Businesses are worried that public option health plans taking shape in some states may end up costing them more than the high premiums they already pay.
Employers increasingly have been open to government involvement in the health-care system out of frustration for high costs that they have been largely unable to rein in. But they fear plans being put in place by states could result in higher taxes on them or hurt their own plans by peeling off young, healthier workers.
“It will affect our risk pools,” said James Gelfand, senior vice president of health policy for the ERISA Industry Committee. “We need not only as many people as we can get in those pools, but we especially need young, healthy people, and it’s generally predicted that when other options are put on the table, the people who are most likely to take other options tend to be the healthy people.”
Employers worry they will be left with a “sicker, older group of people, and once you cross a certain line there, the employer plans just won’t be viable anymore,” Gelfand said. His group represents companies that provide benefits such as health plans.
Employers pay more for health care than any other payers. Since 2010, average family premiums have increased 55%—at least twice as fast as wages (27%) and inflation (19%)—and hitting over $21,000 in 2020, according to the Kaiser Family Foundation, which tracks the cost of employer coverage.
A public option, which would allow consumers to buy Medicare-like plans in the Affordable Care Act exchanges, was embraced by President Joe Biden in his 2020 campaign platform. However, he didn’t include one in his fiscal 2022 budget. He did express support for the idea of providing premium-free, Medicaid-like coverage through a federal public option plan in states that haven’t expanded Medicaid.
In the absence of federal action, a number of states are taking the lead in setting up their own public option plans, and Washington state is expanding the program it already has in place.
In Washington state, which started the first state public option program in 2021, businesses fear it will lead to higher costs. The program was not as successful as Democratic proponents had hoped it would be at reducing premiums.
Gov. Jay Inslee (D) signed legislation (S.B. 5377) in May that would increase state-financed subsidies in 2022 for ACA exchange enrollees earning up to 500% of the federal poverty level, or $132,500 for a family of four. The law will also expand the public option in 2023 to require hospitals to contract with at least one public option carrier in every county in order to participate in public programs like Medicaid if public option programs aren’t available.
“It’s going to increase the cost of employer-sponsored insurance” to pay for the public option and subsidy programs, Amy Anderson, government affairs director for health care and federal issues of the 7,000-member Association of Washington Business, said.
“There was a premium tax that was proposed this session,” she said. That didn’t pass, but “the concern is as you start to provide more on the public option, increase the subsidy, the state will start taxing the premiums” on each person covered, she said.
But state Sen. David Frockt (D), sponsor of S.B. 5377, said in an email that the premium assessment was intended to fund an expansion of the state’s public health program rather than other programs covered by the law.
“Preliminarily we are seeing public option plans now being proposed to be offered in six additional counties, bringing the total to 25 of our 39 counties, from 19,” Frockt said. “But it’s pretty clear we are not going to see them offered in every county next year, which is the trigger,” so the requirement is likely to kick in, he said.
Nevada and Colorado are the latest states to enact their own plans that are similar to public options.
The Vegas Chamber, Nevada’s largest employer group, opposed the state’s legislation (S.B. 420) because of “unintended consequences that we saw,” Paul Moradkhan, senior vice president of government affairs, said.
Under the Nevada law, signed June 9 by Gov. Steve Sisolak (D), individuals and small businesses will initially be allowed to buy plans on and off the state exchange by 2026. Insurance companies that want to bid as Medicaid providers in the state would have to offer a public option plan for the individual market at premiums that are at least 5% lower than average benchmark ACA premiums in the same area, and 15% lower than average benchmark premiums in the state. Benchmark premiums are for plans on which ACA subsidies are based.
An actuarial study is required before the public option can go into effect, and the bill requires there be no disruption to the market, Nevada attorney James Wadhams, who lobbied for state hospitals and the Vegas Chamber, said in an email.
Nevada businesses fear that costs for people who choose public option plans would be shifted to the private sector, and they worry about the impact it could have on small business plans, Moradkhan said. Many chambers in the state offer association health plans, which cover about 10,000 people, and they fear the costs of those plans would rise, he said.
“Someone’s got to make up for that cost” to cover the 5% reduction for public option plans, he said.
Not all businesses oppose public option plans. Small Business Majority (SBM), which has a network of more than 85,000 small business members, has supported the ACA as well as a public option.
Sarita Parikh, co-founder of glow + gather, a four-person family-owned and operated manufacturer of self-care and home goods based in Castle Rock, Colo., is an SBM member who supports Colorado’s law (H.B. 21-1232) signed June 16 by Gov. Jared Polis (D). The law isn’t a full-scale public option, but it requires insurers in the state’s individual and small group markets to offer plans in 2023 at premiums 15% below 2021 rates on an inflation-adjusted basis.
Parikh, who also has her own physical therapy practice, has continued to buy her own UnitedHealthcare Golden Rule Insurance Co. plan that she’s had since before the ACA was enacted in 2010. She said she hasn’t been able to find an ACA exchange plan that matches her need to keep her long-term neurologist to treat her epilepsy and that would save her money.
Parikh sees a public option as “necessary.”
“I think that we have such limited resources as small businesses for what our options are in health care,” she said. “For small businesses to be competitive and to be able to grow and also attract quality employees, we have to be able to provide health-care, and we don’t have those options and resources.”
She said she hopes the law also will live up to its goal of offering higher-quality plans than those currently on the state exchange.
Hospitals are raising concerns that outstanding COVID-19 provider relief funds and an extension of the Medicare sequester could be used to offset the costs of the $1.2 trillion bipartisan infrastructure deal, after the White House’s outline of the framework said it would be partially offset by repurposing unused pandemic relief funds and extending the mandatory sequester. Hospital lobby groups wrote to Senate leaders Tuesday (June 29) saying Medicare shouldn’t be used to pay for unrelated projects.
“We understand the nation must address core infrastructure needs to allow us to continue to serve our communities and our patients. However, we are opposed to the use of an extension of mandatory sequestration, as well as unspent COVID-19 provider relief funds, as financing sources for any infrastructure package,” America’s Essential Hospitals, the American Hospital Association, Association of American Medical Colleges, Catholic Health Association of the United States, Children’s Hospital Association, Federation of American Hospitals, National Association for Behavioral Healthcare, Premier and Vizient, Inc. say in their June 29 letter to Senate Majority Leader Chuck Schumer (D-NY) and Senate Minority Leader Mitch McConnell (R-KY) (emphasis theirs).
President Joe Biden and a group of Republican lawmakers announced an infrastructure deal last Thursday (June 24), and a fact sheet on that agreement says “Repurpose unused relief funds from 2020 emergency relief legislation”are one of the offsets.
AHA on Friday began raising concerns about what that could mean for providers, as HHS still has not allocated $24 billion in provider relief, nor has it made $8.5 billion targeted to rural providers available.
The hospital groups’ Tuesday letter says providers still need those funds, and the money shouldn’t go toward infrastructure.
“The need for these funds remains strong, as many health care facilities are still recovering from the impact of the pandemic, and unfortunately caseloads have increased in some areas of the country due to new virus variants and a lack of vaccinations,” the hospitals say.
The Sacramento Bee reported that the offset could include COVID-19 relief funds for states like California, while the Wall Street Journal reported broadband funds included in pandemic relief legislation could be included. At press time, the White House had not responded to questions on whether provider relief funds would be included as part of that offset.
Hospitals also say that Medicare sequestration shouldn’t pay for non-Medicare projects. “We cannot sustain additional cuts to the Medicare program,” they say.
Lawmakers in April passed legislation to keep a 2% Medicare sequester cut from going into effect until 2022. However, that law didn’t include a provision from an earlier House version that also would have headed off additional sequester cuts created by the American Rescue Plan.
A one-time infusion of cash for state home health programs will fund worker bonuses and training without meeting the Biden administration’s goal of bolstering wages and benefits in the industry, proposals in six states show. President Joe Biden has proposed injecting the home and community-based services industry with $400 billion, mostly through Medicaid. Biden wants to boost wages for home health workers—who currently make about $13 per hour, often without benefits—and cut down years-long wait lists for in-home care for the elderly and people with disabilities.
Democrats Seek to Advance Biden Home-Care Plan Via Medicaid Cash
Congress put a down payment on that plan earlier this year by offering states a one-year increase in the federal share of Medicaid dollars to expand their home care offerings under a February Covid-19 relief law (Public Law 117-2).
The plans outlined by six states — California, Colorado, Maine, Pennsylvania, Vermont, and Washington — show how state governments want to tap into the billions of federal dollars available to expand their Medicaid home and community-based care services but are limited by the temporary nature of the funding. The money could briefly help more Americans get home care, but won’t reach Biden’s larger goals for the industry.
“You balance a budget on things that are real, not on things that might happen,” Matt Salo, executive director of the National Association of Medicaid Directors, said. “You make plans for what’s real now.”
Groups that advise states on matters such as elder care say they expect almost every state to seek some of these funds this year. For lasting change, the plans suggest the larger home health package that Democrats aim to enact later this year must provide assurances to states that the money is permanent.
California is proposing one of the largest expansions in the nation — which it estimates would bring about $3 billion in new federal funds to the state. It wants to create a pilot program to train workers to serve people with Alzheimer’s disease and related dementia, as well as send a one-time $500 check to home-care workers who served patients for any three-month period in March to December of 2020, when Covid-19 cases rose significantly in the state.
California has been trying to expand training stipends for home-care workers as well, in hopes of countering what the plan calls “high turnover and staffing shortages” created by limited training and low compensation.
“We don’t have enough direct care professionals because people leave the field looking for a career ladder,” said Martha Roherty, executive director of the National Association of States United for Action in Aging and Disabilities, a coalition of state agencies that serve the elderly and people with disabilities. “With some training, you can look at the field as a place to make a career.”
Colorado plans to “supercharge” its existing home and community-based services by expanding eligibility. The state looks to take on projects such as short-term grants for behavioral health crises and transition services for people moving from institutions to their homes.
Pennsylvania is seeking $1.2 billion from the federal government to increase payment rates for some direct-care providers and to protect workers by purchasing personal protective equipment.
Washington plans to use the funds to improve access to home and community-based health services, Vermont wants to increase payment rates for some health-care providers, and Maine aims to put much of the new money into workforce stabilization. Those plans would all be in effect for one or two years.
Top Senator Wants Democrats United on Expanding Home Health Care
Sen. Bob Casey (D-Pa.) introduced a bill recently to bridge these short-term funds with Biden’s pledged influx of a larger, longer federal investment.
Casey said he’s hoping states will lay some of the groundwork for his bill and, hopefully, generate support for the legislation.
“We’re already seeing enthusiasm for this,” Casey said.
Democrats will likely include the bill in a legislative package they plan to advance later this year using reconciliation, a procedure that requires only a simple majority in the Senate. All but 10 senators who caucus with Democrats support Casey’s bill, according to Casey’s office.
The House is preparing to consider H.R. 3684, the Investing in a New Vision for the Environment and Surface Transportation in America Act (INVEST Act).
The legislation includes $547 billion to reauthorize surface transportation programs nationwide, including $5.7 billion in earmarks requested by lawmakers.
Click here to view funding for New Jersey-based projects that would be provided by the INVEST Act.
The nation’s hospitals and health systems continued to see gains across key metrics in May compared to dramatic losses experienced in the early months of the COVID-19 pandemic. Volumes and margins both increased compared to 2020 levels, but remain down compared to 2019. Total expenses and revenues, however, rose above both pandemic and pre-pandemic performance.
The increases came as the severity of the pandemic continued to wane. The 7-day moving average of new COVID-19 cases fell 63% over the course of the month, from 49,478 on May 1 to 18,134 on May 31, according to Centers for Disease Control and Prevention data.1 The 7-day moving average of new admissions for patients with confirmed COVID-19 fell 44%, from 4,805 on May 1 to 2,705 on May 31. Meanwhile, the pace of vaccinations dropped precipitously. The 7-day moving average of daily doses administered fell nearly 60%, from 2.3 million on May 1 to 930,703 on May 31. More than 138.5 million Americans had been fully vaccinated by month’s end.
Despite increases in patient volumes—and in outpatient volumes in particular—hospitals continued to operate on narrow margins. The median Kaufman Hall hospital Operating Margin Index2 was 2.6% in May, not including federal CARES funding. With the funding, it was 3.5%. The median Operating EBITDA Margin for the month was 7.2% without CARES and 8.0% with CARES.
Compared to the first five months of 2020, Operating Margin rose 95.2% year-to-date (YTD) and Operating EBITDA Margin jumped 102.4% YTD in May, not including CARES aid. With the funding, Operating Margin was up 56.6% YTD and Operating EBITDA Margin rose 40.4% YTD.
Compared to pre-pandemic levels in the first five months of 2019, however, Operating Margin was down 20.5% YTD without CARES and down 9% YTD with CARES. Operating EBITDA Margin was down 16.7% from January-May 2021 versus January-May 2019 without CARES, and down 10.7% over the same period with the federal aid.
Increasing patient volumes contributed to the YTD margin increases, especially compared to low volumes seen with national shutdowns and restrictions on non-urgent procedures in the early months of COVID-19. While some volume metrics remained well below 2019 performance, others came close to pre-pandemic levels. Adjusted Discharges were up 9.1% YTD compared to January-May 2020, but fell 7.1% YTD compared to January-May 2019.
Adjusted Patient Days rose 14.3% YTD from 2020 to 2021, but were close to pre-pandemic performance, down 0.4% YTD compared to the first five months of 2019. Emergency Department (ED) Visits were essentially flat—down just 0.2%—compared to January-May 2020, but remained significantly below 2019 rates, down 16.1% compared to January-May 2019. Operating Room Minutes jumped 28.3% YTD from 2020, and were close to pre-pandemic levels, up just 0.8% YTD compared to 2019.
Revenues showed positive gains compared to both 2020 and 2019. Gross Operating Revenue (not including CARES) increased 18.6% YTD from 2020, and 5.9% compared to 2019 levels. Inpatient Revenue was up 13.1% YTD versus January-May 2020, and up 2.9% compared to the same period in 2019. Outpatient Revenue saw the biggest revenue increases, jumping 25.1% YTD above last year’s levels, and 6.8% above 2019 performance as demand for ambulatory services continues to rise post-pandemic.
Adjusted expenses saw some improvements compared to early 2020, but were up compared to 2019 levels. Total Expense per Adjusted Discharge was down 1.7% YTD from January-May 2020, but up 16.6% above January- May 2019. Labor Expense per Adjusted Discharge decreased 1.8% YTD compared to the first five months of 2020, but rose 16.9% YTD above 2019. Non-Labor Expense per Adjusted Discharge was down 1.7% YTD from the same period last year, but up 18.0% compared to pre-pandemic levels.
Across the U.S., initial jobless claims fell below 400,000 in May for the first time since March 2020 as the nation’s economy moved toward full reopening. In early June, Treasury Secretary Janet Yellen told Bloomberg News that higher interest rates due to a growing economy could “be a plus for society’s point of view and the Fed’s point of view,” referring to the possible impacts of President Joe Biden’s $4 trillion spending proposal. That same week, the G-7 nations reached a historic agreement on global tax reform backing a global minimum corporate tax rate of 15%.
Recent performance gains provide positive signs of recovery for the nation’s hospitals and health systems, but there still is a ways to go. While the improvements over the devastating lows of early 2020 are to be expected, comparisons to 2019 offer a clear view of how hospitals are faring relative to pre-pandemic levels.
Read the report.
More than 90% of Americans are unaware of a CMS rule allowing patients to view and compare treatment costs on hospital websites so they can shop for lower priced care, according to a recent Kaiser Family Foundation survey.
While only 9% of seniors have researched treatment prices online, they are more likely to know about the rule change than any other age group. Households with incomes over $90,000 are also more likely to know about hospitals’ requirement to disclose pricing data. But these wealthier households spent less time researching prices than those with incomes under $40,000.
“The low level of awareness of this federal requirement is consistent across different age groups, income levels and health status,” KFF said.
The Trump administration rule, which went into effect on January 1, requires hospitals to make pricing information accessible to patients so that they can shop for lower priced care from different providers. The rule also requires they make available a consumer-friendly display of at least 300 shoppable services, including 70 specified by CMS. Hospitals don’t need to post a list of shoppable services if they allow consumers to use a price estimator tool to calculate their out-of-pocket costs.
Prior to the rule’s implementation, hospitals published aggregate, undiscounted charges for services, but that price is rarely what an insurer or patient would pay.
More than 80% of respondents to the May survey said they have not researched the price of hospital treatments in the last six months.
Experts say that consumers aren’t likely to shop around unless it’s easy. The newly available pricing data is more likely to help third-party app developers, researchers and policymakers.
The Biden administration has promised a crackdown on hospitals shirking transparency obligations. More than 50 hospitals didn’t include payer-specific negotiated rates or didn’t comply with some part of the price transparency rule as of March, according to Health Affairs. A dozen hospitals didn’t post any files or provided links to searchable databases that users couldn’t download.
Nearly 92% of survey respondents with a chronic condition, who are more likely to need hospital care, are either unaware or convinced hospitals do not have to share pricing information online. Only 4% of Black consumers polled were aware of the rule compared to their white (9%) and Hispanic (12%) counterparts. Black consumers are also more likely to suffer from chronic conditions than other groups, according to the Centers for Disease Control and Prevention.
Many adults who searched for prices online weren’t more aware of price transparency requirements, with 33% reporting there was no mandate for hospitals to disclose prices compared to 20% among those who did not search for prices.
CMS started auditing hospital websites and reviewing complaints shortly after the rule took effect. According to an agency spokesperson, the first round of warning letters to hospitals were sent in April. CMS can also fine hospitals up to $300 per day for violating the disclosure requirements.
Some hospitals have been fighting price transparency regulations, arguing that consumers don’t use price estimators to determine their care plans and releasing payer-specific rates could increase prices.
The Supreme Court on Monday (June 28) decided not to take up hospitals’ lawsuit over the Trump CMS’ Medicare Part B pay cuts for outpatient clinic visits at certain off-campus hospital facilities, but the court has not decided whether to look at the lawsuit on reimbursement cuts for 340B drugs that hospitals said was linked to the site-neutral suit.
Hospitals in February asked the high court to take up both cases after winning lawsuits over the so-called site-neutral cuts and the Part B pay cuts for 340B drugs at the district court level only to have the U.S. Court of Appeals for the District of Columbia Circuit overturn those rulings. The providers said the appeals court gave too much weight to HHS’ interpretation of the statute in each situation. As both cases are based on the so-called Chevron defense, which addresses how much flexibility agencies have to interpret laws, the American Hospital Association said the cases are complementary.
The Association of American Medical Colleges also asked the Supreme Court to look at both lawsuits, and America’s Essential Hospitals joined AHA and AAMC in asking the Supreme Court to take up the lawsuit over 340B drug pay cuts in Medicare.
AHA General Counsel Melinda Hatton said hospitals are disappointed the Supreme Court won’t hear the site-neutral case. “These cuts to hospital outpatient departments directly undercut the clear intent of Congress to protect them because of the many real and crucial differences between them and other sites of care.”
The Biden administration had argued there was no reason for the Supreme Court to take up the case.
Still, one lobbyist said some had hoped the conservative judges on the high court might use the case as a way to cut back on the deference that Chevron gives to agencies, but it didn’t go that way.
OSHA’s emergency standard protecting health-care workers from Covid-19 that was issued June 10 after months of anticipation originally was intended to protect all workers, a draft version of the rule obtained by Bloomberg Law showed.
The 780-page draft standard and justification formally submitted to the White House on April 26 made it clear Occupational Safety and Health Administration staff had concluded a “grave danger” threatened the health of all U.S. workers, not just workers in health care who had been deemed essential during the darkest days of the pandemic.
“OSHA has determined that employee exposure to this new hazard, SARS-CoV-2 (the virus that causes COVID-19) presents a grave danger in every shared workplace in the United States,” the draft said. “This finding of grave danger is based on the science of how the virus spreads as well as the adverse health effects suffered by those diagnosed with COVID-19.”
Yet, the final version of the emergency temporary standard that took effect June 21 and has a July 6 compliance deadline for employers limited the standard to only health-care employees, prompting at least two lawsuits by unions seeking a broader regulation.
The White House’s Office of Management and Budget provided a copy of the draft standard in response to a request from Bloomberg Law.
While acknowledging the impact vaccines would have on Americans, the April draft still concluded a standard should apply to all workplaces. As more workers become vaccinated and more was learned about the effectiveness of vaccines, OSHA would have several options—including terminating the standard, revising it, or pausing its enforcement.
“OSHA recognizes the promise of vaccines to protect workers, but as of the time of the promulgation of the ETS, vaccination has not eliminated the grave danger presented by the SARS-CoV-2 virus,” the draft said.
A U.S. Department of Labor spokesperson in a statement Monday defended the health-care only decision.
“On June 10, OSHA announced that it could make the most impact by issuing an emergency temporary standard focused on healthcare settings,” the spokesperson wrote in an email. “This approach closely follows the CDC’s guidance for healthcare workers and the science, which tells us that those who come into regular contact with people either suspected of having or being treated for COVID-19, are most at risk.”
Organized labor supporters said workers will have to rely on non-mandatory guidelines for protection since most industries were removed from the final standard.
“Current guidelines are inadequate, and are not enforceable, resulting in millions of workers left unprotected on the job,” AFL-CIO President Richard Trumka said in a statement to Bloomberg Law. “An enforceable workplace safety standard that protects all workers is key to beating this pandemic.”
OSHA said in its April draft that regulations and non-mandatory guidance from the agency and the Centers for Disease Control and Prevention at the time were insufficient.
“OSHA has determined that each of these tools, as well any combination of them, is inadequate to address COVID-related hazards, thereby establishing the need for this ETS,” the draft standard said.
The final version of the emergency standard also dropped the draft’s requirements for employers outside of health care to track all Covid-19 cases among workers and report hospitalizations and deaths to the agency.
Debbie Berkowitz, safety and health program director for the National Employment Law Project in Washington, said the recordkeeping mandates must apply to all employers “to assure that any possible new outbreak in the workplace is found early.”
A significant difference between the draft and final version of the standard are references to the hazards meatpacking workers faced: The final version, which doesn’t apply to the meat-processing industry, made only five references to meatpacking, while the draft version included more than 30 references.
OSHA sometimes relied on general duty clause citations to convince employers, including meatpackers, to comply with OSHA guidance to protect workers from contracting the virus. The clause requires employers to provide workplaces free of known, lethal hazards that can be mitigated.
“One of the General Duty Clause citations OSHA issued in 2020 was to a large, international employer running a meatpacking plant that failed to take sufficient measures to mitigate the spread of COVID-19 among workers,” the draft said. OSHA determined it could only issue one general duty clause citation with a total proposed penalty of $13,494, the maximum penalty allowed by law for serious violations.
“OSHA has been limited in its ability to impose penalties high enough to motivate the very large employers who are unlikely to be deterred by penalty assessments of tens of thousands of dollars, but whose noncompliance can endanger thousands of workers,” the draft said.
It’s not clear from the draft when OSHA dropped the idea of covering all workers in favor of a health-care-only standard.
President Joe Biden issued an executive order to OSHA on Jan. 21 telling the agency to consider the need for a standard and if warranted, prepare the standard by March 15. But OSHA missed that deadline and more weeks passed. Labor Secretary Marty Walsh said on April 6 he had “ordered a rapid update” of the unfinished standard based on the Centers for Disease Control and Prevention analysis of virus dangers and the latest information on vaccinations and the variants.
The draft rule went to the White House’s Office of Information and Regulatory Affairs for a review on April 26. That’s considered the last step before a regulation is published in the Federal Register and becomes official. During a typical review, other agencies vet a draft standard for possible program and jurisdictional conflicts and to ensure the standard can withstand legal challenges.
The emergency standard spent six weeks under review at OIRA, part of the Office of Management and Budget, where it was the focus of more than four dozen meetings with business and worker representatives before being released June 10 (RIN:1218-AD36).
Howard Shelanski, who led OIRA during the second term of the Obama administration, said in an interview earlier this month the OSHA standard was likely subject to a close OIRA review because as an emergency standard, the proposal hadn’t been through a public comment period where OSHA would have listened to concerns and explained why the standard was needed and viable against a court challenge.
When the standard finally was issued, it applied only to health-care workers; other workers would be protected by updated guidance.
During the months between Biden’s order and the standard’s release, business groups argued increasing vaccination rates were making it implausible for OSHA to claim Covid-19 still posed grave danger to workers. And as OIRA’s review continued, the CDC on April 27 and May 13 updated its guidance, relaxing mask requirements for fully vaccinated people.
Unions and other worker support groups said the standard was still needed to protect unvaccinated workers and serve as backstop if Covid-19 variants made vaccines less effective.
The AFL-CIO labor federation, the United Food and Commercial Workers, and National Nurses United filed lawsuits with federal appeals courts on June 24 asking the courts to review the standard.
The standard “fails to protect employees outside the healthcare industry who face a similar grave danger from occupational exposure to COVID-19,” the AFL-CIO said in its petition for review.
The agency wants to pay home health agencies for the quality of care they provide, instead of the quantity of services delivered. In a new rule released Monday, CMS proposed expanding its Innovation Center’s value-based purchasing model — which previously operated in nine states — nationwide effective Jan. 1, 2022.
The Biden administration is looking to extend Obamacare’s annual enrollment season and allow some of the poorest marketplace customers to buy coverage essentially whenever they want, under a new proposal aimed at bolstering the health care law.
CMS on Monday also proposed rolling back Trump-era rules that Democrats argued would have undermined the marketplaces.
Longer enrollment window: CMS said it wants to lengthen the open enrollment season by 30 days starting this fall. For the last few years, the annual enrollment season has run between Nov. 1 and Dec. 15, and CMS plans to extend the deadline to Jan. 15.
However, the agency plans to eliminate the strict sign-up window for Americans who earn under 150 percent of the federal poverty level. These shoppers, who receive generous premium subsidies, would be allowed to sign up each month.
CMS said the policy could help those who lose their Medicaid coverage at the end of the coronavirus public health emergency, when states are again allowed to remove people from the safety net program.
More reversals: CMS is proposing to pull back a Trump-era policy, approved in the previous administration’s final days, that would have allowed states to eliminate their marketplaces and turn enrollment entirely over to private web brokers and agents.
No state had announced plans to ditch their Obamacare markets, and CMS under President Joe Biden was widely expected to roll back the policy. Trump’s CMS last fall separately approved a decentralized enrollment system for Georgia through an Obamacare waiver program, but CMS has signaled it’s likely to revoke that permission.
The Biden administration is also proposing to rescind a Trump policy that relaxed many of Obamacare’s strict guardrails for approving states’ marketplace changes through the Obamacare waiver program. And CMS will roll back another Trump policy requiring insurers to send a separate monthly bill to cover abortion-related services.
Bigger role for navigators: The agency is proposing to hike HealthCare.gov insurers’ user fees by a half-percentage point to fund expanded responsibilities for groups helping enroll people in plans. These so-called navigators, who will receive a record $80 million in the 2022 enrollment season, will be required to give consumers more information about health coverage and their rights.
The Biden administration Monday loosened requirements for drug addiction treatment providers to dispense methadone through mobile clinics, a move that could help ease access for underserved communities.
A final rule (RIN: 1117-AB43) by the Drug Enforcement Administration provides that narcotic treatment providers wishing to dispense drugs through a mobile component don’t need to separately register for that unit. The rule takes effect July 28.
The rule marks the administration’s latest effort to address America’s addiction crisis. The White House previously said it intended to review policies around the anti-opioid drug methadone and publish a final rule on registering methadone treatment vans.
OVERVIEW
More than four years after the 21st Century Cures Act was signed into law, Reps. Diana DeGette (D-CO) and Fred Upton (R-MI) on Tuesday circulated a discussion draft of their proposed Cures 2.0 legislation, setting the stage for negotiations on the long-awaited legislative package.
In addition to proposing new programs and enhancements for the CMS, the 127-page draft bill includes the Telehealth Modernization Act, a bill that would permanently remove Medicare’s geographic and originating site restrictions and allow the Secretary to permanently expand the types of health care providers that can offer telehealth serves and the types of services that can be reimbursed under Medicare. The proposal would also create the $6.5 billion Advanced Research Projects Agency for Health (ARPA-H) the Biden administration called for in its 2022 budget proposal.
NOTABLE PROVISIONS
Centers for Medicare & Medicaid Services
Extending Medicare Telehealth Flexibilities: This policy would permanently remove Medicare’s geographic and originating site restrictions which require a patient to live in a rural area and be physically in a doctor’s office or clinic to use telehealth services. It would also allow the Secretary of HHS to permanently expand the types of health care providers that can offer telehealth services and the types of services that can be reimbursed under Medicare.
Strategies to Increase Access to Telehealth under Medicaid and Children’s Health Insurance Program: This policy would provide guidance and strategies to states on effectively integrating telehealth into their Medicaid program and Children’s Health Insurance Program (CHIP), review the impact of telehealth on patient health and encourage better collaboration.
Breakthrough Products Act: This policy would codify the current Medicare Coverage of Innovative Technology pathway at CMS.
Expanding Access to Genetic Testing: This policy would provide federal support for the use of genetic and genomic testing for pediatric patients with rare diseases.
Medicare Coverage for Precision Medicine Consultations: Requires the Secretary of HHS to create a pilot grant program within the Center for Medicaid and Medicare Innovation to test approaches to delivering personalized-medicine consultations
Public Health
Long-COVID: Directs HHS to conduct a large national survey of patients who self-identify as having long-COVID to assess sources of health coverage, long-term care coverage, and disability coverage. Additionally, the draft legislation directs HHS to convene a series of national meetings (virtually) to serve as the basis of an ongoing long-COVID learning collaborative with individuals and organizations representing key sectors of the health care community.
National Testing and Response Strategy: Requires a national strategy, based off lessons learned, and best practices developed, as a result of the COVID-19 pandemic, that addresses testing, data sharing infrastructure, administration of vaccines and therapeutics, and medical supply readiness to mitigate future pandemics and public health emergencies.
Pandemic Preparedness Rare Disease Support Program: Requires the Secretary of HHS to develop a plan to help rare disease patients overcome challenges in public health emergencies; and establishes a federal grant program for organizations implement the plan.
Developing Antimicrobial Innovations: This policy would establish a subscription model to pay for critically-needed novel antimicrobial drugs. HHS would provide companies with a federal payment, that is delinked from the sales or use of those newly-developed antibiotics, to ensure a predictable return on investment and improve appropriate use of the drug.
Patients and Caregivers
Ensuring Coverage for Clinical Trials Under Existing Standard of Care: Allows Medicare to cover the costs of their beneficiaries in PCORI-funded clinical trials.
Patient Experience Data: Requires drug manufacturers/sponsors to collect and report on patient experience data as part of the clinical trial. It also requires FDA to fully consider all patient experience data collected during the clinical trial; and requires reporting of patient experience data in a transparent manner that is uniform, meaningful and informative to patients and providers.
Educational Programs and Training for Caregivers: Funds educational programs and training for caregivers to learn skills which would allow them to augment a care team and complement, not compete with, a clinical visit.
Research
Research Investment to Spark the Economy: Provides $25 billion to independent research institutions, public laboratories and universities throughout the country to continue their work on thousands of federally-backed projects.
Advanced Research Projects Agency for Health: Authorizes the creation of ARPA-H. The mission of ARPA-H is to speed transformational innovation in health research and speed application and implementation of health breakthroughs by funding projects that could:
ADDITIONAL INFORMATION
Click HERE for the WSC Brief on the CURES 2.0 discussion draft
After weeks of negotiations, President Biden and a bipartisan group of senators have announced a deal on infrastructure spending. The agreement focuses on investments in roads, railways, bridgesand broadband internet, but it does not include investments Biden has referred to as “human infrastructure,” including money allocated for child care and tax credits for families.
According to the White House fact sheet, the plan will be paid for with unused coronavirus relief funds, unused unemployment insurance and sales from the Strategic Petroleum Reserve, among other measures. It is unclear at this point if “unused coronavirus relief funds” includes the roughly $30 billion remaining in the CARES Act Provider Relief Fund.
WHAT’S IN THE AGREEMENT
Transportation: $312 billion
Other infrastructure: $266 billion
New spending + baseline (over 5 years) = $975 billion
New spending + baseline (over 8 years) = $1.209 trillion
PAY-FORS
Click HERE for the WSC Brief on the Infrastructure Agreement
After weeks of negotiations, President Biden and a bipartisan group of senators have announced a deal on infrastructure spending. The agreement focuses on investments in roads, railways, bridges and broadband internet, but it does not include investments Biden has referred to as “human infrastructure,” including money allocated for child care and tax credits for families.
Health policies aren’t part of the bipartisan infrastructure agreement President Biden and a group of senators announced yesterday.
But the deal did move the ball forward for Democrats on their quest to further expand health coverage and lower drug prices: Now they can push top health priorities in a separate, partisan package later this year.
Until yesterday, it was unclear whether Democrats would need to use a budget reconciliation bill to pass their infrastructure priorities on a partisan basis (budget reconciliation requires just a simple Senate majority to pass). But Biden has signed off on a bipartisan agreement crafted by five Democratic and five Republican senators — meaning Democrats can save a reconciliation bill for later.
The bipartisan measure “would pump hundreds of billions of dollars in new spending into infrastructure projects across the country — handing him, if it survives congressional approval, a significant cross-party achievement,” The Post’s Seung Min Kim, Mike DeBonis and Jeff Stein report.
“We have a deal,” Biden said alongside the senators who had negotiated for weeks on a package to revitalize the nation’s road and transit systems, while upgrading broadband and investing in other public-works projects.
“Biden spoke during an impromptu appearance on the driveway outside of the West Wing of the White House after a shorter-than-expected meeting with senators, in which he delivered his formal endorsement of the proposal crafted by Sens. Rob Portman (R-Ohio), Kyrsten Sinema (D-Ariz.) and eight others in the Senate,” our colleagues write.
“The new agreement is nowhere near as expansive as the $2.2 trillion American Jobs Plan, Biden’s own infrastructure measure that he detailed in April,” they add. “But Democratic leaders have made it clear that they hope to push through, potentially with only Democratic votes, a separate package encompassing priorities such as climate initiatives, paid leave and expanded education.”
Some of the items were already outlined by Biden in his previous spending proposals, including $200 billion for permanently expanding the federal subsidies that make private insurance plans sold on HealthCare.gov and state-run marketplaces more affordable. Congress already expanded the subsidies, but only temporarily.
Biden has also proposed $225 billion to create a new paid family leave program, administered by the Social Security Administration, and $400 billion on long-term care.
There’s drug pricing legislation, too. Earlier this month, House Energy and Commerce Chairman Frank Pallone Jr. (D-N.J.) said he’s aiming to get H.R. 3 attached to a spending package this year. The measure allows the federal government to directly negotiate lower drug prices and caps out of pocket spending for prescription drugs in the Medicare program.
And then there’s legislation to get more people enrolled in Medicare and Medicaid. Sen. Bernie Sanders (I-Vt.) has been floatinglegislation to lower the Medicare eligibility age to 60 and expand its coverage to include vision and dental. In the House, Democrats have been working on ways to get Medicaid expansion to people in states where GOP policymakers still refuse to expand it themselves.
A top senator is trying to unify Democrats in supporting a massive investment in home- and community-based health-care services, but faces slim margins in both chambers of Congress.
Sen. Bob Casey (D-Pa.) Thursday unveiled his plan to make what he calls a “historic investment” in Medicaid home- and community-based services. The goal is to cut down the waitlists for such services for the elderly and disabled, as well as improve pay for home-care workers.
“We can’t just say we’re going to expand Medicaid to get rid of the waiting list—but we’re still going to have the same $12-an-hour-workforce,” Casey said in an interview. “We want that balance.”
Casey said he’s found no support from Republicans for the plan, and hopes to pass the measure as part of a larger jobs and infrastructure package with only Democratic votes in the Senate.
That means Casey will need to unify Democrats behind his plan in a 50-50 split chamber. Already 40 Senate Democrats have signed onto the legislation.
Casey told reporters Thursday that the main obstacles are likely the price tag and finding ways to pay for it. The plan would authorize $100 billion for state grants, but the final cost may wind up much higher, depending on how many states elect to participate.
Helping Casey’s effort: unions and domestic workers groups that often align with Democrats are backing the proposal, saying it’s an essential start to better pay and benefits for home-care workers.
“So many years we’ve been pushing on this, with no traction,” Ai-jen Poo, executive director of the National Domestic Workers Alliance, said.
The U.S. overall spent $379 billion in 2018 for long-term services and support—which are used to help seniors and people with disabilities with tasks such as preparing meals, bathing, dressing, and managing medication or mobility, according to figures from the Kaiser Family Foundation. Medicaid paid for more than half of the total, which includes nursing home and home health services.
Biden $400 Billion Care Plan Would Have a Caveat: States Opt In
Demand for home health services is already high: almost 820,000 people in the U.S., most with intellectual or developmental disabilities, are on waiting lists to get home- or community-based care.
Home health aides and personal care aides represent the sixth-fastest growing occupation in the country, according to Labor Department data, and get paid about $12.15 per hour, or $25,280 per year.
In many areas those earnings aren’t enough: Most home health aides qualify for federal help such as food assistance and Medicaid, according to research from PHI, a nonprofit that focuses on direct care workers.
Casey said injecting Medicaid programs with as much as $400 billion over eight years might not solve all these problems, but will go a long way to bolstering the industry.
“I’m certain of one thing: if we don’t make this investment now these waiting lists will grow exponentially,” Casey said.
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