Senate Democrats’ plan to expand Medicare coverage would help a growing senior population often struggling with hefty out-of-pocket medical expenses, potentially providing ballast for the economy in coming years.
Democrats on the Senate Budget Committee agreed Tuesday on a $3.5 trillion spending level for a bill to carry most of President Joe Biden’s economic agenda into law without Republican support. The bill would include one key item that wasn’t in Biden’s plans: vision, dental and hearing benefits for Medicare recipients, who are disproportionately those over 65 years old.
That would provide tens of millions of seniors — many of whom have low incomes — with care that they don’t currently have, likely boosting not only health spending but also freeing up money to go toward other goods and services, particularly essential goods. With 10,000 Baby Boomers turning 65 each day across the U.S., Democrats hope the expanded coverage will also help provide political wins.
“This would be a very significant change for Medicare,” said Tricia Neuman, executive director of the Kaiser Family Foundation’s program on Medicare policy, who said it would be the biggest change since the start of Medicare’s drug benefit in 2006. “How big an impact it will have will depend on the details of the proposals.”
Democrats are leaning toward expanding Medicare Part B, which pays for outpatient services, to include these new benefits, according to two senior Senate staffers familiar with the discussions. Like many other parts of Medicare, there would be no cost-sharing for preventative services and limited copays for elective procedures.
Part B is voluntary and includes premiums, which could rise with the addition of new benefits.
The additional benefits would increase Medicare spending by roughly $358 billion in the decade through 2029, according to a Congressional Budget Office estimate of a previous similar proposal. Two-thirds of that would be for dental and oral health, the nonpartisan agency said. Government spending on this level would provide a boost for gross domestic product.
Dental care, which is closely linked to overall health, is one of the most expensive services. About 30 million seniors haven’t had a dental appointment in the past year, according to Kaiser Family Foundation, including 16 million with annual incomes above $40,000.
About a quarter of Americans over 65 years old have disabling hearing loss, accordingto the National Institute on Deafness and Other Communication Disorders.
People with hearing loss have much higher health costs and lower employment, said Amanda Davis, a senior adviser at AARP. For Medicare-aged beneficiaries that carries knock-on costs for the government and retirement savings as those with hearing loss have less in savings and higher medical bills.
Hearing loss is estimated to cost those affected $297,000 over their lifetime, according to a study published in 2000 by the International Journal of Technology Assessment in Health Care. And the total national cost of first-year hearing loss treatment is projected to rise to $51.4 billion in 2030 from $8.2 billion in 2002, according to a 2010 study in Journal of the American Geriatrics Society.
Senate Democrats laid out an ambitious $3.5 trillion tax and spending agreement that’s slated to include a major expansion of both Medicare and Medicaid, paid for partly with cuts to prescription drug spending.
President Joe Biden hasn’t yet said himself whether he supports the proposal unveiled by Democrats on the Senate Budget Committee Tuesday night, though top aides have expressed enthusiasm. “We’re going to get this done,” Biden told reporters as he arrived at the Capitol yesterday to meet with senators on the measure.
If it holds, the budget agreement will be a victory for the president, bridging divisions among party factions over the size and scope of the package. But it’s a crucial moment for Biden, who will need to persuade Democratic progressives to agree to lower spending more than they wanted while keeping moderates from balking at the price tag. The budget measure would accompany a separate, $579 billion bipartisan infrastructure plan that Biden has endorsed, raising the total spending of his economic agenda beyond $4 trillion.
A senior Democratic official said the $3.5 trillion in proposed spending would be offset by health care savings, tax hikes on companies and the wealthiest Americans, and economic growth.
One leading proponent of closing the “Medicaid gap” said yesterday that extending coverage to more than 2 million Americans will have a hefty price tag, possibly as much as $400 billion, Alex Ruoff reports.
Sen. Bernie Sanders (I-Vt.) told reporters that the budget resolution will include a placeholder for extending insurance coverage to the roughly 2.2 million people in 12 states who could’ve been in Medicaid if their state governments would expand their public health insurance programs under the Affordable Care Act’s rules.
However, a debate continues over the best way to accomplish that goal and proponents say it’s costly.
Rep. Lloyd Doggett (D-Texas) said it could cost $400 billion to get all 2.2 million covered. Some of Doggett’s colleagues have floated the idea that the ACA has already paid for this cost, but the Texas Democrat rejected that as “wishful thinking.”
“The notion that we already paid for it is not going to fly with the Congressional Budget Office,” Doggett told reporters yesterday.
The price tag is the main impediment for including this in a budget reconciliation package, Rep. Jim Clyburn (D-S.C.), the House Majority Whip, told reporters. “All the ways are pretty expensive and that’s the reticence part,” he said.
Medicare Expansion Would Help Seniors: The plan to expand vision, dental and hearing benefits for Medicare recipients, who are disproportionately those over 65 years old, would help a growing senior population often struggling with hefty out-of-pocket medical expenses, potentially providing ballast for the economy in coming years.
It would provide tens of millions of seniors — many of whom have low incomes — with care that they don’t currently have, likely boosting not only health spending but also freeing up money to go toward other goods and services, particularly essential goods. With 10,000 Baby Boomers turning 65 each day across the U.S., Democrats hope the expanded coverage will also help provide political wins.
Democrats are leaning toward expanding Medicare Part B, which pays for outpatient services, to include these new benefits, according to two senior Senate staffers familiar with the discussions. Like many other parts of Medicare, there would be no cost-sharing for preventative services and limited copays for elective procedures. Part B is voluntary and includes premiums, which could rise with the addition of new benefits. Read more from Katia Dmitrieva and Alexander Ruoff.
Nursing homes want HHS to release the estimated $24 billion in unallocated provider relief soon and allocate $10 billion specifically for nursing homes, estimating nearly 2,000 facilities are at risk of closing over the course of the pandemic.
The American Health Care Association and National Center for Assisted Living warned of possible closures over a month ago when it asked for more provider relief and joined other advocates to ask HHS to extend the provider relief spending deadline beyond June 30. Nursing homes also drummed up support from 50 lawmakers, who on June 4 asked HHS to dedicate $10 billion in provider relief for long-term care facilities.
HHS stopped short of giving a complete extension on June 11 and instead tied the spending deadline to when providers received relief, giving each recipient one year to spend all their relief.
AHCA renewed its call in a press release Monday (July 12) for HHS to quickly distribute the remaining provider relief.
The last provider relief distribution was announced in October, and HHS is still making distributions to providers — sometimes months after they applied. Some experts see the existence of a fourth reporting period as proof that there will be another provider relief distribution. In December, Congress directed HHS to consider provider losses and expenses through March 2021 when determining the next distributions.
“While overall the situation has improved, this battle with the virus is not over, and now we face a new battle. Our sluggish economic recovery puts thousands of facilities in danger of closing, threatening access to long term care for vulnerable seniors and individuals with disabilities,” Mark Parkinson, AHCA president and CEO, said in the press release Monday.
AHCA found in a recent survey of members that only 24% of long-term care facilities are confident they can stay afloat until next year. Nursing homes say on top of long-standing Medicaid underfunding, they’re dealing with increased costs and reduced revenue.
The American Hospital Association has also asked HHS to quickly distribute the remaining provider relief. Hospitals also are concerned, according to a letter to Senate leadership on June 29 that Congress might try to use outstanding provider relief and an extension of the Medicare sequester to offset the bipartisan infrastructure deal’s costs. Hospitals again raised concerns about a possible sequester extension in a letter this week.
The administration and Congress have yet to announce whether they plan to use provider relief or the Medicare sequester to pay for the final bipartisan infrastructure bill, though both were listed in an earlier document on the bipartisan deal. — Dorothy Mills-Gregg (dmillsgregg@iwpnews.com)
Senate Majority Leader Chuck Schumer (D-N.Y.) set a deadline to wrap talks on both the bipartisan infrastructure package and an agreement among all Democrats on moving forward on a budget resolution.
The move puts pressure on Republicans to cut a deal quickly on the $579 billion infrastructure plan and on moderate Democrats to agree to the $3.5 trillion budget blueprint that is moving on a separate, parallel track. Schumer has to manage the tension between centrist Democrats who have led a push for the bipartisan measure, and the party’s progressives, who don’t want to move forward on infrastructure without assurances their priorities will be addressed in the bigger, Democrats-only budget package.
“The time has come to make progress. And we will,” Schumer said today on the Senate floor.
Schumer said he would take a crucial procedural step on Monday that would clear the way for an initial vote next Wednesday on the on the $579 billion infrastructure package. He also said he wants Senate Democrats to agree by Wednesday on moving forward with the budget resolution that will carry other major portions of President Joe Biden’s agenda.
The move creates some political risk. Republicans don’t want the two packages linked, and some Democrats are withholding their support for the budget plan until more details are filled in. In addition, some GOP senators are balking at moving forward on the infrastructure plan without having legislation fully ready. Schumer would need 60 votes in the 50-50 Senate to proceed.
The group of Democratic and Republican senators working on the infrastructure bill were meeting today in an attempt to complete negotiations and discuss Schumer’s deadline. Read more from Erik Wasson and Steven T. Dennis.
Meanwhile, Speaker Nancy Pelosi (D-Calif.) said today the House can be expected to change and “realign some of those priorities” contained in the $3.5 trillion Senate Democrat budget blueprint, Billy House reports.
Senate Majority Leader Chuck Schumer set a Wednesday deadline for agreements on the duo of packages carrying President Joe Biden’s infrastructure and economic agenda, putting pressure on Republicans and moderate Democrats.
The House Ways & Means Committee is looking at a proposal to close the so-called Medicaid gap by expanding premium tax subsidies so that those affected could buy an exchange plan, according to health subcommittee Chair Lloyd Doggett (D-TX), but he said the House Energy & Commerce Committee is drafting a plan to close the gap through a new federal Medicaid-like program.
The work comes as congressional leaders lay plans to tackle the Medicaid gap issue as part of Democrats’ upcoming reconciliation package.
Both approaches have advantages and disadvantages, Doggett said during a webinar hosted by the Southerners for Medicaid Expansion coalition Wednesday (July 14). The purported Energy & Commerce proposal would provide more comprehensive coverage and benefits than exchange plans, but it would take time to set up. The Ways & Means proposal could be established quickly but there are questions about how to deal with deductibles and co-pays with exchange plans, the congressman said.
Doggett, who has also introduced a bill that would let local governments expand Medicaid themselves in non-expansion states, said he wouldn’t disparage either approach. But he added that he doesn’t want to see a temporary fix or a solution that switches people between the marketplace and Medicaid.
“That is a false hope and confusion for disadvantaged people that will just mean that they don’t get what they deserve after more than a decade of waiting,” he said.
A spokesperson for Ways & Means did not directly answer questions about the details of the proposal Ways & Means is crafting, but said the committee is working with others, as well as congressional leadership, and details are still being worked out. The spokesperson said the committee wants to find a comprehensive solution that can be implemented quickly.
An Energy & Commerce spokesperson did not respond to questions about Doggett’s assessment of the committee’s plan.
Several Democratic lawmakers, including House Majority Whip Jim Clyburn (D-SC), have said getting these people coverage is a priority in the upcoming reconciliation package, likely to be voted on this fall. Sen. Raphael Warnock (D-GA) already introduced a bill Monday (July 12) that takes the route Energy & Commerce is reported to be exploring by directing CMS to create a federal Medicaid look-alike program available in the states that have not yet expanded Medicaid to people making up to 138% of the federal poverty level.
Senate Majority Leader Chuck Schumer (D-NY) told Inside Health Policy Wednesday morning there is space for legislation to close the so-called Medicaid coverage gap in the $3.5 trillion budget resolution presented Tuesday night (July 13), which provides a framework for the reconciliation package. House Speaker Nancy Pelosi (D-CA) reaffirmed this in a letter sent to House members about the budget deal Wednesday.
Schumer did not give details on how much money could be devoted to closing the Medicaid coverage gap, but a senior Democratic aide said the deal will be offset in part by drug pricing reforms, including a repeal of the Trump administration’s rebate rule.
A press release for Warnock’s bill said the plan requires no additional offsets, since Congress already appropriated funding for Medicaid expansion in the Affordable Care Act. But Doggett disagrees.
“The notion that we already paid for it is not going to work with the Congressional Budget Office,” Doggett said. “We haven’t already paid for it, and in fact, most of the pay-fors for the Affordable Care Act have been subsequently repealed by Congress.”
The Urban Institute put out a report on June 30 estimating how much it would cost to expand eligibility for premium tax credits for exchange plans to people making below 100% of the federal poverty level.
This kind of expansion, using the ACA’s subsidy schedule from before the American Rescue Plan enhancement of the subsidies, would cost the federal government an estimated $181 billion over 10 years. Enhancing all subsidies to match the ARP would cost $270 billion over 10 years, and enhancing premium and cost-sharing subsidies would cost $335 billion over 10 years, the report says.
A follow-up report published Wednesday from some of the same researchers found that a public option that pays providers at Medicare rates and is offered in the exchanges to people in the Medicaid coverage gap would cost the federal government less than using exchange benchmarks. — Maya Goldman
Home health agenices want the Biden administration to reconsider a proposed rule that would reduce their Medicare payment rate by nearly 4.4% for a third straight year in 2022.
The “behavior assumption adjustment” in the proposed Home Health Prospective Payment System rule would lower Medicare payments, on the “assumption” that home health agencies would alter their billing and coding activity to maximize reimbursements under the Patient-Driven Groupings Model (PDGM), a value-based payment system that Medicare implemented in 2020.
After lowering payments by nearly 4.4% in 2020 and 2021, the PDGM’s behavioral adjustment and other factors call for another 4.36% reduction in 2022 in order to meet federal budget neutrality requirements.
But industry groups say the Centers for Medicare & Medicaid Services is setting payment rates based on flawed assumptions about agencies’ anticipated behavior under the PDGM system. They cite a recent analysis of 2020 Medicare claims data by health economists at Dobson DaVanzo & Associates, that shows agencies didn’t change their billing and coding practices as the CMS expected.
The dispute is the industry’s latest dust up involving the PDGM, the biggest change in Medicare home health reimbursement in more than 20 years.
“To continue this cut for the third year, we think is not appropriate,” said Joanne Cunningham, executive director of the Partnership for Quality Home Healthcare. “We think the 4.36% cut should be halted.”
The proposed rule expects some home health agencies to list the highest paying diagnosis code as the “principal diagnosis code” in order to “be placed into a higher-paying clinical group.”
It also anticipates agencies will report more patient ailments, or “secondary diagnoses,” in order to receive a “comorbidity adjustment” to their Medicare payments. It further envisions agencies increasing home visits to get higher Medicare payments.
William Dombi, president of the National Association for Home Care & Hospice, questioned the methodology, calculations, and modeling that the CMS used to project the likelihood of these questionable practices.
“Looking at behavioral changes is completely different from simply looking at the outcome of a model from a spending perspective,” Dombi said. “They need to go back to the drawing board to come up with a methodology that fits an analysis of behavioral change.”
Home health agencies provide services to beneficiaries who are homebound and need skilled nursing care or therapy. In 2019, traditional Medicare spent $17.8 billion on home health services for 3.3 million beneficiaries, according to the Medicare Payment Advisory Commission.
While home health care is far less costly than institutional care, Medicare has historically overpaid for services. This limits their cost-saving impact on the program.
The PDGM sets Medicare payments for home health agencies based on patients’ clinical characteristics—like the type and severity of ailment—rather than the volume of care provided. It’s part of Medicare’s move to value-based care, a concept that’s replacing traditional fee-for-service payments by creating greater incentives for providers to control costs and improve patient outcomes.
The PDGM was designed to curb the volume of therapy services provided by home health agencies. But ever since it was implemented in 2020, industry groups have chafed at the behavioral assumptions Medicare uses to adjust payments.
The CMS originally expected sketchy billing and coding practices to increase Medicare’s home health payments by 6.4%, or $1 billion, in 2020. Similar estimates have since guided agency efforts to reduce the payments.
But the the industry-backed study found that Medicare home health spending was 1.3% lower than projected in 2020.
“Given Medicare’s own data about home health provider behavior, it is troubling that the agency continued the unjustified behavioral assumption cut for 2022,” Cunningham said in a recent partnership statement. “However, we remain encouraged that the agency states their intent to continue examining the data with the prospect of a future payment adjustment. We intend to continue working with the agency to ensure an adjustment is properly made.”
Dombi said any rate cuts should be based on actual observed evidence of billing and coding misbehavior. But with only the Covid-affected data from 2020—the first year that PDGM was implemented—the CMS has to rely on its projections until enough data is available.
“We hoped we wouldn’t have any kind of contentious circumstances with this proposed rule out there. But there does seem to be, at its core, a significant difference of view as to what CMS should be looking at,” Dombi said.
Both groups are expected to submit formal comments to the CMS on the proposed rule.
Senate Democrats say they’ll fully pay for their $3.5 trillion plan for child tax credits, climate measures, education, and other measures, but it’s unclear how many of their proposed pay-fors will actually raise revenue or cut spending.
Democrats plan to adopt a budget resolution with reconciliation instructions for a major legislative package that would include corporate tax hikes and a higher income tax for top earners, according to an outline by a senior Democratic aide. An expansion of Medicare would be funded by cuts to drug prices, while higher emission standards and carbon tariffs would be used to combat climate change, Bloomberg News’ Jordan Fabian and Erik Wasson report.
But the plan also banks on “long-term economic growth” as a pay-for, a reference to dynamic scoring, which could score the bill as less costly due to potential economic growth spurred by its investments.
Sen. Joe Manchin (D-W.Va.), a key moderate, told reporters he’s OK with some reliance on dynamic scoring in the effort to ensure the bill is fully paid for. But Manchin said he raised concerns during a lunchtime meeting between President Joe Biden and Senate Democrats that inflation could be triggered by a flood of spending.
“I said I’m concerned about inflation, and I said I want to see more of the details,” Manchin told reporters yesterday.
Related: Manchin, Tester Hold Back on Budget Deal Awaiting Details
More broadly, though, some fiscal conservatives are wary of the promise that the $3.5 trillion bill’s cost will be fully offset. Maya MacGuineas, president of the Committee for a Responsible Federal Budget, said she’s concerned lawmakers won’t rely on entirely legitimate offsets, especially because they relied on gimmicks to agree to pay-fors in infrastructure talks.
“So far, the only real indication we have is the bipartisan infrastructure bill, which is the first piece of all of this, and a lot of the pay-fors unfortunately are either exaggerated or not going to score properly,” MacGuineas said in an interview on Bloomberg Radio’s Balance of Power yesterday. “And they call it fully paid for, but it’s going to come up well short of that promise. That leaves me very concerned that this next bill will also not be really paid for in a meaningful way.”
Read more: Biden Agenda Gains Senate Ground With Big Hurdles Remaining
Bicameral Agreement: Speaker Nancy Pelosi (D-Calif.) praised the Senate Democratic outline yesterday, calling it “a victory for the American people” in a letter to colleagues. “Our House Committees stand ready to work with the Senate, as this topline agreement is turned into legislative text,” Pelosi wrote.
Firearm injuries in the U.S. cost more than $1 billion per year, with public insurance programs picking up more than half the tab, according to a federal watchdog.
Senate Democrats’ $3.5 trillion spending package will unleash a gusher of hundreds of billions of dollars for progressive priorities, from climate programs to an expansion of Medicare to promised green cards for some undocumented immigrants, according to new details released on Wednesday.
Majority Leader Chuck Schumer, Budget Chair Bernie Sanders (I-Vt.) and Sen. Mark Warner (D-Va.), a moderate on the budget panel, briefed the rest of the Democratic caucus during lunch with President Joe Biden in the Capitol on Wednesday. They discussed some of the biggest components of the planned spending bill that Democrats aim to pass without Republican support using the budget process. That filibuster-proof process starts with a budget resolution, which Senate Democrats have agreed to set at a ceiling of $3.5 trillion.
And while that resolution’s text is still forthcoming, once it arrives it will have few specifics of how Democrats will turn Biden’s priorities into legislation. That makes the policy highlights unveiled Wednesday, as vague as they are, a meaningful spotlight on the scope of the party’s spending ambitions, which would be financed by a shaky combination of tax reform, health savings like lowering prescription drug costs, and the assumption of long-term economic growth.
“Let me be clear — this is a huge bill. This is a complicated bill. This is a transformative bill,” Sanders told reporters after lunch. “In some cases, it doesn’t provide all the funding that I would like right now.”
But with 50 Democrats in the upper chamber and no votes to lose, “compromises have to be made,” Sanders said.
The proposal would expand Medicare to cover dental, vision and hearing services for seniors. It would also fund health care for about 2 million people living in red states that have refused to expand Medicaid. Both provisions were major priorities for liberals, who had originally pushed for trillions of dollars more in a total package.
As promised, the plan will include key commitments from Biden’s “families” and “jobs” plans, including universal prekindergarten for 3- and 4-year-olds, child care subsidies and an increase in the maximum Pell Grant to defray college costs for lower-income students. Democratic leaders also intend to fulfill the president’s pledge to provide more nutrition assistance, paid family and medical leave, and affordable housing.
Democrats plan to use the package to extend the popular increase in the Child Tax Credit, which Congress boosted in March, to a maximum of $3,600 a year for children under 6 years old and $3,000 for older kids. The plan would also continue the current increase for the Earned Income Tax Credit and the tax break for child care costs.
Many Democrats have called for a permanent extension of the Child Tax Credit, which the IRS will start sending out in monthly payments on Thursday. But Senate Democrats aren’t yet specifying the length of the extension they want to provide, stressing that it depends on the cost of the bill and additional input from lawmakers.
Rep. Pramila Jayapal (D-Wash.), who leads the Congressional Progressive Caucus, cited key wins during a call with reporters on Wednesday, including universal child care, paid leave and the Medicare expansion provisions.
“There isn’t a big area of our priorities that was left out,” she said. Still, progressives will be pushing for bigger investments in child and elder care.
“You can be assured, we are pushing for as much as we can possibly get,” Jayapal said.
The inclusion of immigration policy in Democrats’ still-unwritten party-line spending bill is another huge demand for both progressives and members of the Congressional Hispanic Caucus. Both groups were relieved to see their issue included in the budget highlights, though they received few details. It’s also unclear if immigration reform will withstand the scrutiny of the Senate parliamentarian, the official who decides which provisions pass muster with the byzantine rules guiding the budget reconciliation process that governs the bill’s fate.
Progressives and Hispanic Caucus members have pushed for a pathway to citizenship for several key undocumented groups, including so-called Dreamers who were brought to the U.S. as children and “essential workers” during the pandemic, including farmworkers. But a senior Democratic aide confirmed only that the budget would include legal permanent residence for immigrants, without providing additional details — which may not be known for weeks.
The early approval that the budget blueprint won from the left wing of the party didn’t extend across the entire House Democratic caucus. Several moderates privately balked at the overall price tag, which they feared would require hefty tax hikes to pay for the package and fuel GOP attacks.
To help pay for the plan, Senate Democrats plan to beef up tax enforcement and raise corporate and international taxes. They are also seeking to hike rates on “high-income” individuals, but have yet to agree on exactly what income brackets would be hit and how much more those earners would pay.
Three kinds of tax hikes are off that table, however: increases on families making less than $400,000 a year, small businesses and family farms — a sign that Democrats are leery of attacks casting them as “tax-and-spend” liberals.
On climate, Democrats plan to include a clean energy standard that would deliver 80 percent clean electricity by 2030. How to structure that standard in order to survive the arcane reconciliation rules remains unclear, although Democrats and environmental advocates have brainstormed a number of possible approaches.
The budget resolution would also spell out funding for clean energy and electric vehicles incentives, a civilian climate corps, a clean energy accelerator and programs to boost weatherization and electrification of buildings. Democrats are pledging to deliver on Biden’s promise to curb greenhouse gas emissions by 50 percent across the U.S. economy by 2030.
Democrats are also calling for “methane reduction” and “polluter import fees,” though it was not immediately clear what those policies would entail.
Some of the climate provisions are already giving Sen. Joe Manchin (D-W.Va.) heartburn, however. After lunch with Biden, Manchin, a centrist whose vote will be critical to the budget’s success, said he’s concerned about fossil fuels getting short shrift in the final bill.
“I want to see more of the details,” he said.
The policy details unveiled Wednesday are a meaningful spotlight on the scope of the party’s spending ambitions.
Senate negotiators struggled Tuesday to shore up enough support for both a bipartisan infrastructure bill and a large tax and spending measure backed only by Democrats, marking a significant political hurdle for quick congressional approval of President Joe Biden’s $4 trillion economic agenda.
A group of 22 Democratic and Republican senators plans to huddle Tuesday night to sort out lingering problems with their proposed $579 billion physical infrastructure package, while a separate group of Senate Democrats will meet in the evening to discuss the top-line spending level for the second package.
The biggest issue for the infrastructure bill is how Congress intends to pay for it — through increased tax enforcement and user fees — as well as re-purposed pandemic relief money and incentivizing private investment.
The nonpartisan Congressional Budget Office has not agreed with the senators that a $40 billion investment in the IRS will net $100 billion in newly collected tax revenue. Some Republican senators who previously supported the deal said that poses a problem.
Republican Senators Jerry Moran of Kansas and Mike Rounds of South Dakota said they want to see the bill fully paid for in a CBO score. Rounds, however, added that he felt the bill was “getting there.”
Other Republican senators, such as lead negotiator Rob Portman of Ohio and Mitt Romney of Utah, are more willing to forgo official CBO blessing if they are convinced the bill pays for itself. The White House has previously said there is $1 trillion in unpaid taxes to be reaped from increased audits.
Romney said the CBO isn’t likely to give senators full credit for beefed up Internal Revenue Service enforcement, dynamic scoring — which counts on revenue gains from anticipated faster growth — and other items the group believes will pay for the package.
“My test is, is it paid for in my own mind,” Romney said.
Republicans also remain concerned that Democrats will link passage of the infrastructure bill to the budget measure, which so far has no GOP support.
Senator Thom Tillis of North Carolina, one of the 11 Republicans to back the tentative infrastructure deal, said his biggest concern is that House Speaker Nancy Pelosi wants to tie approval of the infrastructure package in her chamber to Senate clearance of the budget resolution.
“I’m actually more concerned about what I’m hearing from Speaker Pelosi on the linkage of this bill to reconciliation. We’ve got to get that sorted out,” Tillis said.
Democrats, who met privately with White House officials Monday night, remain divided over the size of the budget resolution, which would essentially serve as a blueprint for much of Biden’s domestic agenda.
Senate Budget Chairman Bernie Sanders is still fighting for a $6 trillion package, with only $3 trillion of that paid for through tax increases and allowing Medicare to directly negotiate drug prices with pharmaceutical companies. Sanders wants to add an expansion of Medicare, immigration reform, expanded child tax credits and other social spending to Biden’s proposal.
But that is a problem for the most conservative Democrat in the caucus, Joe Manchin of West Virginia, whose vote will be pivotal. Unity is key for the party in the evenly divided Senate, where Vice President Kamala Harris casts tie-breaking votes to pass legislation without Republican support.
Manchin told reporters Tuesday that both the infrastructure bill and the second measure “should be fully paid for.”
“We have put enough free money out,” he said.
Manchin has also said he would not back the full corporate tax increase Biden has proposed, to 28%, favoring instead a 25% rate.
Budget Committee Democrats have said they hope their Tuesday night meeting can clear away some of the differences and allow for a Senate floor vote as soon as next Tuesday.
Democrats are planning to skip formal committee votes and bring the budget resolution, which will outline ceilings for spending and floors for revenue in the follow-on tax and spending package, directly to the floor. Votes this month on the budget will set up further action on that second package in September, or later.
A Democrat attending both sets of Tuesday meetings said to take the turbulence with regard to both tracks in stride.
“A lot of these deals die a thousand deaths before they actually get through,” said Senator Mark Warner of Virginia.
A coalition of health-care organizations called on medical facilities Tuesday to mandate that their workers get vaccinated against the coronavirus, saying the strategy has worked to fight influenza and other infectious diseases and is necessary to contain the pandemic.
“COVID-19 vaccination should be a condition of employment for all healthcare personnel,” the coalition’s statement reads, warning that “a sufficient vaccination rate is unlikely to be achieved” without a vaccine mandate.
The statement and accompanying guidelines — signed by the Society for Healthcare Epidemiology of America, the Infectious Diseases Society of America and five other medical groups — come amid a raging debate about health care, as some organizations impose new vaccine requirements and as infectious-disease expert Anthony S. Fauci suggested last weekend that “there should be more mandates” at the local level to curb virus spread.
But federal officials have balked at instituting national requirements on health-care workers, and many health-care organizations have said they do not plan to require their staff members to get vaccinated against the coronavirus. Some nurses and other health-care personnel have quit or sued organizations that imposed coronavirus vaccine mandates, claiming that the measures are unethical or illegal, although a federal judge rejected one such lawsuit last month.
The guidelines announced Tuesday — which include recommendations for engaging wary employees, navigating regulations and how to enforce a mandatory coronavirus vaccination policy — were crafted by a team of nearly 30 experts during the past two months.
“We think [it] will provide support for organizations that were thinking about making the vaccine a condition of employment for their health-care workers,” said Hilary M. Babcock, an infectious-disease expert at Washington University School of Medicine in St. Louis and a past president of the Society for Healthcare Epidemiology of America, who co-wrote the guidelines.
Although cases of covid-19, the disease caused by the virus, have plunged nationally, Babcock said the vaccine push remains a priority, pointing to a new outbreak in her state driven by the delta variant.
“If this [variant] isn’t affecting your local community, the next one potentially might,” she said. “It is still a good practice to try and get all health-care workers vaccinated so that they are protected.”
Outside experts agree that vaccine mandates are warranted, more than a year into the pandemic and with tens of millions of adults still refusing to get vaccinated despite the wide availability of shots.
“One thing that really upsets me is we’re hitting a wall,” said Paul A. Offit, director of the Vaccine Education Center at Children’s Hospital of Philadelphia, lamenting that national vaccination rates have stalled and that the virus continues to spread. “What do you do then? And I think the only answer to that question is you compel people to vaccinate. It’s certainly legal. It is not your inalienable right as a U.S. citizen to catch and transmit a potentially fatal infection.”
A number of health systems, including in Maryland and D.C., have moved to require coronavirus vaccines for their employees, arguing that they are essential to protect staff and vulnerable patients. The strategy has boosted vaccination rates: More than 2,000 employees at the University of Pennsylvania Health System in Philadelphia have received shots since the system announced in May that it would require all staff members to be vaccinated by September, said Patrick J. Brennan, the system’s chief medical officer.
But many other organizations have balked, noting that the vaccines have yet to receive full approval from the Food and Drug Administration. The American Hospital Association — which has repeatedly called for mandatory flu shots for health-care workers — has yet to weigh in on coronavirus vaccine mandates. The hospital organization said it is continuing to consult with members and clinical experts on the path forward.
“Let’s be honest,” said Ashish K. Jha, dean of Brown University’s School of Public Health, “some health systems are bold and creative, but a lot of them just want to stay below the headlines and just do their thing and don’t want to be courageous. And right now, this feels courageous because they know they’re going to get some pushback from some small minority of employees, and they’d rather not take that on.”
Jha, who has argued that the Hippocratic oath “demands” that health workers get vaccinated, said holdout hospitals’ concerns were probably overblown, citing the example of Houston Methodist. More than 97 percent of that hospital system’s workers complied with a vaccine mandate, with about 2 percent requesting exemptions and the remaining 153 workers getting fired or resigning last month.
“If hospitals do it in concert … the number of health-care workers who will quit and move is pretty tiny,” Jha predicted. “You’re not going to have 20 percent of health-care workers move out of a city or a state.”
But Jha said he was concerned to learn that some of the unvaccinated workers who left Houston Methodist had been hired by other institutions. “The risks that they pose have now been transferred from Houston Methodist to other institutions,” he said. “The organizations that are stepping up and saying, ‘We’ll hire unvaccinated front-line health-care workers’ … I find [that] a bit more puzzling.”
Some prominent children’s hospitals, such as Boston Children’s Hospital and Children’s Hospital of Philadelphia, have yet to require their staff members to be vaccinated, despite treating many patients who are not yet eligible to receive vaccines. The FDA has yet to authorize coronavirus vaccines for children younger than 12.
Jha said he was disappointed that children’s hospitals had not led the way on vaccine mandates.
“Children’s hospitals literally have a vast majority of their patients unvaccinated — and yet, most children’s hospitals that I’m aware of have not mandated this,” he said. “That strikes me as particularly stunning. And I don’t understand that.”
Offit, who is helping to craft vaccine policies at Children’s Hospital of Philadelphia, said he expects more holdout organizations to move forward with vaccine requirements, including his own.
“We are going to mandate this vaccine, that’s going to happen, [but] I suspect it’s probably not going to happen until these vaccines are approved, which will be soon,” he said. “We just found a lot of the people who were resistant for that reason, even though it’s a bad reason.”
Most physicians, surgeons, and specialists would see only minor increases or reductions in their Medicare payment rates next year under a proposal released Tuesday by the Biden administration.
The rate reductions outlined in the proposed 2022 Medicare physician fee schedule are due to budget neutrality provisions in the Medicare Act that require program payment hikes be offset by equal reductions elsewhere.
In 2021, the Consolidated Appropriations Act provided a “one-time, one-year increase in the Medicare physician fee schedule of 3.75%” to “provide relief during the COVID-19 public health emergency.” The legislation effectively averted a 3.75% cut in 2021 for providers, who were struggling to recoup revenue they had lost during the pandemic.
Congress isn’t likely to do the same in 2022, now that the Covid-19 vaccines have caused infections and deaths to plummet. But a host of medical organizations are seeking congressional action to head off the proposed cut and others that could be coming later.
David B. Hoyt, executive director of the American College of Surgeons, was still going over the 1,700-plus page rule Tuesday evening, but expressed concerns about the pay cuts.
“It appears that while CMS is taking notable strides to improve health equity and access to care, the rule maintains the cuts to surgical care that Congress stopped last year,” Hoyt said in a statement on behalf on the Surgical Care Coalition. “These cuts harm the care patients need and deserve, which is the opposite of what CMS is trying to achieve. Without congressional action, surgical care faces a significant payment cut and threatens patient access to critical treatments and procedures.”
Under the new proposed rule from the Centers for Medicare & Medicaid Services, the multiplier—or “conversion factor” used to determine reimbursement for services and procedures in traditional Medicare—would drop slightly to $33.58 in 2022 from $34.89 in 2021. That would erase the one-time 3.75% increase awarded for 2021.
In a statement, Anders Gilberg, senior vice president for government affairs at the Medical Group Management Association, said his organization “is concerned about the potential impact of the proposed 3.75% reduction to the conversion factor due to budget neutrality requirements and will seek congressional intervention to avert the cut.”
In the new proposal, audiologists, cardiac surgeons, pathologists and infectious disease specialists would see a 1% reduction in payments. Cardiologists, allergy/immunologists, and those practicing nuclear medicine and hematology/oncology would see a 2% reduction.
Interventional radiologists, however, would see cuts of 9%, and vascular surgeons face an 8% reduction, while radiation oncologists and radiation therapy centers would see a 5% Medicare pay cut.
Payment rates wouldn’t change for clinical psychologists and social workers, colon and rectal surgeons, critical care providers, general surgeons, or nephrologists under the proposal. Anesthesiologists, neurologists, nurse practitioners, obstetrician/gynecologists, and those practicing internal medicine would see a 1% bump in payments.
The Surgical Care Coalition is lobbying Congress to act before the end of the year to head off roughly 9% in potential Medicare payment cuts in 2022.
The possible cuts next year include the loss of this year’s 3.75% pay hike, the coalition said. In addition, the moratorium on the 2% Medicare sequestration pay cuts also expires at the end of the year, unless Congress takes action to extend it.
And additional Medicare payment cuts of up to 4% are also possible in 2022 after the massive American Rescue Plan increased the federal budget, which triggered mandatory cuts under the Pay-As-You-Go Act of 2010, the coalition said. Congressional action would be needed to waive the PAYGO cuts.
The proposed rule also would allow patients in any geographic location, including their homes, access to telehealth services for diagnosis, evaluation, and treatment of mental health disorders. The proposal would also Medicare to pay for mental health visits provided by rural health clinics and federally qualified health centers.
“The COVID-19 pandemic has put enormous strain on families and individuals, making access to behavioral health services more crucial than ever,” said a statement from CMS Administrator Chiquita Brooks-LaSure. “The changes we are proposing will enhance the availability of telehealth and similar options for behavioral health care to those in need, especially in traditionally underserved communities.”
CMS on Tuesday (July 13) proposed to continue covering certain Medicare telehealth services through the end of 2023 as part of the 2022 physician fee schedule and laid out plans for expanded coverage of telehealth for mental health care, just one day after a bipartisan group of House lawmakers asked HHS Secretary Xavier Becerra to use that regulation to avoid a so-called telehealth cliff at the end of the COVID-19 public health emergency.
Reps. John Curtis (R-UT), Doris Matsui (D-CA), Peter Welch (D-VT) and Michael Burgess (R-TX) also asked HHS what criteria it will use to decide which telehealth services are clinically appropriate, when the agency anticipates sharing telehealth use data from the public health emergency, how it will determine fair pay levels for telehealth and how telehealth will work with value-based pay programs.
One lobbyist said the lawmakers are asking the right questions, and stakeholders need the answers from CMS.
In a July 12 letter to HHS Secretary Xavier Becerra, the lawmakers say they want Congress and the department to work together to permanently expand telehealth after the public health emergency. As part of that, they ask for Becerra to lay out the gaps in HHS’ authority where Congress will need to step in to permanently expand telehealth.
Telehealth coverage is expected to continue via waiver through the end of the public health emergency, which the Biden administration said earlier this year would likely last through the end of 2021. A stakeholder letter spearheaded by the Alliance for Connected Care, expected to go to House and Senate leadership later this month, says the expiration of telehealth coverage at the end of the emergency “would have a chilling effect on access to care.”
CMS on Tuesday said the agency is evaluating the temporary expansion of telehealth services during the public health emergency — though Becerra has indicated telehealth services are unlikely to go away.
“As CMS continues to evaluate the temporary expansion of telehealth services that were added to the telehealth list during the COVID-19 PHE, CMS is proposing to allow certain services added to the Medicare telehealth list to remain on the list to the end of December 31, 2023, so that there is a glide path to evaluate whether the services should be permanently added to the telehealth list following the COVID-19 PHE,” a CMS fact sheet on the rule says.
CMS also proposes to require an in-person, non-telehealth service be offered by a physician that provides mental health telehealth services within the six months prior to an initial telehealth service, and at least once every six months after that. However, the Alliance for Connected Care and others are gathering stakeholder support for a letter that seeks to remove what they allege are arbitrary restrictions on telehealth services for mental health.
“Not only is there no clinical evidence to support these requirements, but they also exacerbate clinician shortages and worsen health inequities by restricting access for those individuals with barriers preventing them from traveling to in-person care. Removing geographic and originating site restrictions only to replace them with in-person restrictions is short-sighted and will create additional barriers to care,” the stakeholders’ planned letter says.
CMS also proposes to allow audio-only telehealth for the diagnosis, evaluation, or treatment of mental health disorders furnished to established patients in their homes — but that allowance would be limited. The agency proposes to allow audio-only telehealth for mental health services providers who have the capacity for two-way, audio/video communications, but the beneficiary can’t, or does not consent to, using two-way, audio/video technology.
The agency asks for feedback on whether additional documentation should be required in beneficiaries’ medical records to support the clinical appropriateness of audio-only telehealth for mental health; whether CMS should preclude audio-only telehealth for some high-level services; and any additional guardrails the agency should put in place to minimize program integrity and patient safety concerns.
CMS proposes to allow Rural Health Clinics and Federally Qualified Health Clinics to use telehealth for mental health visits, as well.
“RHCs and FQHCs are not authorized to serve as distant site practitioners for Medicare telehealth services after the end of the COVID-19 public health emergency. However, this proposed change would allow RHCs and FQHCs to report and receive payment for mental health visits furnished via real-time telecommunication technology in the same way they currently do when visits take place in-person, including audio-only visits when the beneficiary is not capable of, or does not consent to, the use of video technology,” the fact sheet says.
CMS also proposes to allow opioid treatment providers to furnish counseling and therapy services using audio-only interactions once the COVID-19 public health emergency ends when audio/visual communication is not available to beneficiaries.
“The COVID-19 pandemic has put enormous strain on families and individuals, making access to behavioral health services more crucial than ever,” said CMS Administrator Chiquita Brooks-LaSure. “The changes we are proposing will enhance the availability of telehealth and similar options for behavioral health care to those in need, especially in traditionally underserved communities.”
The Medical Group Management Association said the proposed 2022 physician fee schedule is a mixed bag. Senior Vice President for Government Affairs Anders Gilberg said the group is “encouraged that CMS heeded our call to expand coverage for audio-only mental health services and views this proposal as a positive step to increase access to vulnerable populations,” but it is concerned by a proposed 3.75% reduction to the conversion factor due to budget neutrality requirements. He said in a statement that MGMA “will seek congressional intervention to avert the cut.”
Stakeholders had been watching to see how CMS would handle the Trump administration’s policies around evaluation and management code changes and other associated policies. CMS’ fact sheet says the agency is “engaged in an ongoing review of payment for E/M visit code sets.” The agency also put forward proposals to change how shared evaluation and management visits are handled, including having the clinician that provides the substantive portion of the evaluation and management bill for the visit.
CMS also proposes to clarify that that the time when a teaching physician is present can be included when determining what kind of evaluation and management code to bill, and how critical care visits should be handled.
The agency also proposes to allow Medicare Part B to directly pay physician assistants starting in 2022, among other policy changes.
Biden’s Two-Track Economic Agenda Hits Turbulence in SenateBloomberg | July 13, 2021
Coalition says health workers should be required to get coronavirus vaccineWashington Post | July 13, 2021
Congress starts summer sprintThe Hill | July 12, 2021
Biden says he’ll enforce Trump-era rules requiring hospitals to post their pricesWashington Post | July 12, 2021
WSC Brief: House Appropriations FY 2022 Labor-HHS Spending BillWSC | July 12, 2021
Biden’s Push for More Competition: What’s in the Executive OrderBloomberg | July 9, 2021
Schumer Warns of Possible August Work on BudgetBloomberg | July 9, 2021
HHS Updates Interoperability Standards to Support the Electronic Exchange of Sexual Orientation, Gender Identity and Social Determinants of HealthHHS Press Release | July 9, 2021
Biden EO Directs HHS To Create Standardized Health Plan OptionInside Health Policy | July 9, 2021
Providers Seek Medicaid Reimbursement Hike For Opioid TreatmentInside Health Policy | July 8, 2021
HHS: Burden Of Proof On Provider Relief Recipients When ReportingInside Health Policy | July 8, 2021
Senate Could Take Up Infrastructure, Budget Resolution As Soon As July 19Inside Health Policy | July 8, 2021
WSC Brief – Site-Neutral Payment: Legislation, Regulation, and LitigationWSC | July 8, 2021
WSC has selected, and provided links, to particular WSC policy briefs and news articles from the past week that our clients may have missed.
Lawmakers are starting to return to Washington, D.C., for a weeks-long summer sprint with some of their biggest priorities hanging in the balance.
The Senate will return on Monday from a two-week July 4 recess. The House will return next week after a three-week break.
Democrats have two big priorities heading into the crucial summer session: Infrastructure and trying to find a path forward on voting rights, after a bill stalled last month in the Senate.
Democrats still need to work out major questions on the strategy for getting President Biden’s sweeping spending plan through Congress with razor-thin majorities and competing factions.
A bipartisan group of more than 20 senators are still working to turn their bipartisan framework, which would spend $1.2 trillion over eight years, into legislation amid skepticism that they’ll be able to find a way to convincingly pay for the bill. Meanwhile, Democrats are still haggling over a top-line figure for a separate, larger bill that they want to pass under reconciliation, which allows them to bypass the 60-vote filibuster in the Senate.
Senate Majority Leader Charles Schumer (D-N.Y.) has vowed to take up both the bipartisan bill and a budget resolution that paves the way for the Democratic-only bill, likely later in the year, before the Senate leaves for a summer recess.
“As Senate Democrats prepare for the upcoming work period, we must approach our work with the same unity and urgency that we have embraced all year. … My intention for this work period is for the Senate to consider both the bipartisan infrastructure legislation and a budget resolution with reconciliation instructions, which is the first step for passing legislation through the reconciliation process,” Schumer wrote in a letter late last week to his caucus.
To get the bipartisan bill through the Senate, Biden and the group are going to have to win over nearly a dozen Republicans and balance demands from progressives who are wary of allowing the smaller bill to move without an “ironclad” guarantee from their moderate colleagues on the details of the larger Democratic bill.
Senate Minority Leader Mitch McConnell (R-Ky.) hasn’t said if he will support the bipartisan plan, saying in Kentucky last week that he believes it needs to be “credibly” paid for.
“I think there’s a decent chance that may come together. All I’ve said is, I would like for it to be paid for,” he said.
Democrats are expected to get no GOP help to pass their second bill under reconciliation, meaning they will need total unity from their 50-member Senate caucus and near unity in the House.
Meanwhile, the party is under growing pressure from outside groups, as well as some members of the House, to figure out a way to break the stalemate on voting rights.
Democrats were able to put up 50 votes last month to advance a sweeping bill known as the For the People Act, after Schumer cut a deal with Sen. Joe Manchin (D-W.Va.) to allow him to get an amendment vote on his narrower version of the bill.
A Senate Judiciary subcommittee is expected to hold a hearing this week on the Voting Rights Act and Sen. Amy Klobuchar (D-Minn.), the chairwoman of the Senate Rules Committee, will hold a hearing next week in Georgia on voting and election access.
Schumer also reiterated in his letter to the caucus that he reserves the right as majority leader to bring the For the People Act back up for a vote. But any election or voting legislation faces a buzzsaw in the Senate because of the legislative filibuster, which requires 60 votes for most legislation to pass.
Biden is under growing pressure to try to sway the holdouts on changing the legislative filibuster to at least support a carveout, warning if they don’t state-level laws will restrict access to the ballot for key voting groups.
House Majority Whip James Clyburn (D-S.C.) told Politico that Biden should “endorse” the idea of creating a carveout to the filibuster specifically for legislation that applies to the Constitution.
Biden could “pick up the phone and tell [Sen.] Joe Manchin, ‘Hey, we should do a carveout,’ ” Clyburn said. “I don’t care whether he does it in a microphone or on the telephone — just do it.”
Capitol Police funding
Senators are at a stalemate over funding for the Capitol Police as it faces a cash squeeze.
The House passed a $1.9 billion emergency supplemental package in May that included roughly $44 million for Capitol Police, would also reimburse the National Guard and D.C. police for their work at the Capitol after the Jan. 6 attack and also includes funding to help “harden” the Capitol and start a Quick Reaction Force to help bolster the Capitol Police.
That bill stalled in the Senate amid Republican skepticism, but the funding crunch sparked new warning bells late last week amid reports that, without an influx of new money, the Capitol Police could be forced to enact furloughs. Sources told The Hill that the Capitol Police could shift around funding from other areas to prevent the furloughs.
Senate Republicans suggested they are open to a more narrow bill that focuses on funding for the National Guard and Capitol Police. The roughly $632 million proposal includes nearly $521 million to the National Guard, roughly $97 million for the Capitol Police and $15 million for the Architect of the Capitol.
“We should pass now what we all agree on: The Capitol Police and National Guard are running out of money, the clock is ticking, and we need to take care of them,” Sen. Richard Shelby (Ala.), the top Republican on the Appropriations Committee, said in a statement.
Republicans would then return to the broader question of funding to help strengthen security measures around the Capitol once an assessment and plan about what steps need to be taken is complete around the Capitol complex, where the last layer of fencing that went up after the attack was taken down over the weekend.
But Sen. Patrick Leahy (D-Vt.), the chairman of the Appropriations Committee, indicated that he wants to go further and will release his proposal, previously made to Republicans, this week.
Leahy argued that the GOP plan didn’t adequately cover the resources needed to secure the Capitol, the cost of investigating and prosecuting the attack or reimburse agencies that assisted. He also signaled that he wants to tie an unrelated issue, special immigrant visas for Afghans who aided the U.S. military, into the bill.
“A violent insurrection happened. A pandemic happened. And the President announced the withdrawal of American troops from Afghanistan. These events created urgent needs that must be met,” he said.
AUMF
The Senate is poised to wade into the debate over repealing a 2002 war authorization passed for the Iraq War, as Congress ramps up its efforts to rein in the executive branch’s war authority.
The closed-door briefing, which is expected to focus on recent strikes in Iraq and Syria, comes after the Senate Foreign Relations Committee postponed an expected vote on a measure from Sens. Tim Kaine (D-Va.) and Todd Young(R-Ind.) that would repeal the 1991 and 2002 authorizations for the use of military force, which are both related to Iraq.
Republicans requested more information from the administration before the committee vote and Foreign Relations Committee Chairman Robert Menendez (D-N.J.) agreed to schedule the briefing. The panel is still expected to vote later this month on the Kaine-Young resolution, which is expected to have enough support to pass out of committee.
Nominations
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