Senate Introduces Virus Funding Proposal:
On July 27, Senate Majority Leader Mitch McConnell (R-KY) introduced the Health, Economic Assistance, Liability Protection and Schools (HEALS) Act. The HEALS Act is a package of COVID-related funding bills and represents the Senate’s opening offer on passing the next round of emergency funding. Similar to the House proposal passed in May, the Senate package has not drawn bipartisan support. The deadlock will most likely mean a narrow agreement is eventually passed before the Senate leaves town on August 7. Some of the must-fund items which could be included in a narrow package are extending Unemployment Insurance, school funding and additional PPP and hospital funding.
Included in the HEALS Act is an appropriations section which includes more than $118 billion in emergency funding for HHS. Of that amount, $225 million would be allocated for Rural Health Clinics from the Public Health and Social Services Fund; $7.6 billion would go towards community health centers out of the Public Health and Social Services Emergency Fund; and $25 billion would go to hospitals out of the provider relief fund.
The Senate proposal also included language extending Medicare telehealth waivers through December 31, 2021, unless the public health emergency gets extended beyond that date. Telehealth expansion for FQHCs and RHCs would last for five years. The bill would continue the telehealth expansion from the CARES Act for five years beyond the end of the public health emergency, enabling beneficiaries to receive telehealth from those providers – which could act as a distant site – regardless of where beneficiaries are located. The bill would also have a MedPAC report on the impact of telehealth flexibilities on access, quality, and cost by July 1, 2021. HHS would be required to post data on telehealth use during the pandemic and give Congress recommendations on how to handle such coverage.
The Senate proposal also addresses the Medicare advanced and accelerated payments provided to hospitals through CARES. The Senate bill would delay until January 1, 2021, the date when providers would need to start repaying Medicare Part A and B loans. It also would provide additional time until the loans must be repaid in full prior to having to pay interest.
The HEALS Act contains liability reforms for providers and health care facilities. It seeks to create an exclusive cause of action for personal injury caused by the treatment, diagnosis, or care directly affected by COVID-19. The cause of action would apply to all COVID-19 related injuries from last December through October 1, 2024 – including cases already pending. Under the bill, plaintiffs in these cases would need to show their injuries were caused by the defendants’ gross negligence or willful misconduct. Damages would also be limited to economic losses and punitive damages would be prohibited.
FY 2021 Appropriations Moves in the House:
On July 30, the House passed H.R. 7617, which is an omnibus package of Fiscal Year (FY) 2021 appropriation bills including funding for the Department of Health and Human Services. The House passed bill would fund the State Offices of Rural Health grant program at $12,500,000 for FY 2021, which begins October 1, 2020. The bill also funds the Flex Program at $55,609,000 and the Small Rural Hospital Improvement Grant program at $21,942,000 for FY ’21.
The Senate has not begun their appropriation process which means a Continuing Resolution will most likely be passed to extend FY 2020 funding through the November election.
Congress Picks up Pace as June turns to July
The House is back in session for the final week of June and is expected to meet throughout July. During the week of June 29, the House will vote on H.R. 1425, the Patient Protection and Affordable Care Enhancement Act. The bill will most likely pass on party lines and is not going to be taken up by the Senate. The legislation would expand the ACA’s tax credits, pressure states to expand Medicaid programs with the promise of more federal funding, and cap individual premiums at 8.5% of their income. The bill also allows immigrants living in the US under DACA to get access to subsidized insurance plans.
Beginning the week of July 6, the House will begin marking up Fiscal Year 2021 appropriation bills. The Labor-HHS bill, which sets the funding level for the SORH, FLEX and other rural health programs, is included in the HHS funding bill and is scheduled for markup July 7. The full House is expected to consider the bills on the floor the weeks of July 20 and July 27. The Senate will most likely not begin the markup process until September. Expect Congress to pass a continuing resolution through the November election.
Also beginning the week of July 6, the Senate is expected to begin negotiations with the White House on the next COVID-legislative package. During June, the Senate HELP Committee held a telehealth hearing that looked into which of the 30-plus temporary telehealth changes should be made permanent post-COVID-19 emergency. HELP Chairman Alexander (R-TN) called for Medicare to permanently lift restrictions on telehealth coverage for rural areas. Look for the next Senate COVID legislative package to include language making some of the temporary rural provisions permanent.
Rural Health-Related Bills Introduced in June
Rep. Sherrill (D-NJ) and Hern (R-OK) introduced the “protect Telehealth Access Act.” H.R. 7391 seeks to eliminate a requirement that someone receiving telehealth services must be located in a rural area or health professional shortage area, and that the person may only get telehealth services at home and in limited circumstances. Here is the press release.
Rep. Liz Cheney (R-WY) and Rep. Jason Smith (R-MO) introduced H.R.7338, the bill would amend title XVIII of the Social Security Act to allow HHS to waive requirements of telehealth services under Medicare. The bill would allow seniors to utilize CARES-related telehealth provisions after the national emergency period expires.
Senator Cindy Hyde-Smith (R-MS) introduced S.3998 to amend title XVIII of the Social Security Act to simplify payments for telehealth services furnished by Federally Qualified Health Centers or Rural Health Clinics under Medicare.
Rep. Guest (R-MS) introduced H.R.7208 to amend the Small Business Act to include hospitals serving rural areas or areas of persistent poverty in the Paycheck Protection Program.
Senator Mike Rounds (R-SD) introduced S.3917 to establish a home-based telemental health care demonstration program for purposes of increasing mental health services in rural medically underserved populations.
Rep. Norma Torres (D-NM) introduced H.R.7190 to amend the Public Health Service Act to provide for the establishment of a virtual health pilot program to facilitate utilization of remote patient monitoring technology to maintain or expand access to health care services for individuals in rural areas during the COVID-19 emergency period. Senator Martha McSally (R-AZ) introduced companion legislation in the Senate, S. 3951.
On May 15, the House passed H.R. 6800, the Health and Economic Recovery Omnibus Emergency Solutions Act. The massive $3 trillion Coronavirus Relief bill is not going to be considered by the Senate, but does represent a starting point in the next virus-relief package. A few of the bill highlights include: an additional $100 billion to the Public Health and Social Services Emergency Fund; reduce the interest rate in Medicare Advanced Payment loans for all hospitals; include hazard pay for frontline healthcare workers; and a requirement for the promulgation of emergency OSHA standards for healthcare workers. Notably absent from the bill was a liability protection measure which Senate Republicans have said is a “red-line” for their support. The Senate will begin putting together their own COVID-relief package this month. The bill is expected to be much smaller in scope.
Appropriations: Along with consideration of an additional COVID-relief bill, Congress will use June and July to attempt to advance the Fiscal Year 2021 appropriations bills, which are one of the few “must-pass” legislative items this year. House leadership has indicated they will not begin the markup process until Congress has reached an agreement on the next Coronavirus relief bill. The Senate has hinted they may hold markups before the July 4 recess, although a markup of the Labor-HHS package has traditionally been one of the later bills to move.
NOSORH will meet with lawmakers and their staff throughout the process and urge them to increase funding for the State Offices of Rural Health Program to $15 million annually. NOSORH has been in discussions and will continue to advocate for increased funding and reauthorization for the Medicare Rural Hospital Flexibility grant program.
Bills Introduced: A bipartisan group of senators introduced the Save our Rural Health Providers Act. Sens Lisa Murkowski (R-AK), Joe Manchin (D-WV), and Cindy Hyde Smith (R-MS) introduced the bill which seeks to create a new formula to ensure the provider relief fund has a dedicated set-aside amount directed towards rural areas of the U.S. The bill would create a 20 percent benchmark in the Provider Relief Fund which according to a press release would allocate more than $10 billion to rural states. The bill also grants priority for facilities that provide care for populations with limited access to health infrastructure. A companion bill was introduced in the House by Rep Small (D-MN) and Hagedorn (R-MN).
Also this month, Senators Schatz (D-Hawaii), Murkowski (R-AK), Boozman (R-AR) and Peters (D-MI) introduced the Health Care Broadband Expansion During COVID-19 Act. The bill directs $2 billion to help health care providers increase broadband capacity and expand telehealth services during the current public health crisis.
NOSORH and the fifty State Offices of Rural Health congratulate and appreciate the work of the National Rural Health Association team for their great work advocating for rural providers across the nation during this public health crisis. These are tough times for all. We value NRHA’s “rural voice louder” now more than ever. Thank you Alan Morgan, Maggie Elehwany, Mason Zeagler, Max Isaacoff, and the entire NRHA team for exemplary leadership and advocacy.
The Senate returns to Washington on May 4 for the first time since late March. The House will most likely return on May 11.
Putting together and passing a CARES 2.0 will be the main priority for Congress during the spring session. The legislation will likely include additional relief for hospitals, some form of liability protection, and funding for state and local governments to respond to COVID. Congress may consider a number of rural health-related provisions in the next recovery package including: increased flexibility for telehealth, supporting increased funding for broadband access, allowing CAHs to cost settle after the COVID pandemic, and updates to the Medicare Rural Hospital Flexibility Program.
Unlike the first three stimulus bills passed by Congress, members are considering including other non-COVID health priorities like surprise billing and drug pricing (H.R. 3/S. 2543) into CARES 2.0. The timeline for Congress moving a fourth stimulus is unclear, with Republican leadership indicating they would like to see how current virus funding impacts states and regions.
HHS Begins Distribution of Payments to Rural Hospitals, Providers with Elevated COVID Admissions: On May 1, HHS announced that $10 billion will be distributed to rural acute care general hospitals and Critical Access Hospitals, Rural Health Clinics, and Community Health Centers located in rural areas. Funds will be directly deposited, rural providers need not apply. Each RHC will receive a minimum of $100,000. CAHs will each receive a minimum of $1 million with the median receiving $3.6 million. HHS released a chart detailing the rural payment amount by State. Texas, Iowa, and Minnesota appear to receive the biggest share.
HHS also announced that $10 billion will be distributed to 395 hospitals who provided inpatient care for 100 or more COVID patients through April 10, 2020. $2 billion will be distributed to certain hospitals based on their Medicare and Medicaid disproportionate share and uncompensated care payments. HHS released a chart detailing the payment amounts by State.
Appropriations Update: With Congress returning in May, House and Senate appropriators will have limited time to pass their Fiscal Year (FY) 2021 funding bills. With Congress already approving trillions of dollars in stimulus funding this year, many programs are bracing to see how the committees write their FY 21 spending bills. Some of the house appropriations subcommittees are targeting late June as a date to move their bills.
COVID-19 Spurs Passage of Landmark Spending Bills
With the spread of COVID-19 throughout the United States, Congress passed and the President signed into law three major funding bills addressing the COVID-19 crisis. Below is a look at the three bills and a preview of what’s next for Congress.
On March 6, President Trump signed into law H.R. 6074 – The Coronavirus Preparedness and Response Appropriations bill. This bill provides $950 million to the Centers for Disease Control and Prevention for grants to states. The bill also included $100 million to HRSA under the Health Centers Program as defined by section 330 of the Public Health Service Act.
On March 18, the President signed into law H.R. 6201 – the Families First Coronavirus Response Act. This multi-billion dollar spending bill largely addressed funding Unemployment Insurance and expanding the Emergency Family Medical Leave Act.
On March 27, the President signed into law H.R. 748 – the CARES Act. The Cares Act is the most significant of the three funding measures and includes billions of dollars in federal funding and many substantive rural provisions.
Fourth Stimulus Bill on the Horizon
A fourth stimulus bill is already being worked on by House Democrats. The bill is expected to address shoring up health systems, creating protective standards for frontline healthcare workers, and boost infrastructure along with some other priorities. With Congress working remotely until at least April 21, Senate Republicans have indicated they would prefer to wait and see how CARES funding impacts the virus before committing to a fourth funding bill.
Last month, NOSORH and 22 State Offices of Rural Health attended the National Rural Health Association’s Policy Institute in Washington, D.C. “NRHA did a great job of bringing together policymakers and rural stakeholders in a jam-packed week focused on rural health,” said Teryl Eisinger, NOSORH CEO.
During the week, NOSORH spent multiple days meeting with members and staff on Capitol Hill. With the prospect of major rural health legislation being advanced by Congress this May, NOSORH used the visits to remind Congress on the importance of rural health and advocate for continued funding for the SORH and Flex programs. It is anticipated in rural health circles that Congress could advance rural health legislation as part of a larger health package, including surprise medical billing.
A highlight of the NOSORH effort during the Institute was presentation of the NOSORH Legislator of the Year Award to Representative Kurt Schrader (OR 5th District). This award recognizes an outstanding individual federal legislator for their work and support of rural health initiatives that address national rural healthcare needs. Congressman Schrader’s district runs from the Pacific Ocean to the Cascade Mountains with 22 certified Rural Health Clinics, 6 rural hospitals, 17 rural EMS agencies and 2 tribal clinics. He is a leading member of the House Energy and Commerce subcommittee on Health and in 2018 was the lead Democrat sponsor of the State Offices of Rural Health Reauthorization bill.
The award was presented by Bob Duehmig, Deputy Director of the Oregon Office of Rural Health, during a meeting of rural Oregon constituents and members of the Oregon Office of Rural Health. “It was great to see Bob and his state team getting right to the heart of what matters in rural Oregon with Representative Schrader. Bob facilitated the discussion with each member of that state team ready with simple, meaningful input for Mr. Schrader,” said Eisinger.
Duehmig was one of the 46 state coordinators NRHA taps to help organize Hill visits during the Institute. Ten other SORH also served in this role. Thanks to the NRHA for sharing data and their great work of making our voice louder and building the momentum!
Fiscal Year 2020 Appropriations Become Law
During the final legislative week of December 2019, Congress passed and the President signed into law, the Fiscal Year (FY) 2020 HHS Appropriations bill. Congress appropriated the State Offices of Rural Health (SORH) Grant Program $12,500,000 for Fiscal Year 2020. The amount is an increase of $2.5 million for the SORH line over FY 19. The $12,500,000 for SORH was authorized to be appropriated through the State Offices of Rural Health Reauthorization Act of 2018 which was signed into law.
Also included in the spending bill was $53,609,000 for Medicare Rural Hospital Flexibility Program and $19,942,000 for the Small Rural Hospital Improvement Program (SHIP) for FY 2020. Congress funded both programs at the same amount in FY 2019. Also included in the Health Resources and Services Administration rural health account was $110,000,000 in funding for the Rural Communities Opioids Response Program.
At a broader level, the spending deal extended a number of health programs through May 22, 2020. This May deadline is intended to create pressure for a Memorial day deal for health care items such as prescription drug pricing and surprise billing and potentially rural health care, with surprise billing being the most likely to pass.
Rural Health Bill Introduced
Senator Dick Durbin (D-IL) and Rep. Adam Kinzinger (R-IL) introduced legislation to re-open the Critical Access Hospital necessary provider program. The Rural Hospital Closure Relief Act (S. 3103/H.R. 5481) would allow the HHS Secretary to waive the current requirement that CAHs be located at least 35 miles from another hospital as long as they meet specific criteria, including: (1) being located in a rural area: (2) demonstrating two consecutive years of financial loses; and (3) serving a patient population with a high percentage of Medicare recipients, a population with a high percentage of individuals below 150% of the federal poverty level, or being located in a federally-designated health professional shortage are.
The legislation could potentially be included in the Senate Finance Committee’s expected rural health package that may be introduced later this year.
House Committee Meets on Rural Health Measures
On January 8, the House Energy and Commerce Committee held a hearing to discuss the advancement of a number of health care-related bills. Among the legislative measures considered by the committee were:
The bills could be considered by the full House in the coming weeks and months.
Passage of Stopgap Shutdowns Potential Midnight Shutdown
On November 21, President Trump signed a continuing resolution bill funding the government through December 20, 2019. This stopgap measure provided Congress four additional weeks to reach an agreement on a Fiscal Year 2020 spending bill. The continuing resolution (H.R. 3055) cleared the Senate and was signed into law just hours before the midnight deadline.
The funding bill contains funding extensions for many health care programs, such as community health centers and teaching health centers that operate graduate medical education programs, and extends the community mental health services demonstration program. It also delays again the nearly $4 billion in Medicaid Disproportionate Share Hospital (DSH) cuts.
Congress now has less than two weeks to pass an omnibus spending bill for FY ’20 or pass another CR. Senate leaders are predicting an additional CR will be needed through February or March of 2020. Throughout 2019, the National Organization of State Offices of Rural Health (NOSORH) has called on the Senate to increase the funding for the State Offices of Rural Health (SORH) grant program. Please contact NOSORH if you are interested in reaching out to your Senators.
Congress Mulls Rural Health Package Before Year-End
With just weeks remaining in 2019, NOSORH has been meeting with House and Senate staff on a possible year-end rural health package. The long-awaited package of rural health legislation would come out of the Senate Finance and House Ways and Means Committees.
On the House side, the Ways and Means Committee released a Request for Information in November to interested rural stakeholders. NOSORH submitted extensive comments to the committee and is working with the Co-chairs of the Ways and Means Rural Health Taskforce on next steps. The chairs of the task force are Reps. Terri Sewell (D-AL), Jodey Arrington (R-TX), Danny Davis (D-IL), and Brad Wenstrup (R-OH).
Senate Rural Health Caucus Introduces Bill
On November 20, the Co-chairs of the Senate Rural Health Caucus, Senator John Barrasso (R-WY) and Tina Smith (D-MN), introduced the Strengthening Our Rural Health Workforce Act of 2019. The bill, S. 2902, seeks to establish a new National Rural Health Care Workforce Commission. The Commission would develop both short and long-term goals to improve the rural health workforce and help coordinate work to achieve these goals across federal agencies and at the national and state levels. The legislation would also award grants for States to translate the new Rural Health Workforce recommendations into reality. A summary of the bill can be found here. The bill has been referred to the Senate HELP Committee.
Congress Celebrates National Rural Health Day
On November 21, Rep. Abby Finkenauer (D-IA) introduced H. Res. 719, a resolution in support of National Rural Health Day. The resolution expresses that Congress supports the goals and ideals of National Rural Health Day, celebrates rural health care providers and rural Americans and commits to advancing legislation to improve health care in rural America. The resolution had the bipartisan support of 12 other House members. Approximately 40 members of Congress and various other congressional committees tweeted their support of NRHD on November 21.
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.