month,” Parkinson said. “And we’ve been wrong.”
The aid bottleneck is inconsistent with one of the first commitments Biden made when he took office in January. The day after he was sworn in, the president signed an executive order to make it easier for Americans to get treatment if infected with the novel coronavirus, saying his administration “shall promptly . . . provide targeted surge assistance to critical care and long-term facilities.”
Federal health officials declined to discuss reasons for the delay, but HHS said in a statement: “We continue to work expeditiously to get these funds out the door and will be announcing another distribution of funds soon. Plans are being finalized.”
Becerra has been asked repeatedly on Capitol Hill about the provider fund. In his most recent testimony, in June, he said that during the Trump administration, “there wasn’t enough transparency in the process, how the money was allotted. . . . We’re trying to provide that transparency, make sure we direct the money where it’s needed.”
The secretary did not address how the money could be redirected or when it might be released.
Pandemic relief laws that created the fund last year said the money should be used to help compensate health-care institutions and practitioners for extra expenses and loss of revenue attributable to the coronavirus. The laws do not specify how quickly the money must be spent.
About one-fourth of the $178 billion Provider Relief Fund remains, according to March and July reports by the Government Accountability Office, which urge HHS to tell Congress when it plans to give out the money.
Hospital executives and health-care advocates say the inaction this year has been especially problematic in parts of the country where the pandemic arrived relatively late.
That is because all of the money released so far was distributed on the basis of providers’ financial condition and coronavirus burden during the first half of 2020. That was useful for early hot spots, such as New York, while putting at a disadvantage hospitals and other sources of care in states such as Arizona, California and Texas, where surges of patients with covid-19, the illness caused by the virus, did not emerge until a summer ago.
The timing “has felt like a mismatch for us,” said Carmela Coyle, president of the California Hospital Association, which commissioned a consultants’ study that shows the state’s hospitals have received about $8 billion from the fund — about half of their losses.
The lack of federal money to help buffer the financial shock after June 2020 is hurting places such as Katherine Shaw Bethea Hospital in Dixon, Ill., a rural community about 100 miles west of Chicago that was Ronald Reagan’s boyhood home. Early last winter was the first time during the pandemic that KSB, as it is known, had more patients than beds. But its losses and expenses did not wait that long to manifest themselves.
Even before it received a single covid-19 case, the hospital lost 40 percent of its typical patients in spring 2020 as the state ordered a halt to elective surgeries and some people just stayed away. KSB spent $2 million on pandemic preparations: converting patient rooms to negative air pressure (a germ-containment measure), paying steep prices for scarce protective gear, and erecting a triage tent that turned out not to be needed.
KSB received nearly $14 million between April and June last year for the hospital and its physicians practice. And it accepted almost $11 million in spring 2020 in advance Medicare payments that it must now repay.
“I don’t want to seem non-grateful,” said David L. Schreiner, the hospital’s president and chief executive, “but it didn’t come close to what we needed.” Last summer, the Illinois hospital furloughed 124 of its roughly 1,000 employees and cut the pay of doctors and administrators by 10 percent.
Lately, KSB has been losing about $1 million a month as hopes for a return of other patients were thwarted first by the winter coronavirus surge and now by the fast-spreading delta variant.
The hospital just sold a building used for business offices and plans to move into rental space in October, saving about $10,000 a month. It has suspended plans to renovate obstetrics rooms. For the first time, it has taken out a line of credit.
The 80-bed hospital plans to cut some services, Schreiner said. He does not know whether to set it in motion. For months, he said, he has been waiting to find out whether KSB will get more provider-relief money or aid from the $8.5 billion in rural health aid that is part of the American Rescue Plan that became law in March. “It’s like there is a secret sauce that no one is sharing,” he said.
The stress from not knowing how much more federal help might arrive is “10 on a scale of 1 to 10,” Schreiner said. “Not knowing that, I have to assume it’s not coming, and I am hurting people — both patients and employees — by not having those dollars. I don’t want to close down programs and then the dollars come, and I would have left them open.”
In the waning months of the Trump administration, health officials devised a plan to spend all the money that was left.
HHS in April 2020 had begun to give money away in batches. As a way to get money out fast, the first batch was based on a hospital’s volume of Medicare patients — and ended up favoring health-care providers that had many patients who were privately insured or on the federal insurance system for older Americans. Substantial payments went to several large, well-heeled health systems that gave some of the money back.
There were distributions for places that at the time were coronavirus hot spots and for health-care providers in rural places, nursing homes and hospitals treating many low-income patients.
Last fall, Trump administration health officials set up a new method — Phase 3, it was called — in which hospitals that already had received payments could apply for more. Four-fifths of the recipients of that $24.5 billion got their Phase 3 payments by the end of 2020, though information from the Health Resources and Services Administration (HRSA), the HHS agency overseeing the money, says some aid allocated in that phase arrived as late as March.
It was November when Trump administration health officials began work on what they envisioned as a fourth and final phase. For the first time, they would allow applications that were based on pandemic-related losses and expenses from the second half of 2020. The plan was sent for review by the White House Office of Management and Budget, according to a senior HHS policy official from the Trump administration who spoke on the condition of anonymity to describe internal dynamics.
When the Biden team arrived, the former Trump official said, “they stopped work on Phase 4. . . . This was the tough part. We had made promises to all these people that . . . their phase was coming.”
Joanna Hiatt Kim, the American Hospital Association’s vice president for payment policy, noted that most of the U.S. covid-19 cases and hospitalizations happened after June 30, 2020. “The massive winter wave, and now the massive wave we are in, none of those have been targeted for funds,” she said.
Early this year, amid an unprecedented surge, some big health networks such as Grady Health System in Atlanta feared the financial repercussions.
One of the nation’s largest health-care systems, Grady received $125 million for its hospital and $31 million for running Georgia’s biggest nursing home, treating uninsured patients and providing other services. All the money was spent by June 2021.
“We thought there would be more forthcoming, based on the fact there was still a significant amount of funds sitting in the Provider Relief Fund,” said John M. Haupert, Grady’s president and chief executive. “There wasn’t much communication.”
Recognizing that the pandemic is not ending anytime soon, Haupert worries about Grady’s financial scenarios for next year, with its forecasts suggesting it could lose up to $100 million. Because deep financial problems nearly forced it to close more than a decade ago, Grady is required by its board at least to break even.
So Grady developed a plan to improve revenue and reduce expenses.
“We have begun implementing part of that plan,” Haupert said, “but then you go into another surge like this, and you need to do what you need to do to take care of people.”
Originally, hospitals, nursing homes and others faced a June deadline to spend the money they had received. Much of the health-care industry complained that it needed more time, and, late this spring, the Biden administration granted the extra time.
That rule change, however, did not say when any of the remaining money would be released. Still, the industry expected that federal health officials would soon let the money flow — until the provider fund was nearly diverted altogether for a different purpose: to help pay for a $1 trillion infrastructure package that was one of Biden’s main domestic priorities.
In the end, the infrastructure bill that passed the Senate last month did not touch that money. And the health-care industry and its advocates are now leaning harder than ever on HHS to release the undistributed funds.
According to the HRSA, the $43.7 billion in the provider fund includes $24 billion that health officials have not allotted for a particular purpose or have on hand, in part because of money that some well-off health systems returned.
“Our message has been a simple one: There’s money left. It’s needed. Please get it out,” the California Hospital Association’s Coyle said.
Scores of House members have sent a letter to Becerra on behalf of long-term-care facilities. Forty-one senators just dispatched their own letter, asking him to release the funds “without any further delay.”
The American Hospital Association has written to Becerra several times. Its most recent letter, from the middle of last month, noted that the current increase in coronavirus cases and covid-19 hospitalizations is producing staffing shortages and driving up other costs. Hospitals and health systems, it said, are finding “their resources — human, infrastructure and financial — are being stretched to the brink.”
Acting HRSA administrator Diana Espinosa offered a vague explanation of her agency’s work on the fund in a July letter responding to LeadingAge, a coalition serving older Americans.
Echoing Becerra’s words on Capitol Hill, Espinosa wrote, “As we continue navigating this pandemic, HHS strives for greater transparency and proactive communication” about the fund. As for timing, Espinosa wrote, “HHS is committed to distributing the remaining provider relief payments as quickly and equitably as possible, while utilizing effective safeguards to protect taxpayer dollars.”
Earlier last month, the White House issued a document describing ways in which the administration was working to improve the health of rural communities through the American Rescue Plan, with $8.5 billion from the March law expected “in the coming weeks.”
American Hospital Association officials said they are unaware of any description of how the money will be distributed, let alone of money being sent.
Schreiner, debating whether to cut programs at the rural hospital in western Illinois, said he has not heard anything about it.
Democrats are hustling to finalize their gigantic social spending plan during the dog days of summer recess, wary they will blow their target date to finish as Congress faces a crush of deadlines later this month.
Speaker Nancy Pelosi has ordered committee leaders to battle it out with their Senate counterparts to resolve all major disputes this week on what will be included in the up-to-$3.5 trillion bill. But wide gulfs remain between the House and Senate on central pieces of the package, including expanding Medicare, shoring up Obamacare, raising taxes and curbing carbon emissions.
That cross-Capitol disagreement is only the first of many headaches ahead for Democrats trying to muscle through the social spending measure in just a few weeks by simultaneously crafting, vetting and whipping it. Pelosi and Senate Majority Leader Chuck Schumer see such high-velocity multitasking as the only way to ensure the proposal moves alongside the bipartisan Senate-passed infrastructure bill, which is set for a House vote in less than four weeks. But if Democrats fail in their goal to finalize the social spending plan before the infrastructure vote, they risk blowing both key parts of President Joe Biden’s agenda.
“It is pushing it. All we can do is try,” House Budget Chair John Yarmuth (D-Ky.) said after the chamber voted last week to lock in the Sept. 27 infrastructure deadline.
“We’re trying to kind of pre-conference this to the greatest extent” to minimize House-Senate divergence, he added.
House Democratic leaders have not started preparing their members for the possibility that the social spending bill won’t be finished when the chamber votes on the infrastructure bill by Sept. 27, vowing they will get it all done through sheer force of will.
House committees kick off markups on Thursday to begin churning out the pieces of the final spending package, even as intraparty arguments continue privately over what exactly to include in the legislation. Democratic leaders, senior lawmakers and aides are scrambling behind the scenes to settle the types of major policy disputes that would normally take months or years to be resolved.
Senate Finance Chair Ron Wyden (D-Ore.), who is in charge of drafting the largest piece of the spending plan, described it as “a vastly bigger effort” than enacting the pandemic aid package in March. That Covid relief bill used the same filibuster-proof reconciliation process Democrats are now using to pass their social spending plan without Republican support.
Democrats are still haggling over several major issues, including when to sunset popular provisions in the coming years to fit within the $3.5 trillion cap they have set for themselves. Top Democrats have privately aired worries that a dizzying array of different end dates for various programs in the coming years could come back to haunt the party if Republicans control Congress or the White House and refuse to extend those policies.
For example, Democrats are currently debating when to set the expiration of a popular expansion of the child tax credit they passed in the pandemic aid bill. Some Senate Democrats are pushing for 2024, while their House counterparts argue that robs the party of any leverage it would have when a slew of Trump-era tax provisions expire the next year, in 2025.
Senior Democrats are also tussling over a much bigger issue — Senate Budget Chair Bernie Sanders’ (I-Vt.) push to expand Medicare to include vision, dental and hearing benefits. The dental plan in particular could cost hundreds of billions of dollars and may not be implemented for up to five years, coming at the cost of what some Democrats see as their best chance to permanently strengthen Obamacare and score a political win in the 2022 midterms.
Even once those disputes are resolved, the Senate parliamentarian will shape the endgame by almost certainly forcing Democrats to make further tweaks, a core feature of the reconciliation process they’re using to bypass the Senate filibuster.
“It takes an immense amount of focus on detail and scrubbing,” Wyden said. “It’s a lot of heavy lifting.”
To head off some of those potential pitfalls, Democrats have for months been fielding input from the parliamentarian on their plans. The Senate Finance Committee’s top lawyer is being “fed intravenously,” Wyden joked, since he is “camped out” seeking feedback from the parliamentarian at all hours.
All year, Democrats have laid the groundwork for enacting the $3.5 trillion proposal, releasing detailed outlines and marking up bill text for many of the provisions they plan to tie together. That includes the proposal Wyden’s panel approved in May to revamp clean energy incentives and the framework he and other Senate leaders released last week to hike taxes on corporations’ foreign profits.
“Nobody is gonna be surprised at a lot of what we’re offering up for consideration,” Wyden said.
Further complicating Democrats’ fast-track plan is the slew of critical deadlines coming at the end of the month, including funding the government, raising the debt ceiling and a promised House vote on the Senate-passed bipartisan infrastructure bill by Sept. 27.
Acknowledging the potential for missing those marks, Democrats in both chambers have already started casting blame on their colleagues across the rotunda.
One senior Democratic aide said the action is really centered in the House now after weeks of breakneck Senate action, stressing that the party can move expeditiously when it needs to. This aide pointed to swift passage of Biden’s $1.9 trillion Covid rescue plan earlier this year as well as last month’s multitrillion-dollar budget measure.
But another senior Democratic aide pushed back against that assertion, noting that the House had a big moment when it passed its budget last month and adding that both chambers are working closely with the White House to finish the social spending bill on time.
Republicans are amused by the power struggles the mega-legislation has exacerbated between House Democrats and their peers in the Senate.
Allowing the Senate to take the lead in negotiating the bipartisan infrastructure plan “tells you how anxious” Pelosi is “to get this legislation through,” Rep. Tom Cole (R-Okla.) said in an interview.
“The fact that we did a $1.2 trillion infrastructure bill with essentially very little input from the House — it was an institutional surrender to the Senate,” he added.
House Democratic leaders hoped that locking in the infrastructure bill deadline would intensify pressure to advance the social spending plan simultaneously. But so far, the move has only seemed to harden the long-running standoff between the party’s moderates and progressives about just how big and bold to go while Democrats control all levers of power in Washington.
Progressives are vowing not to support the Senate-passed infrastructure bill later this month if the social spending plan is not teed up for a vote at the same time. Moderates, meanwhile, insist they won’t support the up-to-$3.5 trillion bill unless leadership holds firm to its Sept. 27 commitment.
Republicans argue that the sense of urgency Democratic leaders are fostering will help them pressure wary moderates into acquiescing to the social spending bill, as Republicans promise united opposition.
“The speaker is going to move at light speed and insist her conference vote in lockstep to do it,” said Rep. Kevin Brady (R-Texas), his party’s top member on the House Ways and Means Committee. “The most extreme liberals among the House Democrat caucus will succeed in linking and holding hostage infrastructure to the tax-hikes-and-spending bill.”
The House and Senate return to Washington in September with a daunting to-do list, including staving off a potential shutdown when the fiscal year ends Sept. 30 and raising or suspending the debt ceiling before it’s breached, potentially as soon as October.
The Senate resumes Sept. 13. House committees will hold markups and hearings over the next several weeks before members return for floor votes on Sept. 20.
Congressional Democrats gave committees a deadline of Sept. 15 to draft pieces of a budget reconciliation package. The resulting measure, which could total as much as $3.5 trillion, would allow them to advance elements of President Joe Biden’s economic plan with only Democratic votes. As part of a deal between moderates and progressives that allowed the budget resolution kickstarting that process to move forward, the House has until Sept. 27 to consider the Senate-passed bipartisan infrastructure package (H.R. 3684; see BGOV Bill Summary).
Several pandemic-related programs also expire in September, including additional unemployment aid and increased Supplemental Nutrition Assistance Program benefits.
The Supreme Court on Aug. 26 ended the Centers for Disease Control and Prevention’s Aug. 3 revised eviction moratorium that was supposed to expire on Oct. 3.
Download the updated BGOV OnPoint: 2021 Dates to Watch
Congressional Democrats’ push to add dental, vision and hearing coverage to Medicare is running into resistance from powerful health industry lobbies — an early sign of the battles facing lawmakers when they return to debate a $3.5 trillion social spending package.
Progressives see expanding the popular entitlement as essential to fulfilling their campaign pledges and keeping Democratic control of the House and Senate. But the reforms threaten the bottom line of insurers who administer private Medicare plans and sell supplemental coverage for dental, vision and hearing services. Groups like the American Dental Association, worried their members will be paid less in traditional Medicare than in private Medicare plans, are also pushing to limit the new benefits to the poorest Americans.
Prospects for Medicare expansion are further complicated by a price tag that could exceed $350 billion over a decade and surpass the cost of other health priorities under discussion, like an extension of Obamacare subsidies or an expansion of in-home care. With moderates like Sen. Kyrsten Sinema (D-Ariz.) already insisting on shrinking the size of the overall package, the expansion could yet founder on budgetary concerns, if Republicans remain unanimously opposed.
“What we want to do is a lot more expensive than what we are going to be able to do,” House Budget Chair John Yarmuth (D-Ken.) acknowledged this week.
House and Senate committees now assembling the package are weighing options like a longer phase-in of benefits, skimpier coverage with more cost-sharing or even means-testing that would restrict new benefits to only the poorest beneficiaries.
Rep. Lloyd Doggett (D-Texas), chair of the House Ways and Means health subcommittee, said seniors could wind up paying a percentage of the cost of their dental, vision and hearing services, despite misgivings about how that could weigh on some low-incomeMedicare recipients.
“We’ve argued a little bit about the importance of ensuring that the people that are the neediest are the ones that are sure to be able to get some help,” he said.
Groups including the American Dental Association are trying to influence the outcome, telling Congress to offer a more generous benefit, but onlyto individuals earning less than 300 percent of the federal poverty line.
“Let’s focus on those who currently can’t afford to see a dentist, people who are most likely to end up in the emergency room,” said Michael Graham,the association’s senior vice president for government and public affairs.
But many lawmakers and advocacy groups say such means-testing in Medicare would set a dangerous precedent and change the nature of a program that serves more than 61 million elderly and disabled beneficiaries.
“Dental is one of the least affordable medical services, more than prescription drugs or anything else, so to say you’re only going to offer help to some people doesn’t work,” said Melissa Burroughs, associate director for strategic partnerships at the advocacy group Families USA. “We’re talking about a benefit that we want to reach all Medicare enrollees.”
AARP is also lobbying for as generous a benefit as possible, warning of a political backlash should it take too many years to kick in or cover too few services.
“We’re saying to Congress: ‘Make sure you do a good job with the dental, vision and hearing benefits,’ because if our members show up at their dentists and the new program doesn’t cover anything, they’re going to be upset,” said Bill Sweeney, the group’s senior vice president for government affairs. “It has to be comprehensive.”
Health insurers are pushing back, warning that the cost of new coverage could limit other benefits they offer in private Medicare Advantage plans — such as free transportation to medical appointments or free over-the-counter drugs.
“Asking 27 million Americans to pay for new dental, vision, and hearing benefits in lieu of services they affirmatively chose and have come to rely on is unnecessary and unfair,” said Matt Eyles, president and CEO of America’s Health Insurance Plans, the industry’s big Washington lobby.
Insurers want Congress to increase the amount the government pays private Medicare Advantage plans to offset the cost of covering the new benefits. But progressives like Doggett say payments to Medicare Advantage are already too high and are instead looking at slashing them to help fund the overall bill.
“If we can’t pay for this with [drug price negotiation], we should look at the excessive payments given to Medicare Advantage plans,” he said. “[Insurance companies] don’t have an interest in having traditional Medicare provide comprehensive coverage and that’s all the more reason, in my opinion, that we need to do it.”
An insurance industry source said Congress’ deliberations are “freaking out” companies who worry that seniors will drop their private plans en masse and migrate to traditional Medicare once the new benefits are in place. But the source said the industry is mindful of the optics of publicly opposing coverage of eyeglasses, dental care and hearing aids, and is largely lobbying behind the scenes.
Democratic House and Senate staffers say they aren’t giving much weight to the industry’s arguments. A senior Senate Democratic aide said the insurers’ concerns were “not unexpected” and “a perennial thing” whenever major reforms are on the table.
“We’re still full steam ahead on adding these benefits,” the aide said. “It’s long overdue.”
Top Democrats insist the new Medicare benefits will be in the package in some form, pointing to recent endorsements from House and Senate leadership and President Joe Biden and portraying the expansion as a once-in-a-generation chance to help tens of millions of older Americans. But aides caution that the program may not be as generous as some expect.
Doggett said the House is debating having hearing and vision benefits, which are estimated to be much cheaper than dental care, kick in during the first few years after passage, with a longer phase-in plan for dental. But the senior Senate Democratic aide said the upper chamber is working on an interim policy to give seniors some “immediate relief” — in the form of help paying for all three services right away while the administration works to set up the full benefit in the coming years.
Arguments over when the benefits will start and end, and what services will be covered at what level, are likely to be in play for weeks to come. Among the unresolved questions are whether the emphasis be on free preventative care, as it is in many other government health programs. Democrats also have to decide whether to only authorize the benefits for a few years, wagering they’ll be in the majority when it comes time to renew it.
“As with any health policy, there will have to be tradeoffs,” another senior Democratic aide acknowledged. “That’s why we’re now struggling to balance timing, co-insurance and generosity in different categories of benefits.”
Prospects for Medicare expansion are further complicated by a price tag that could exceed $350 billion over a decade and surpass the cost of other health priorities under discussion.
Invalid Email Address