On the week of October 28, the Senate began deliberation on a Labor-HHS appropriations bill for fiscal year (FY) 2020. Senate Majority Leader McConnell filed cloture on the motion to proceed to the House-passed Labor-HHS spending bill (H.R. 2740). However, on October 31, the vote to pass the House bill and begin floor debate failed in a 51-41 vote.
Congress has a November 21, 2019 deadline to enact funding for FY 2020. If a bill is not passed by then another continuing resolution will need to pass. Members indicated this week that a continuing resolution could extend into early spring of 2020.
NOSORH is working with Congress to ensure the State Offices of Rural Health line is funded at the House-passed level of $12,500,000 for FY ’20. The current Senate measure only includes $10,000,000 in funding.
Telehealth Package Introduced:
On October 30, a bipartisan group of lawmakers reintroduced the CONNECT for Health Act, a bill intended to expand payment for telehealth services. The comprehensive telehealth package would remove geographic restrictions on payment for various services, including for virtual mental health treatment.
The bill, S. 2741, would also allow patients to get coverage for treatment they receive at home. The bill would also encourage CMMI to test out a new telehealth payment model for Medicare and allow some restrictions on telehealth coverage to be waived during national and public health emergencies.
The bill was introduced by Senators Brian Schatz (D-HI) and John Thune (R-SD). A companion measure, H.R. 4932, was introduced on the House side by Rep. Mike Thompson (D-CA). While the telehealth package is unlikely to pass as a stand-alone package, a number of provisions from the bill could be advanced in other legislative vehicles. Last Congress a number of provisions included in the CONNECT Act made it into the 2018 Bipartisan Budget Act.
Trio of Rural Health Bills Introduced:
On October 29, three rural health-related bills were introduced in the House.
Companion bills were introduced in the Senate earlier this year by Senator Marsha Blackburn (R-TN). Earlier this summer, Senate Finance Committee Chairman Chuck Grassley (R-IA) indicated the committee may look to advance a more comprehensive rural health bill. Were that to occur, these bills could be in consideration.
Action Needed for SORH Appropriation
NOSORH is asking State Offices to contact their Senate members and request that House and Senate conferees agree to the House appropriated and Congressional authorized number for the SORH. In 2018, Congress passed and the President signed into law (Public Law 115-408), the State Offices of Rural Health Reauthorization Act of 2018 (S. 2278). The law authorizes the appropriation of $12,500,000 for the SORH grant program for each of fiscal years 2018 through 2022. Feel free to share this SORH Appropriations Factsheet.
Senate Releases FY 2020 Labor-HHS Appropriations Bill
On September 18, Senate appropriators released a draft FY 2020 appropriations bill for the departments of Labor, Health and Human Services (HHS), Education and related agencies. The draft Senate Labor-HHS bill included reductions in overall rural health spending compared to its House counterpart.
The Senate bill would fund the State Offices of Rural Health (SORH) at $10 million annually compared to the $12,500,000 the House appropriated. If the Senate bill passes in its current form, the two chambers would need to reconcile a number of substantive differences on both spending levels and policy provisions including the SORH line.
Congress Averts Shutdown, Passes CR
On September 26, the Senate passed a continuing resolution (CR) that funds the federal government at the Fiscal Year (FY) 2019 rate until November 21, 2019 and avoids a government shutdown. Senate passage of H.R. 4378 clears the way for President Trump to sign the bill by September 30, the final day of FY 2019.
The CR delays the $4 billion Medicaid disproportionate share hospital (DSH) payment cuts scheduled to take effect October 1. This is especially timely as earlier this week, CMS finalized its rule implementing cuts to state Medicaid DSH allotments by $4 billion next year. Under this rule, DSH payments will set cuts worth $8 billion for the following five years. These cuts are set to take effect November 22, 2019. Additionally, it extends the Certified Community Behavioral Health Clinic demonstration program through November 21. The legislation also extends funding for Community Health Centers, the National Health Service Corps, Teaching Health Centers that operate graduate medical education programs, among others.
Lawmakers from both parties are optimistic that this will be the only continuing resolution needed for funding fiscal year 2020, which begins October 1. However, ongoing disputes on issues including abortion policy, the border wall, and spending levels for non-defense programs could lead to several more stopgap measures.
On July 25, the House of Representatives passed a two-year budget agreement (H.R. 3877) that establishes the framework for Congressional spending over the next two fiscal years and suspends the debt limit through July 31, 2021. The Senate is set to pass the House agreement this week and will be signed into law. With the budget in place, Congress will begin work on passing fiscal 2020 spending bills. The Senate Appropriations Committee has yet to release any of the 12 annual spending bills and is expected to introduce the bills in September.
The Republican-controlled Senate will need to pass, and then reconcile differences with the Democrat-controlled House, who has already passed 10 of 12 FY ’20 spending bills. In order to pass the often partisan Labor-HHS-Education spending bill, Congress could pair it with the traditionally more bipartisan Defense spending bill, similar to last Congress (PL 115-245). Fiscal Year 2020 begins October 1, 2019, leaving Congress only 15 legislative days to fund the federal government.
Earlier this year, the House passed their version of the House Labor-HHS-Education bill which included a $2.5 million increase in State Office of Rural Health grant funding over FY ‘19. Also included in the spending bill is $59 million for Medicare Rural Hospital Flexibility Grants and $19,942,000 for the Small Rural Hospital Implementation Grant Program.
Congress and Administration Focus on Rural Health Delivery:
On July 16, the House Ways and Means Committee announced the creation of the “Rural and Underserved Communities Health Task Force.” The purpose of the task force is to discuss the challenges of delivering health care in rural and underserved areas and explore holistic bipartisan policy options that could improve outcomes and care in these communities. The four co-chairs leading the panel will be Reps. Danny Davis (D-IL), Terri Sewell (D-AL), Brad Wenstrup (R-OH) and Jodey Arrington (R-TX). The Task Force held its first meeting on Thursday, July 25.
Also in July, the Health Resources and Services Administration (“HRSA”) awarded approximately $20 million in Rural Residency Planning and Development Program (“RRPD”) grants. Recipients across 21 states will receive up to $750,000 over a three-year period to develop new rural residency programs while achieving accreditation through the Accreditation Council for Graduate Medical Education. The RRPD program is part of HRSA’s multi-year initiative to expand the physician workforce in rural areas by developing new, sustainable residency programs in family medicine, internal medicine and psychiatry.
Rural Health Bills Introduced in July:
Sen. Robert P. Casey Jr. (D-PA) introduced S. 2157 to amend Title XI of the Social Security Act to expand the use of global payments to hospitals in rural areas.
Rep. Anthony Brindisi (D-NY) introduced H.R. 3672 to provide relief for small rural hospitals from inaccurate instructions provided by certain Medicare administrative contractors.
Appropriations Process Rolls Along
On May 9, the House Appropriations Committee passed by a vote of 30-23 the annual Labor-HHS spending bill for the upcoming fiscal year. The full-committee passage came two weeks after the House Labor-HHS Appropriations Subcommittee introduced their fiscal year (FY) 2020 spending bill.
As passed by the committee, the bill provides $12,500,000 for the State Offices of Rural Health, a $2.5-million-dollar increase over FY 2019 funding. Also included in the spending bill is $59 million for Medicare Rural Hospital Flexibility Grants and $19,942,000 for the Small Rural Hospital Implementation Grant Program. The next step for the Labor-HHS bill is before the full House of Representatives, which hopes to pass the bill no later than June 27.
The Senate Appropriations Committee has yet to introduce any of their spending bills for FY 20. Senate Appropriations Chairman Richard Shelby (R-AL) has indicated the Senate’s desire to pass a disaster relief bill before embarking on the annual appropriations bills. The Senate and House bills are expected to significantly differ with the House bill having controversial policy riders included in the committee-passed bill.
Funding for FY 2020 expires in 123 days on September 30, 2019.
HELP Committee Leaders Release Draft Bill Targeting Health Care Priorities
Senate Health, Education, Labor, and Pensions (HELP) committee leaders Sen. Lamar Alexander (R-TN) and Sen. Patty Murray (D-WA) released a wide-ranging draft bill addressing health care issues such as surprise medical billing, prescription drug costs, and urgent public health concerns. The proposal is separated into five main sections: approaches to tackling balance or “surprise” medical billing, reducing prescription drug costs, increasing transparency in health care, bolstering public health, and improving the exchange of health IT. According to Sen. Alexander, legislation combining these proposals with ones from the Senate Finance Committee will be marked up this summer with the goal of having it reach the President’s desk by July.
For surprise medical bills, patients would be tasked with paying bills as if they are receiving in-network care when they are unexpectedly treated out-of-network in an emergency situation or at an in-network facility.
The proposal includes several measures addressing public health concerns, including combating vaccine misinformation and maternal mortality. To increase transparency in the health care system, the draft proposes to require plans to maintain updated provider directories. Plans and providers would also be required to give patients estimates of their expected out-of-pocket costs within 48 hours of a request. The draft also contains many drug pricing provisions, such as speeding low-cost generic drugs to market.
The committee is requesting comments on the discussion draft. Comments must be submitted to LowerHealthCareCosts@help.senate.gov by 5 PM on Wednesday, June 5, to be considered. A section-by-section summary can be found here.
Rural Health Bill Introduced this Month
Senators Brian Schatz (D-HI) and Lisa Murkowski (R-AK) introduced the Expanding Capacity for Health Outcomes Act of 2019 (ECHO Act). The bill is intended to increase access to health care services in rural areas by expanding the use of technology-based collaborative learning and capacity building models. The bill builds on findings of the 2016 ECHO Act that was signed into law and required HHS to examine ECHO models and report to Congress.
The ECHO model is an innovative medical education program that uses interactive videoconferencing to link specialist teams with primary care providers in rural areas. The bill, S. 1618, would create a program to provide grants and technical assistance to further develop and evaluate the ECHO model and similar models.
Reps. Mark Green (R-TN) and Bennie Thompson (D-MS) introduced H.R. 2990 to amend title XVIII of the Social Security Act to permit States to designate without any mileage limitations facilities that are located in rural areas as critical access hospitals. The bill would repeal the “35-mile rule” that currently bars hospitals from pursuing a Critical Access Hospital (CAH) designation.
Currently, a rural hospital must be at least 35 miles away from another hospital to receive the CAH designation. If passed, the bill would allow states to designate a facility a CAH if it meets the other requirements: (1) the hospital must have 25 or fewer inpatient beds; (2) must provide 24/7 emergency care services; and (3) the average length of stay for acute care patients must be 96 hours or less.
The following update was provided by Hall Render, NOSORH Policy Liaison:
FY 20 Spending Bills Introduced in Congress
On April 29, the House Labor-HHS Appropriations Subcommittee introduced their fiscal year (FY) 2020 spending bill. The bill provides $12,500,000 for the State Offices of Rural Health, a $2.5 million increase over FY 2019 funding. Also included in the spending bill is $59 million for Medicare Rural Hospital Flexibility Grants and $19,942,000 for the Small Rural Hospital Implementation Grant Program. The House subcommittee meets on April 30 to advance the spending bill to the full House Appropriations Committee. The Senate Labor-HHS subcommittee is expected to introduce their spending bill in May. Funding for FY 2020 begins on October 1, 2019.
CMS Proposes Changes to How Rural Hospitals Are Paid
On April 23, CMS issued its proposed hospital inpatient payment update for fiscal year 2020. In particular, CMS proposed changing the formula to reimburse rural hospitals. The proposal changes how it calculates the Medicare wage index to limit the disparity between what high-and-low-wage index hospitals get paid. If implemented, the rule would increase the wage index for hospitals below the 25th percentile, and decrease the wage index for hospitals above the 75th percentile. The proposal would be in effect for at least four years starting this October. Decreases in a hospital’s wage index would be capped at five percent for FY 2020. The Medicare wage index has long been a source of frustration for Congress. The deadline for submitting comments on the proposed rule is June 24, 2019.
House Committee Advances Legislation to Bolster ACA
During the first week of April, the House Energy and Commerce Committee advanced six measures intended to bolster the ACA. The measures include more funding for state-based ACA marketplaces, federal navigator programs and a reinsurance bill intending to lower ACA premiums (H.R. 1385, H.R. 1386, H.R. 1425).
The three other measures passed are focused on Trump administration policies aimed at changing the ACA: H.R. 1010 reverses the administration’s expansion of short-term health plans; H.R. 986 requires the administration to rescind guidance that made it easier for plans to soften protections for pre-existing conditions; and H.R. 987 that would restore ACA outreach and enrollment funding.
This legislation was advanced hours after the House passed a resolution condemning the Trump administration’s decision to support a federal court case in Texas that repeals the ACA. In a 240 to 186 vote, the House passed a resolution calling on the Justice Department to “halt its new advocacy for abolishing the Affordable Care Act,” which the measure calls ‘an unacceptable assault’ on Americans’ health care. The resolution is largely symbolic, as the Republican-led Senate will not advance the measure.
Rural Health Bills Introduced this Month
Sen. Shelley Moore Capito (R-WV) introduced S. 1190 to amend Title XVIII of the Social Security Act to provide for payments for certain rural health clinic and federally qualified health center services furnished to hospice patients under the Medicare program. The bill would remove a statutory barrier in current law that inhibits seniors’ access to hospice in rural communities, allowing them to receive hospice from their local primary care practitioner. The bill seeks to allow RHCs and FQHCs to receive payment for practitioners’ services while caring for their patients in hospice care.
Sen. Todd Young (R-IN) introduced S. 1045 to amend the Public Health Service Act to expand the authority of the HHS Secretary to permit nurses to practice in health care facilities with critical shortages of nurses through programs for loan repayment and scholarships for nurses.
The NOSORH Policy Committee asks that all SORH and their partners reach out to their members on appropriations. NOSORH is seeking an increase in appropriations for the SORH line to $12.5 million to match the SORH authorization language. Please check in with your members of the appropriations committee to ensure their support of increased appropriation, determine the deadline for any requested submission and ask for their support. Please contact Andrew Coats, Legislative Liaison, if you need assistance or with any questions.
President Releases Fiscal Year 2020 Budget Proposal
On March 11, President Trump released his administration’s fiscal year 2020 budget. As it goes for every presidential budget, the proposal stands zero chance of being implemented in its entirety. The condensed version of the budget can be found here.
The Health Resources and Services Administration’s (HRSA) budget request does not request funding for the Rural Hospital Flexibility program, State Office of Rural Health, and the Rural Residency Planning and Development. The lack of the funding has been consistent with HRSA budget requests in recent years. With Congress passing into law the Reauthorization of the SORH program at the end of the 2018, we remain hopeful that Congress will fund the SORH line as called for in recent law.
Other health care priorities include:
Medicaid: The budget calls for trillions in cuts to the growth of Medicaid (and Medicare). The administration is seeking to overhaul Medicaid through block grant funding. By implementing block grant or per capita caps, this would cut $1.5 trillion over 10 years in Medicaid spending.
340B: The budget also calls for giving HRSA more control over 340B by asking for “broad regulatory authority for 340B to set enforceable standards of program participation.” The budget requests Congress require hospitals to report their 340B savings and explain how the money is used. This was included in last year’s budget, and there were a couple bills introduced last Congress mirroring this. If Republicans couldn’t move this last year, there is little chance in the new Congress.
Bad Debt and Uncompensated Care: The budget calls for bringing “transparency to several Medicare payments to hospitals.” The proposal calls for reducing the reimbursement for bad debt from 65 percent to 25 percent over three years starting in fiscal year 2021. Rural hospitals with fewer than 50 beds, critical access hospitals, rural health clinics and FQHCs would be exempt. The budget also proposes to cut uncompensated care payments. Starting in fiscal year 2021, uncompensated care payments would be made to hospitals based on their share of charity care and non-Medicare bad debt, as included on their Medicare cost-reports. The bad debt proposal would save $38.5 billion over 10 years and the uncompensated care proposal would save $98 billion over 10 years.
Others: Another hospital-related proposal of note would consolidate the Hospital Value-Based Purchasing Program, Hospital-Acquired Condition Reduction Program and Hospital Readmissions Reduction Program into a single program.
House Democrats Unveil Single-Payor Legislation
House Democrats introduced sweeping “Medicare for All” legislation, providing the most detailed plan to overhaul the current healthcare system by enrolling all U.S. residents in a single-payer, government-run health plan. It would cover a more expansive set of benefits than the current Medicare program and restructure payment for institutional healthcare providers such as hospitals and skilled nursing facilities. The measure does not include a price tag or specific proposals for financing the new system, which analysts estimate would cost tens of trillions of dollars over a decade. The lead sponsor, Rep. Pramila Jayapal (D-WA), said she will release a separate list of suggested funding mechanisms.
The single-payor, government-run healthcare system under Medicare for All would cover a range of services at no out-of-pocket cost to patients. The measure would not only cover primary and preventive care, as well as inpatient and outpatient hospital services, but also long-term care support services that are not currently covered by Medicare. Every insurance program in the U.S. would be changed, leaving only the veterans’ health program and the Indian Health Service in place. Providers such as hospitals or skilled-nursing facilities would be paid through a global budget so that hospitals would receive a quarterly lump sum to cover items and services. Additionally, individual providers would be paid based on a national fee schedule set by the HHS secretary. A section-by-section summary of the bill, along with other information on the legislation, can be found here.
Senator Pat Roberts (R-KS) was recently recognized as the NOSORH 2018 Legislator of the Year for his sponsorship of the SORH reauthorization bill. Cynthia Snyder, Director of the Kansas Office of Primary Care and Rural Health, and Teryl Eisinger, NOSORH Executive Director, presented his award at the NRHA Policy Institute last month. Senator Roberts met with NOSORH representatives and shared his experiences and vision for rural health. “Senator Roberts has been a champion for rural health throughout his career,” said Snyder. “He has made tremendous strides to improve the quality of rural health care and access to it. I’m pleased that NOSORH has recognized his numerous achievements in this area.”
Other State Offices of Rural Health were also well represented at the Policy Institute. A NOSORH members meeting at the Institute included updates from FORHP with information on upcoming new programs, discussion of the NOSORH request for additional appropriation and a toast to Andrew Coats and the Policy Committee for their efforts in achieving SORH reauthorization.
The following update was provided by Hall Render, NOSORH Policy Liaison:
Federal Budget Season Heats Up
With the 35-day shutdown throughout January, funding for the fiscal year 2020 budget and appropriations cycle has been pushed back a month. The President’s budget request, which is normally released in early February, should be released by mid-March. The late release date provides Congress with a tightened window to pass FY 2020 spending bills by the start of the new fiscal year, October 1, 2019. It has been reported that President Trump will propose a five percent cut to non-defense discretionary spending in his upcoming budget proposal to Congress. “With House Democrats supporting spending increases to non-defense spending, the President’s proposal won’t survive Congress,” said Andrew Coats, NOSORH’s Legislative Liaison.
HRSA Announces Upcoming Rural Grant Funding Opportunity
On February 4, the Health Resources and Services Administration’s (HRSA) Federal Office of Rural Health Policy announced plans to award approximately 75 grants of up to $1 million. The grants would seek to expand opioid and other substance use disorder services in high-risk rural communities. The grant award will cover a three-year period and require awardees to implement a set of core substance and opioid use disorder prevention, treatment and recovery activities that align with HHS’s Five Point Strategy to Combat the opioid crisis. All domestic public and private entities, nonprofit and for-profit, will be eligible to apply. The services must be provided in a HRSA designated rural area. HRSA intends to release a notice of funding opportunity in the coming weeks.
CMS Unveils Overhaul of Medicare Payment for Emergency Treatment
On February 14, CMS launched a voluntary payment experiment, the Emergency Triage, Treat and Transport (“ET3”) model, allowing first responders more flexibility to treat patients on the scene, through telehealth or at an urgent care clinic. CMS will pay participating ambulance teams to transport patients to hospital emergency departments, transport patients to other settings like a primary care physician’s office, use telehealth or provide care on the scene under supervision of a qualified practitioner. Currently, Medicare reimburses ambulance providers if they transport patients to the hospital, skilled nursing facility or dialysis center. The voluntary demonstration will likely begin in 2020 and run for five years. CMS will phase in the model across the country and will phase it to 30 percent of emergency room visits.
ACE Kids Act Reintroduced in the Senate
On February 5, Senate Finance Chairman Chuck Grassley (R-IA) reintroduced a bipartisan bill intended to provide states with the option of providing coordinated care for children with complex medical conditions through Medicaid.
The Advancing Care for Exceptional Kids Act is intended to make it possible for home health providers to coordinate care, lower costs and improve quality outcomes for children with complex medical conditions on Medicaid who require specialized care. The bill (S. 317) was referred to the Senate Finance Committee, which has jurisdiction over Medicaid.
The following update was provided by Hall Render, NOSORH Policy Liaison:
Short-Term Funding Deal Reached to End Government Shutdown
On January 18, President Trump announced a deal to temporarily reopen the federal government and end the longest shutdown in U.S. history. The deal funds the remaining federal agencies until February 15, giving lawmakers more time to try to work out a compromise on the immigration and border security issues. President Trump called on the Senate to bring the proposal to the floor for a vote immediately. The House is hoping to clear the bill by unanimous consent. The agreement is considered the product of negotiations between the Senate’s top leaders, Majority Leader Mitch McConnell (R-KY) and Minority Leader Chuck Schumer (D-NY), who met on Thursday following the failure of two measures in the Senate to reopen the government.
While the shutdown did not impact HHS-related programs, some rural health programs and projects could be delayed due to the month-long shutdown. Projects including hospitals and addiction treatment facilities backed by grants awarded last fall by the USDA’s rural development program could be impacted. Congress now has less than three weeks to come up with a solution for a border security deal, however most lawmakers believe another shutdown this year is unlikely.
Senate Clears Medicaid Extenders Measure
On January 17, the Senate passed by voice vote legislation to extend certain Medicaid policies known as “extenders.” The measure will go to the president’s desk for signature since the House passed the bill. The extenders were passed late last session by both the House and the Senate but through different bills that were never signed into law.
This bill alters several Medicaid programs and funding mechanisms. Specifically, the bill includes $112 million for a roughly three-month extension of the Money Follows the Person demonstration, which helps state Medicaid programs transition older adults and people with chronic illnesses back into their communities. It also temporarily extends the applicability of Medicaid eligibility criteria that protect against spousal impoverishment for recipients of home- and community-based services. Additionally, it reduces the federal medical assistance percentage (i.e., federal matching rate) for states that have not implemented asset-verification programs for determining Medicaid eligibility and reduces funding available to the Medicaid Improvement Fund beginning in FY 2021.
Rural Health Related Bill Introduced
On January 18, Senate Health Committee Chairman Lamar Alexander (R-TN) and Ranking Member Patty Murray (D-WA) introduced legislation that extend community health centers and four other federal health programs. The legislation (S. 192) would provide five years of mandatory funding for the Community Health Center Program, National Health Service Corps, Teaching Health Center Graduate Medical Education Program, Special Diabetes at the NIH, and Special Diabetes for Indians. Mandatory funding for the programs is set to expire after September 30, 2019. The Senate HELP Committee is scheduled to hold hearings on the programs and will likely vote to advance the bill later this year.
The 2019 National Rural Health Association Policy Institute is in Washington, D.C. on February 5-8, and NOSORH has resources to help you prepare for the conference. NOSORH will be hosting the webinar “Preparing to Engage with Legislators & Policymakers” on January 17th at 1:00 pm ET. This webinar will focus on understanding the environment on Capitol Hill, SORH legislative priorities for the new Congress, and how to “orient” new congressional members (and resources available) and conduct a Hill visit with state partners. Click here to register for the webinar.
In addition, one-page state profiles, like this one from South Carolina, are available to help SORH document the impact of their work. For help in completing your state’s profile, please contact Donna Pfaendtner at firstname.lastname@example.org no later than Friday, January 25, 2019. A SORH factsheet will be provided for your use at the Policy Institute and Hall Render staff will be available to join you on Hill visits.
While in D.C., be sure to attend the NOSORH Members Meeting on Tuesday, February 5th at 6:00 pm ET in the Capitol Room. Stay tuned for more details about this meeting.
For more information, please contact Matt Strycker at email@example.com