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 2021 Budget Request Sent to Congress
On February 10, the Trump Administration released their Fiscal Year 2021 budget request to Congress. Similar to previous years, HHS requested Congress make significant cuts to both discretionary and mandatory programs across the board. Within the HRSA budget, both the State Offices of Rural Health (SORH) and the Medicare Rural Hospital Flexibility (Flex) grant program lines were zeroed out for FY 2021. Also from the HRSA budget, the Administration asked for an increase for Rural Health Outreach Grants by $10M. Funding for the Rural Residency program was not provided.
While the annual budget proposal provides a peek into an Administration’s priorities, it is non-binding on Congress. The budget process for Congress begins in March with over 50 appropriations committee hearings scheduled throughout the month. Congress will also deal with supplemental funding for the Coronavirus. While HHS is expected to reprogram funding from HHS, HRSA funding is not believed to be impacted.
NOSORH will work to ensure Congress continues to fund the SORH program at its statutorily authorized level of $12,500,000 million.
Rural Health-Related Bills Introduced
Rep. David McKinley (R-WV) introduced H.R. 5924. The bill seeks to amend the Public Health Service Act to authorize a loan repayment program to encourage specialty medicine physicians to serve in rural communities experiencing a shortage of specialty medicine physicians.
Rep. Jodey Arrington (R-TX) introduced H.R. 5808 to amend Title XVIII of the Social Security Act to provide coverage of rural emergency medical access services under the Medicare program.
Rep. Brendan Boyle (D-PA) introduced H.R. 5681, the Protecting Communities from Hospital Closures Act of 2020.
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.
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.