Did You Hear About That? – October 2024

Federal Outlook

Presidential Candidate Stances on Health Care

As everyone is aware if they have watched any cable news recently, the presidential election is right around the corner. Today I would like to breakdown each candidate (the real candidates, VP Kamala Harris & Donald Trump) stances on health care and long-term care specifically. I would like to make it clear that HCA will not be endorsing any candidate for president and the point of this piece is educate on the candidates stances.

Long Term Care

Kamala Harris

• Harris proposed a new plan to expand home care services under Medicare to help people with functional or cognitive impairments, and add a vision and hearing benefit to Medicare, paid for by expanding Medicare drug negotiations and other policies. When announcing the plan, Harris made it clear that this is aimed at the “sandwich generation”, the people who take care of aging parents as well as their own kids.
• Proposes to partner with private technology companies to expand remote patient monitoring and telehealth and strengthen the home-care workforce.
• Would most likely continue newly established minimum staffing requirements for nursing facilities, including other requirements to support nursing facility workers.
• Would most likely follow in Biden administrations footsteps in promoting higher payment rates for home care workers (with pass-through, see 80/20 Medicaid rule), and reduce the time people wait for services.
• Proposes working with Congress to end Medicaid estate recovery, a practice in which the state recoups the costs of Medicaid LTSS from the home and estates of deceased enrollees; or using administrative action to expand the circumstances in which families may be exempted.

Donald Trump

• For the most part, Trump has not been public on his proposal for long term care. I would expect most of actions around long-term care to be centered around reducing regulations, unlike Kamala Harris.
• Trump has proposed to protect seniors by “shifting resources back to at-home Senior Care,” addressing disincentives that contribute to workforce shortages, and supporting unpaid family caregivers through tax credits.
• While President, issued regulations relaxing oversight for nursing facilities, including removing the requirement to employ an infection preventionist. 

Medicare

Kamala Harris

• Like the current Biden-Harris Administration, Harris will likely continue to push to expand and fully fund Medicare.
• During the 2019 Democratic presidential primary, supported a Medicare for all approach with a role for private insurance, however her campaign has since indicated she would not seek to advance Medicare for all as president and has supported the ACA and expansions to broaden coverage and make health care more affordable.
• Biden-Harris administration proposes to “protect Medicare for future generations” in part by extending solvency of the Medicare Part A Trust Fund by raising Medicare taxes on high earners and closing tax loopholes and proposes to expand Medicare and Social Security (details not specified).
• A Harris presidency could see a continued effort to expand telehealth access for Medicare services.
• Will likely continue the Biden administration newly established staffing requirements for Medicare-certified nursing facilities.

Donald Trump

• For a long time, the Republican party has pushed to cut Medicare spending. But this election cycle Trump and the Republican Party have publicly committed not to cut Medicare if Trump wins the White House, with the GOP’s platform stating the party will “fight for and protect Medicare with no cuts, including no changes to the retirement age.” Project 2025, which has been linked to Donald Trump, does include language about cutting Medicare funding.
• While he has not called for cuts, the nonpartisan Committee for a Responsible Federal Budget projects that because of his proposal to cut taxes on social security benefits, it could result in Social Security and Medicare receiving $1.6 trillion less in revenue between 2026 and 2035 than if the current rules stayed in place, causing Medicare to become insolvent in 2030, six years sooner than currently projected.
• Trump has proposed to protect seniors by “shifting resources back to at-home Senior Care,” addressing disincentives that contribute to workforce shortages, and supporting unpaid family caregivers through tax credits.
• Trump is proposing reversing increases made to Medicare Part B premium but has not signaled how he would do it.
• Trump is a firm believer in private companies’ involvement in health care. During his presidency he signed legislation that expanded treatment for substance use disorders and other mental health conditions and allowed Medicare Advantage plans to offer additional benefits for chronically ill enrollees. Trump could look to expand Medicare Advantage plans.

Medicaid

Kamala Harris

• Harris would most likely continue the Bidens administrations 80-20 payment rule that was approved last year.
• Like her stance on Medicare, Harris is a strong proponent for expanding Medicaid services. Harris, along with the Biden administration, have pushed to expand funding for Medicaid as a way to expand health coverage and improve continuity of coverage, reduce the rate and number of uninsured, expand access to care, and reduce health disparities.
• Harris has touted the Biden-Harris administrations efforts to expand federal matching funds for priority areas under Medicaid, such as incentivizing states to expand Medicaid home and community-based services (HCBS)
• She has signaled that she would work with Congress to try to extend Medicaid coverage in the 10 states that haven’t expanded it under the ACA. The Biden-Harris Administration enacted legislation to strengthen the ACA, including an additional fiscal incentive for states to adopt the ACA Medicaid expansion and temporary enhanced subsidies for Marketplace coverage.
• Harris has championed Biden-Harris administration efforts to reduce maternal mortality and morbidity, including encouraging states to adopt the postpartum Medicaid coverage extension.
• The Biden-Harris Administration withdrew demonstration waivers approved in the Trump Administration related to work requirements, and encouraged waivers to expand coverage, reduce health disparities, address the social determinants of health, and help individuals transition out of incarceration.

Donald Trump

• During his last presidency, Trump approved waivers that included work requirements as a condition of Medicaid eligibility, premiums, and other eligibility restrictions. He also took administrative action to relax Medicaid managed care rules and increase eligibility verification requirements. 
• Unlike Medicare, Trump has not said anything publicly about not making cuts to Medicaid.
• Trump has previously proposed restructuring Medicaid financing into a block grant or a per capita cap as well as limiting Medicaid eligibility and benefits. Trump approved waivers that included work requirements as a condition of Medicaid eligibility, premiums, and other eligibility restrictions. 
• Though he has not stated publicly, Trump could look to roll back the Biden 80/20 payment rule.
• Project 2025 does talk about reforming financing for Medicaid in vague terms, calling for a more “balanced or blended” matching rate and the use of things like block grants, which essentially “cap” how much money can come to a state for Medicaid.

State Outlook

Ballot Question 1: Should the State Auditor Have Free Reign to Audit

While most of the media focus has been on the presidential and senate races across the country, back home in Massachusetts voters will need to consider their stance on key ballot question that would have an immense impact on the state legislature, its relationship with the executive branch, and the public.

Ballot Question 1: Do you approve of a law that would grant the state auditor the authority to audit the state legislature?

The state auditors’ job is to audit. Seems pretty straight forward! right??? Well, that depends on who you talk to. This all started back in March of 2023, when state auditor Diana DiZoglio unsuccessfully tried to audit the state legislature. DiZoglio, a former State Senator herself, stated that the reason why she wanted to audit the legislature was to shine a light on the historically dark under belly of the state legislature whose inner workings have been kept quiet, away from the public, behind closed doors. This audit would have covered budgetary, hiring, spending, and procurement information, information regarding active and pending legislation, the process for appointing committees, the adoption and suspension of legislative rules, and the policies and procedures of the Legislature.

DiZoglio was met with a brick wall of resistance from legislative leadership. House Speaker Rep. Ron Mariano and Senate President Karen Spilka, de facto leaders of the state legislature, refused to comply with the audit and did not turn over any information. They argue that her audit would violate checks and balances and is an overreach of the executive branch, some real old school James Madison arguments. DiZoglio didn’t take no for an answer and filed the current ballot question to the state Attorney General Andrea Campbell, to bring the audit to the public and leave it up to all of us to decide if she should be allowed to audit the legislature.

Recent polls show that 70% of voters plan to vote “Yes” on the ballot question. Many watchdog groups have pointed out that currently it is difficult to get any internal information about the legislature’s workings. Neither its committee votes nor hearing testimony are available to the public. There is also a lot of questions that have been raised recently on how legislative leadership uses fear and muscle to block legislative action and to hold tight control over committee seats and the budget process. Jonathan Cohn, policy director at Progressive Mass said that “we hold the status of being the only state where the governor’s office, the legislature, and the judiciary, all claim full exemption from the public records law,”.

While the polls show public support, there are people outside of the legislature that have raised concerns with audit. DiZoglio predecessor Suxanne Bump has been very vocal in saying that the her audit is going to far.  Bump said that the proposition went “beyond the bounds of legitimate government auditing.” An audit of the legislature, she said, would be inherently subjective, given there are no hard legal standards for how the legislature should legislate. “I’m sure, indeed, there are steps that could be taken to open up more of the legislative process to scrutiny, but this idea of auditing the deliberative processes of the legislature is not the way to go,” she said. “This is not a matter that’s going to be resolved at the ballot box.” Attorney General Campbell has also raised concerns about the audit. When DiZoglio said in August of 2023, that she would pursue litigation against the legislature, a move that would need the approval of Campbell, Campbell determined that DiZoglio lacks the legal authority to conduct such an audit and found no historical precedent for the type of audit she was seeking. She said that the litigation DiZoglio was pursuing was “not necessary or appropriate.” Campbell did allow Question 1 to make it onto this year’s ballot, but warned that constitutional limitations could affect how the ballot proposal would be applied if passed.

DiZoglio said that she and her staff have uncovered at least 117 instances of the Legislature being audited since the state auditor’s office was created in 1849. This stopped occurring in the early 1990s, she said.

Even If the proposition passes, primary legislative functions like voting and committee assignments would still remain exempt, according to analysis by the Tufts Center for State Policy Analysis. The Tufts report also emphasized that the legislature would have “a lot of leverage to resist investigations,” like refusing to consent. The vote would also likely face lawsuits to block the implementation of the authority if its is granted through the ballot question.

Rarely in modern times are citizens given the chance to truly influence how a legislature operates. If we believe in Lincolns message that our government should be “a government of the people, by the people, and for the people” then it is our responsibility to think critically about this and give our honest opinion how we feel about the current checks and balances in our state government.

Health Worker Shortages Forecast Thru 2028

Continued worker burnout and more demand for care from an aging population will drive health care workforce shortages into 2028, though with significant variations by state, according to a Mercer analysis. Mercers’ analysis shines a light on the acute need for more nurse practitioners, even in states like California and Texas that will have overall surpluses of health workers. The U.S. is expected to be short 100,000 health care workers by 2028, Mercer projects.

Mercer projects that Massachusetts will be amongst the states with the highest shortage of health care workers, with the analysis projecting that Massachusetts will be short over 12,000 workers (2.46%) by 2028. Only 13 states will be able to meet the demand for nursing aides, according to the projection. Home health and personal care workers, who represent nearly one-quarter of the health workforce, are projected to exceed demand nationally by almost 48,000 workers, though shortages are expected in states including North Carolina and New York. Massachusetts is expected to have a surplus of 5,000 home health and PCAs. This is due to recent large investments in home health/homemaker services over the last couple years, with rates for services increasing for the first time in 7 years.

With a rate review for some home health/homemaker services coming up in 2025, it is imperative that we push the Healey administration and the legislature to fully fund these services going forward, so that rates do not fall behind market demands, like they were for years before COVID.