Advocacy – Think Home Care Blog

Did You Hear That? – November 2024

Federal Outlook

What a Donald Trump Presidency Means for Health Care

After months of speculation, the American people have voted that they hate Joe Biden in sunglasses and his love of ice cream by electing Donald Trump to be the 47^th president of the United States.

While border security and Trumps DOJ pick are getting all the headlines, lets jump into how this could affect health care in America.

Healthcare Privatization/De-Regulation

President-elect Trump loves de-regulation as much as he loves tariffs. Like in his first term, Trump will look to further deregulate and further privatize the health care sector. During his first term Trump and the Republican party tried to repeal and replace Obamacare but failed due to then Senator John McCain most dramatic thumbs down vote. I would not be shocked if Trump and republicans looked again to repeal Obamacare, which House Speaker Mike Johnson noted to in an interview before the election. I will also note that Trump has not noted what his new health care plan would be. Famously in the debate with Harris, Trump said he had the “concept of a plan”.

Most likely we should expect that Trump and the GOP party will look to expand privatization of Medicare by aggressively promoting Medicare Advantage. Conservatives argue that Medicare beneficiaries are better off in Advantage plans, which offer more benefits than the traditional, government-run program. Critics say increasing insurers’ control of the program would trap consumers in health plans that are costlier to taxpayers, expose seniors to high prior authorization requirements, and have at times left the sickest patients high and dry when they decide to drop certain medical coverage. In 2023, Medicare Advantage plans cost the government and taxpayers about 6% — or $27 billion — more than original Medicare, though some research shows they provide better care.

Advantage plans have also been less likely to cover home-based/long term care services, leaving many patients without the option. A recent report by the Senate Permanent Subcommittee on Investigations found that Medicare Advantage plans had high denial rates for care in institutions where patients go after hospital stays. For the largest insurers, the rejection rates for such care were between about three and 16 times their denial rates for all services in 2022. In traditional Medicare, hospitals and nursing homes determine who gets such services. Trump’s campaign said he would prioritize home care benefits and support unpaid family caregivers through tax credits and reduced red tape. He did not explicitly note what red tape he would reduce and how he would look to prioritize home care benefits.

Trump said on the campaign trail that he wants 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. But he didn’t say exactly how he aims to shift resources back to at-home care.

Medicaid Changes

A key part of Trumps presidential campaign was his goal to cut government spending across the board. Medicaid is the third-largest program in the federal budget, accounting for $616 billion of spending in 2023, according to the Congressional Budget Office. Trump campaigned on a promise not to make cuts to the two largest programs: Social Security and Medicare. That makes Medicaid the “obvious place” for Republicans to raise revenue to finance their agenda, said Larry Levitt, executive vice president for health policy at KFF. Cuts would likely result in fewer and fewer households being covered.

Trump and the GOP could also look to curtain Medicaid enrollment by implementing working requirements, as he did in his first term. Additionally, Republicans may try to cap federal Medicaid spending allocated to states, experts said. The federal government matches a portion — generally 50% or more — of states’ Medicaid spending. That dollar sum is uncapped. Republicans may try to covert Medicaid to a block grant, whereby a fixed amount of money is provided annually to each state, or institute a per-capita cap, whereby benefits are limited for each Medicaid enrollee.

Trump has signaled that he wants to roll back most of Bidens executive actions, which could include the Medicare 80/20 rule. This would be a huge win for providers who would be immensely impacted by the rule that would require 80% of repayment rates to go directly to wages.

RFK Jr.

RFK Jr. being nominated to be Secretary of Health and Human Services was not on my bingo card for 2024. RFK Jr. joined Trumps team in the final months of the election and pledged that if he is confirmed he would work to “Make America Healthy Again”. RFK Jr. is an interesting person to put it mildly. The son of Robert F Kennedy, RFK Jr. has called for getting ultra-processed foods out of school lunches as part of a goal to reduce the incidence of diet-related chronic diseases and ban hundreds of food additives and chemicals, such as food dyes. He has also called for the removal of fluoride in public water, has promoted use of raw milk, and is a known vaccine skeptic, who has pushed false medical claims that vaccines are linked to autism. So, he is kind of all over the board.

If confirmed, RFK Jr. would oversea CMS, has not made his feelings public (which is honestly shocking) on long-term care. It is not known if he would push CMS to expand home-based care access or if he would look to cut government services. All we can expect is that if he is confirmed, something will change in a major way.

State Recap

Compromise Economic Development Package Signed By Governor Healey: Includes Nurse Licensure Compact Provision

After months of speculation, the long awaited economic development package has been passed and signed by Governor Healy. This comes after the legislature failed to produce a compromised package by the end of session in June. Most importantly to the home-based care sector, the package includes a provision that would add Massachusetts to the Nurse Licensure Compact (NLC). The NLC, which HCA has supported for years, would allow nurses from other states to practice in Massachusetts, increasing the pool of potential nurse candidates for unfilled home-based care nurse positions. Massachusetts was the only state in the New England Region not to be apart/pass legislation to be a part of the NLC. HCA heavily advocated to conference committee members about the importance of the nurse compact provision being included in any final package. The package also includes language that would create a pathway in Massachusetts for physicians previously authorized to practice medicine outside the United States to practice in an underserved region of the Commonwealth.

Outside of the NLC provision, the package authorizes $3.96 billion in capital programs, according to a three-page summary. That includes another $500 million over the next 10 years for the life sciences industry, renewing state support that dates back to the Patrick administration. The new language increases the annual tax credit authorization for the cornerstone industry from $30 million to $40 million, and adds health equity, biosecurity, digital health and artificial intelligence to the Life Sciences Center’s mission. The package is also loaded the bill with significant policy riders, including reforms to clear the way for development of a soccer stadium on a parcel of land in Everett, and language requiring ticket sellers to clearly disclose prices online and bans the use of automated ticket purchasing software, tools that opponents say drive up prices in the secondary market.

After waiting six day, Governor Healey signed off on nearly the entirety of the 319-page bill and returned only one section dealing with automobile insurance with an amendment.

Fiscal Year ‘26 Planning Kicks Off At Dec. 2 Revenue Hearing

While fiscal year ’26 doesn’t actually start until July 1, 2025, state’s financial managers are going to kick off their budget-writing work on Monday, Dec. 2 with the annual consensus revenue hearing. Legislative leadership and Finance Secretary Matthew Gorzkowicz haven’t announced what experts will be asked to testify on the future budget, but it usually includes representatives from the Department of Revenue, Treasury, Mass. Taxpayers Foundation, and others.

Following the hearing, the trio will have to agree on a state tax revenue estimate for fiscal 2026 by Jan. 15. That estimate serves as a key building block for budget proposals that Gov. Maura Healey will unveil by Jan. 22, followed by a House budget proposal in April and a Senate plan in May.

Most officials on Beacon Hill expect fiscal 2026 will be a challenging budget year, as non-surtax collections have softened and spending demands mount. Gorzkowicz told the Local Government Advisory Commission this month that the Healey administration “think[s] that there’ll be continued challenges going into FY ’26 and we expect that it’ll be another tight year in terms of trying to balance the budget.” The same state law that requires agreement on a consensus revenue number also dictates that the consensus revenue agreement “shall be included in a joint resolution and placed before the members of the general court for their consideration.

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.

Did You Hear That? – September 2024

Federal Outlook

Potential Government Shutdown? Congress Continues to Prove that Doing Nothing is a Challenge

Once again, like every year, we are flirting with another government shutdown. The government is set to shutdown if a final deal or more likely a stopgap measure is not passed. Potential government shutdowns are nothing new now, we have been flirting with a government shutdown every year for what feels like an eternity and once again the potential shutdown is because of image politics.

The biggest holdup that could cause a government shutdown is that House Republican leadership for any stopgap package be tied to presidential candidate Donald Trump-pushed SAVE Act, which would require that people show proof of citizenship to register to vote.

House Speaker Mike Johnson announced this week that he will be holding a vote on his current package, which he previously pulled from the floor, that would fund the government for 6 months, to March 2025, and linking it with the SAVE Act. This package is already expected to fail, with a number of GOP lawmakers, a mix of fiscal conservatives and defense hawks, vowing to tank the package erasing Republicans razor thin majority in the House, 220-211. Some conservatives have stated publicly that they would never vote for a stopgap funding bills, while Armed Services Chairman Mike Rogers, has warned that a half year is too long for military spending to remain stagnant. On the other hand, the vast majority of House Republicans have signaled that they support the package and that they would like to see a vote held which would put lawmakers on the record.

Democrats, who are pushing for a ‘clean’ three-month funding extension without additional provisions, all plan to vote no, saying that the SAVE Act is a “poison pill”. Legislators argue that the SAVE Act is a redundant piece of legislation because it is already illegal for illegals to vote in elections and any instance of it happening is extremely rare.

Trump has publicly pushed at his rallies and over social media that Republicans should require the SAVE Act to be included in any funding package, or shutdown the government. Speaker Johnson did not signal if he would follow Trumps calls, but history has shown that he most likely would. “We’ll see what happens with the bill, all right? We’re on the field in the middle of the game. The quarterback’s calling the play. We’re going to run the play,” Johnson said. “I’m very confident, I know that all the Republicans believe in election security. We have some people who dislike CRs. You know what? I dislike continuing resolutions as well.”

Some Republicans have raised that it would be foolish to cause a government shutdown right now. Senate Republican Leader Mitch McConnell in a press conference warned his fellow Republicans that it would be “politically beyond stupid” for Congress to force a government shutdown a few weeks before Election Day, saying Republicans would “certainly” be blame. McConnell stopped short of calling on House Republicans to abandon their plans of advancing a bill that has no chance of passing the Senate, but made it clear that he wants to see some kind of bipartisan compromise over the next 13 days to avoid a shutdown.

So once again we are in the same position. Congress is yapping back and forth, vying for time on Fox and Face the Nation, flirting with a government shutdown that would have a real impact on Americans. It is really sad that our government system has fallen to this level, where it is impossible to even get a simple budget passed without going through all the hoopla. I know most of us have turned completely cynical towards Congress and have given up any hope, but in my opinion that only makes things worse. It is up to us to really think about who we are sending to Congress. We have no one to blame but ourselves for the current state of Congress, because we elected these partisan fatheads, who care more about making noise and being famous, then about being true legislators. When you go to vote in November, truly think about who you are voting for. Am I voting for them just because they are the same party as me? or am I voting for a person that I believe truly cares about serving their people.

Federal Recap

HCA Submits Comments for Home Health Payment Rule

At the end of August, HCA submitted its comments to the CMS Proposed CY2025 Home Health Rule. For a refresher, In June, the Centers for Medicare & Medicaid Services (CMS) released their annual proposed rates for Medicare home health services, proposing a permanent prospective adjustment to the CY 2025 home health payment rate of -4.067%. The proposed rule includes a CY 2025 home health payment update of 2.5%, which is offset by an estimated 3.6% decrease related to the PDGM rebalancing and an estimated 0.6% decrease that reflects a proposed fixed dollar loss. Overall, CMS estimates that Medicare payments to home health agencies in CY 2025 would decrease in the aggregate by 1.7%, or by about $280 million, compared to 2024 levels. This comes after CMS applied a 3.925% and a 2.890% reduction in CY23 and CY24 respectively. If implemented as proposed this would result in a 10% reduction over the last 3 years.

In our comments, HCA argued that additional cuts will further hinder home care agencies’ abilities to provide these vital services and that it could lead to more agencies going out of business, further shrinking coverage across the state. HCA met with the Massachusetts Congressional delegation over the last couple weeks to update them on the situation and to urge them to support The Preserving Access to Home Health Act of 2023 (S.2137/H.R. 5159), which would safeguard access to essential home-based, clinically advanced healthcare services for America’s older adults and people living with disabilities by preventing the Centers for Medicare & Medicaid Services (CMS) from implementing devastating cuts.

State Outlook

Still a Chance for Nurse Licensure Compact Amendment

As I’ve said numerous times over the last 2 months. Things are sssslllooooowwww at the state house. Glacier slow, Snorlax slow! Big Papi running to first slow! Rockstar roll-out of GTA 6 slow!!!!!

One thing to continue to look out for over the next couple of months is the legislature’s ongoing negotiations on the economic development bill. As a refresher legislature failed to pass an economic development package before the end of formal session on July 31^st. The economic development package would provide billions of dollars in bond authorizations and tax credits aimed at lifting the state’s life sciences and climate tech industries, as well as possibly legalize happy hour in the commonwealth for the first time in 40-years. One key provision that was proposed in the Senate version was language that would add Massachusetts to the Nurse Licensure Compact (NLC).

The NLC, which HCA has supported for years, would allow nurses from other states to practice in Massachusetts, increasing the pool of potential nurse candidates for unfilled home care nurse positions. Since the economic development packages included bond provisions, it must be passed during a formal session. House Speaker Ron Mariano and Senate President Karen Spilka have publicly expressed a willingness to return for a formal session once a deal is reached. Governor Healey has also pushed for the legislature to hold a formal session to pass the package sooner than later, but it is yet to be seen when that will be.

Negotiations on a final package have been ongoing over the last 2 months of informal sessions. The House and Senate differ greatly on how much the life science provisions should be funded, as well as the need to include the NLC provisions. HCA has been meeting with House and Senate members to raise the importance of including the NLC language in a final package.

A package could come out tomorrow, it could come out on thanksgiving, no one knows!! I hope that it is sooner rather than later, because I’m running out of things to write to fill this blog!

State Recap

Healey Signs Slimmed Downed Supplemental Budget

Months after Governor Healey originally proposed a supplemental budget, the legislature finally responded to her repeated emails saying, “any updates?” with a slimmer compromised package. Healey originally filed a $534.7 million supplemental budget on March 18, saying that it would “target resources at our most time-sensitive deficiencies, using available federal reimbursements and other resources to minimize the net cost to the state.”

Like an insurance provider to a patient, the legislature said, “we can do it cheaper”. The legislature sent back a significantly slimmed down compromise package, with a bottom line of $362 million. The largest spending item that didn’t make the cut: $175.5 million for supplemental payments to safety net hospitals through the Medical Assistance Trust Fund — which would be wholly offset by federal reimbursements. In addition to the supplemental payments through the Medical Assistance Trust Fund, lawmakers also scrapped funding for struggling hospitals and community health centers in their compromise deal. Which is interesting since we are seeing numerous hospitals on the brink of closing due to steward hospital greed.

The proposed supp budget deal does, however, provide more than $61.1 million for the health and human services workforce. The budget also includes $228 million for programs designed for those who prefer to get long-term care services in their home or community, rather than in an institutional setting, and $20 million to support survivors of violent crimes as dollars from Washington have dried up in recent years — both of which will be paid for fully by federal American Rescue Plan Act dollars.

We are concerned that additional funding for the home care line items were not included in the proposal, because from our analysis we believe that the home care POS line item is under funded by $40 million and the case management line item is underfunded by $8 million. We are hoping that they will look to do another supplemental budget in the winter when the new session is opened to fill the gap between the legislatures slimmed down package and Governor Healey’s package.

Governor Signs Long-Term Care Reforms into Law

Infection control plans, uniform patient transfer forms, heightened scrutiny of private equity and much more headline a compromise long-term care reform bill that Governor Healey signed .signed at the beginning of the moth. Nearly a month after legislative leaders ended their formal sessions for the term without an agreement on the bill — and more than 18 months after House Speaker Ron Mariano dubbed it one of his top priorities.

While the bill focuses mainly on nursing homes and long-term care facilities, it does include a couple of sections pertinent to home care. The bill would establish a task force, that The Alliance is named too, that would be tasked with studying and proposing recommendations to address acute care hospital throughput challenges and the impact of persistent delays in discharging patients from acute to post-acute care settings.

The bill also calls for EOHHS to administer a workforce training grant program to “advance skills of certified nurses’ aides, home health aides, homemakers and other entry-level workers in long-term care facilities to improve quality of care and improve worker access to and participation in a career pathway to become a licensed practical nurse.”

Rep. Thomas Stanley, who helped craft the original legislation and co-led the compromise talks on behalf of the House, called it “the first major overhaul in a quarter of a century.” The bill would increase state scrutiny of the role of private equity and real estate investment trusts in long-term care. In addition, Long-term care facilities would need to file disease outbreak response plans with the Department of Public Health to ensure they have measures in place ahead of time to prevent the spread of diseases.

The bill seeks to speed up discharges by requiring MassHealth and commercial insurers to craft a common transfer form to cut down on the administrative burden. Another section of the bill calls for a two-year pilot program requiring prior authorization requests related to hospital discharges to be completed by the next business day, even over the weekend, instead of the current two-day timeline.

The bill would require the division of insurance to develop a uniform prior authorization form for admission to a post-acute care facility or transition to a home health agency for any inpatient of an acute care hospital requiring covered post-acute care services. It also would require all acute care hospitals to use that uniform prior authorization form, and all payers or entities acting for a payer under contract to accept that form as sufficient to request prior authorization for the requested service, not later than 30 days after the form has been developed by the division of insurance.

Passage of this bill checks off one of the “top priority” pieces of legislation that in both chambers failed to complete before they wrapped up the last formal session of the term on August 1.

Gov. Maura Healey on Friday signed into law a package of reforms overhauling the long-term care industry in Massachusetts.

Did You See That! – August 2024

Federal Outlook/Recap

Presidential Race and Presidential Race Alone

Let me just cut to the chase so i don’t waste your time. Congress is on halt until January 2025 when a new President is sworn in. all action that happens in Congress will be directly related to helping messaging for either presidential campaign, case in point the Democratically controlled Senate forcing a vote on the child tax credit to show that Republicans aren’t for it even though the VP candidate JD Vance is pushing for one, or the Republican controlled House, forcing a vote on making it illegal for illegal immigrants to vote in presidential election, to make Vice President Kamala Harris speak to why Dems voted against it.

Now until next year, is the mother of all dog and pony shows on Capitol Hill. As an employee of the Home Care Alliance I will not be sharing my views on the presidential elections, so that no one misconstrues my views for the associations views. There will still be state updates over the next couple of months, and if anything comes up federally of importance i will write about it.

till then, sit back, grab a football helmet and get ready for the most brutal 4 months of our lives.

State Outlook

What Happened to My Piña Colada?

With session ending on July 31st, August is usually the time when the state house goes quiet. Legislators head off for vacation to get some R&R and unwind from work before kids go back to school in September. Not this year.

As has been reported by every major news outlet across Massachusetts, the state legislature failed to pass numerous big ticket pieces of legislation before the end of session, such as, an energy package, gun reform, long term care package, private equity reform, and an economic development package. Democrat party leadership in the House and the Senate had been touting their goals of passing each one of these big ticket items for over 2 years, but due to internal fighting between the House and the Senate, they failed to make any progress before July 31st came and went.

The most noteworthy bill not passed, is an economic development package, which is usually passed in session. While according to state law, legislation can pass during an informal session which requires 100% of the vote to pass, that is not an option for the economic development package. Since the package includes bond authorization, It has to be passed during a formal session, which can only be called by the Governor, which rarely if EVER is needed. Governor Healey has already signaled that she wants the legislature to continue negotiation between the House and Senate versions of the bill so that they can call a formal session some time before the end of the year. while the two package are for the most part are the same there are key differences that have resulted in the legislature not coming to an agreement. While both packages call for billions of dollars in bond authorizations and tax credits aimed at lifting the state’s life sciences and climate tech industries, the House and Senate disagree on how much money to authorize. The House is demanding a bigger investment than the Senate has signaled they are comfortable with, which has been the main sticking point. Another key provision that was proposed in the Senate version was language that would add Massachusetts to the Nurse Licensure Compact (NLC). HCA has long supported Massachusetts joining the NLC as we believe it will help to alleviate the ongoing workforce shortage for home care nurses that has resulted in countless referrals being denied and patients going home without care. At the moment it doesn’t seem that legislators are close to coming to an agreement, since many legislators have left for their pre planned vacation. HCA has continued to push for the NLC language to be added to any agreed upon package.

Now I can’t sit here and tell you that it is easy to pass legislation, let alone huge pieces of legislation, so I really am not shocked that all of these pieces of legislation were not passed this session. But I will say, they set themselves up for failure by setting their goals for the legislative session as high as the international space station. While we all have grandiose goals and dreams for the future, its important that legislators don’t let their eyes get so big that they lose sight of what is actually possible. It seems like every year legislatures forget that they can’t focus solely on passing legislation that could be used as a template for other states, because every year they have to tackle a huge beast of legislation that cost more than any piece of legislation they will ever pass, The annual budget. Over the last 30 years, Massachusetts has consistently been one of the last states to pass their budget, which prevents legislatures from focusing on other key pieces of legislation that could have a profound effect on the commonwealth. I personally believe that they should change the system so that the budget is set every two years, where they can always pass a supplemental budget if needed, if needed. This would give legislatures time to focus on projects that people really want to see done, such as gun reform, climate change legislation, and long term care legislation.

State Recap

Governor Healey Signs FY25 Budget

On Tuesday, Governor Healey signed the $57 billion FY25 budget, after trimming off trimming $317 million from 60 separate line items in the spending plan with her veto ability. The governor signed nearly all of the budget the Legislature sent her 10 days ago, approving of all but three of the 261 policy proposals lawmakers padded it with. The budget, which the governor’s office said carries a $57.78 billion bottom line after Healey’s actions, increases state spending by about $1.7 billion, or about 3.1 percent, over last year’s budget. It uses about $1.2 billion in one-time revenues to support the outlays during a time of volatile state tax collections and an expected increase in revenues from the state’s new tax on household income above $1 million is also helping the state to boost spending.

I would like to note that after extensive advocacy the final budget does not include inflammatory language that was proposed by SEIU that would 1.) require annual reporting on wages for home providers 2.) Require “Strong enforcement” of 75% permissible use standard 3.) Require EOEA to audit the annual wage reporting requirement to confirm compliance with the 75% pass through requirement. The final budget proposal includes language that would require EOHHS to report on their methodology for how they review chapter 257 rates for home care services.

The single largest veto was in the MassHealth managed care account, where Healey cut $192.3 million and said the remaining $5.9 billion in the account was the “amount projected to be necessary due to anticipated utilization, timing of rate updates, and new revenues.” The three policy sections that Healey returned with proposed amendments deal with a new MassHealth “notice of eligibility” requirement and with $63 million in annual supplemental MassHealth payments to Cambridge Health Alliance (technically two sections). Among 46 states whose fiscal year began July 1, Massachusetts was the last one to put an annual spending plan in place, according to data tracked by the National Conference of State Legislatures. Lawmakers and Healey previously agreed to an interim budget covering state expenses for about a month.

Governor Healey Signs Wage Transparency Bill

Today, Governor Healey signed the wage transparency bill, that now requests employers with 25 or more employees will have to post pay ranges alongside job openings. The new law also requires employers with more than 100 employees to file copies of federally-required equal employment data with the state secretary’s office, which would then be forwarded to the Executive Office of Labor and Workforce Development.

Supporters say the measure would reduce gender and demographic wage gaps. It was backed by the Women’s Legislative Caucus, the business group Associated Industries of Massachusetts, the Mass. AFL-CIO umbrella union, and the Mass. Municipal Association.

State House News reported that The attorney general’s office will conduct a public awareness campaign around the new rules. Their office also has enforcement authority and the ability to impose fines or civil citations for violations of the law, and employees will receive protections against retaliation for asking for salary ranges when applying for a job or promotion, according to the governor’s office. “Gender and racial wage gaps are real. They cause wealth gaps. With this legislation, Massachusetts claims lead position in building economic prosperity through equitable treatment of every worker,” said Evelyn Murphy, co-chair of the Wage Equity Now Coalition in a statement.

Did You See That! – July 2024

Like last year, June is my month to take a step back from the news and give myself a break from the constant stream of aggravating headlines, and head throbbing reports. Which is why there was no piece last month.

Federal Outlook

How the Supreme Court Chevron Ruling Could Affect Home Care

In a historic decision, the Supreme Court overturned a longstanding precedent that gave regulatory agencies greater authority to carry out broad mandates. Two weeks ago, the Supreme Court ruling on a case brought by herring fisherman, undid the legal precedent known as Chevron Deference, a 40-year-old precedent that had instructed lower court judges to defer to reasonable agency interpretations of ambiguous federal statutes. The Court ruled along ideological lines, 6-to-3.

This is a momentous decision that could immensely impact on providers ability to stop CMS from implementing further cuts to the home health payment rate. As you all aware, over the last couple years CMS has consistently proposed/implemented more and more cuts to the home health payment rate. Most recently CMS proposed a 1.7%, or $280 million, decrease to aggregate home health payments for 2025. In response to the cuts in 2023, The National Association for Home Care and Hospice (NAHC) filed a lawsuit against HHS and CMS over their cuts. NAHC argues that CMS methodology used to determine that home health providers have been overpaid is wrong and that their cuts would have substantial effect on access to home care.

In the wake of the undoing of Chevron Deference, the courts could rule that CMS overstepped by proposing massive cuts to home health payments and that they must reverse the cuts. The Supreme Court has also ruled in recent years against regulatory agencies. In 2022, the Supreme Court ruled against HHS and CMS, when prior to 2020 CMS proposed a series of policy changes for hospitals, one of which would have reduced payment, specifically through the 340B drug pricing program, which generally serve lower-income or rural populations. Hospitals argued like NAHC has, that CMS those cuts would hurt patient care, and that CMS did not have the power to levy those cuts in the first place. In ruling against HHS and CMS, they were ordered to pay hospitals back for underpayments.

While nothing is set in stone, recent rulings show that the Supreme Court has changed their longstanding view on how regulatory agencies can use their powers to regulate.

Federal Recap

CMS Proposes Home Health Payment Rate Rule for CY25

In late June, released their proposed home health payment rate rule for CY25. Once again, CMS is proposing cuts to the home health payment rate. According to CMS calculation, to rebalance the Patient-Driven Groupings Model (PDGM) and make it budget neutral, CMS is proposing a permanent prospective adjustment to the CY 2025 home health payment rate of -4.067%. CMS came to this conclusion by determining that Medicare still paid more under the new system than it would have under the old system. This comes after CMS applied a 3.925% and a 2.890% reduction in CY23 and CY24 respectively. If implemented this would result in a 10% reduction over the last 3 years.

CMS also has updated the level of the alleged overpayment reflecting claims from 2020 through 2023 at $ 4,455,407,087 up from $3,489,523,364. The added amount reflects the impact of postponing 2.89% in the 2024 permanent adjustment along with 2023 claims experiences. CMS does not propose to collect any of the Temporary Adjustment in 2025, consistent with its actions in 2023 and 2024.

The CMS proposed rule includes a CY 2025 home health payment update of 2.5%, which is offset by an estimated 3.6% decrease related to the PDGM rebalancing and an estimated 0.6% decrease that reflects a proposed fixed dollar loss. Overall, CMS estimates that Medicare payments to home health agencies in CY 2025 would decrease in the aggregate by 1.7%, or by about $280 million, compared to 2024 levels. The proposal includes a net 2.5% inflation update (3.0%% Market Basket Index — 0.5% Productivity Adjustment).

NAHC highlighted in their report on the proposal that CMS continues to refuse to recognize its unprecedented forecasting error in CY2022 and 2023 rates where the inflation update fell far short of reality by a cumulative 5.2%. All Medicare sectors have suffered from the CMS forecasting error with CMS rejected all calls for correcting the error with an adjustment.

A 4.067%% Budget Neutrality permanent adjustment to account for the one-half of the remaining adjustment from CY2024 (2.89%) plus the additional 2023 data year adjustment of 1.125%
A $4,455,407,087 alleged cumulative overpayment in 2020-2023. CMS has not scheduled a collection of the alleged overpayment in 2025 or any other year yet.
Recalibration of the 432 case mix weights as CMS has done multiple times in recent years. The recalibration leads to a separate budget neutrality adjustment in the payment rates of 1.0035%.
Modification of wage index weights and wage index area designations leading to an budget neutrality adjustment of 0.9885%.
The LUPA add-on for LUPA-only episodes has been modified for each qualifying discipline of service (SN: PT: OT: SLP)
The qualifying Fixed Dollar Loss ratio for outlier payment is increased from the current 0.27 to 0.38. This proposal would decrease the number of episodes qualifying for outlier payment.
Overall, CMS estimates that the Proposed Rule will decrease CY2025 Medicare spending by $280 million (+$415 million inflation update – $595 million rate adjustment – $100 million outlier FDL change).

State Outlook

Not All New Traditions Are Good Traditions

When one thinks of traditions, images of yearly family trips, sporting events, and clam bakes come to mind. July 1^st marked the continuation of a new tradition in Massachusetts. For the 14^th year in a row the state legislature failed to pass a budget before the start of the new fiscal year.

Last week, in preparation of missing the July 1^st deadline to pass a budget for FY25, The Legislature passed, and Governor Healey signed, an interim budget that cover state expenses through the end of July, or until a new budget for FY25 is agreed upon. The last time Beacon Hill had a budget in place in time for the start of a new fiscal year was 2010.

This is a tradition that Massachusetts should not be proud of. At a time when partisan bickering at the federal level squashes any chance of a budget or meaningful legislation being passed, states, including Massachusetts, should look to lead by example, not follow suit. While politicians argue that it’s better to deliberate over a budget rather than rush one, continuously failing to pass a budget on time sets a poor precedent and poses a dark image of the effectiveness of the legislature. Especially this legislature which is controlled by democrats by a wide margin in both chambers.

Failing to pass a budget on time also leads to many important provisions that would be passed through the budget being delayed. Last year, the delay in passing the budget led to the legislature rolling out new initiatives such as free community college and free school meals being delayed over a month. Erin O’Brien, a political science professor at UMass Boston, says those may seem like small inconveniences. But together, they fuel a simmering disillusionment with the government. Growing disfunction within the state house only leads to further resentment by its citizens. The Massachusetts legislature should not take its citizens for granted and should do everything in their power to pass their budgets on time.

State Recap

Senate Passes Housing Bill

The State Senate recently passed their own version of a housing bill that would authorize $5.4 billion in borrowing to spur housing production, and included an amendment that would prohibit most home purchase offers that are conditioned on the buyer waiving or limiting their right to a home inspection.

The bill includes many policy proposal, such as language directing the Executive Office of Housing and Livable Communities to promulgate regulations stating that no offer to purchase a home can be conditioned on the buyer waiving their right to an inspection. Sen. Lydia Edwards, Senate chair of the Housing Committee projected the bill would prompt the creation of 40,000 housing units, a bite out of the 200,000-unit shortage Massachusetts faces. While some senators touted the housing bill as historic in the scope of its bond authorization, the state is currently limited to about $400 million a year in capital spending on housing under its latest five-year capital budget.

This bill comes as housing has become more and more unaffordable for many residents. Home sales across Massachusetts fell to a 12-year low in 2023. Through May, there have been 14,005 single-family homes sold across all of Massachusetts in 2024, a 2.1 percent increase over the sales volume of the same five months of 2023, The Warren Group reported this month. Meanwhile though, the year-to-date median single-family home price has increased 9.3 percent to $590,000.

The House passed their own housing bill a couple weeks ago. Most likely a six-person conference committee will be created with the responsibility to reconcile the House and Senate approaches into a compromise bill that would still need additional votes to get to Healey’s desk.

State House Approves Maternal Health Bill

Recently, the House passed a maternal health bill that aims to expand physical and mental health care options for pregnant women and new mothers. Massachusetts has one of the highest rates of severe maternal morbidity in the country. State health regulators say complications during pregnancy and delivery can cost twice as much in medical spending compared to patients who don’t experience SMM.

Representatives say the legislation could stem the tide of deteriorating maternal health outcomes, particularly among people of color, by creating a pathway for certified professional midwives (CPMs) and lactation consultants to be licensed in Massachusetts, and removing regulatory barriers to open birth centers that offer home-like environments during labor.

The House passed the bill unanimously 153-0. The bill now moves to the Senate who will either vote on the bill as it is or pass their own maternal health bill.

Chen Steps Down As Secretary of Executive Office of Elder Affairs

Last Friday, Elizabeth Chen, who served as the state’s secretary of elder affairs since 2019, announced she was stepping down effective immediately. Health and Human Services Secretary Kate Walsh informed staff of the change Monday and said that Deputy Secretary Robin Lipson would take over the elder affairs secretary position on an interim basis, a spokesperson confirmed.

It is not known at the time why Chen chose to step down from her position. The Healey administration declined to provide any additional information about Chen’s departure. “We are grateful for Secretary Chen’s five years of service to older adults in Massachusetts and wish her well on her future endeavors,” Walsh wrote in an email to the Executive Office of Elder Affairs. “I am also truly grateful to Robin for so kindly agreeing to step into this interim role. EOEA is in good hands — I’m confident this will be a stable transition.”

EOEA Gets a Rebrand

Last week, Governor Healey filed legislation that would change the name of the Executive Office on Elder Affairs to the Executive Office of Aging & Independence. The proposal, which coincides with Older Americans Month in May, is a result of “significant research” that found aging adults do not resonate with the term “elder,” Healey’s office said. Rather, they prefer terms such as “aging” and “older people.”

The bill is meant to reduce stigma around getting older, normalize the aging process, and emphasize that older individuals value their independence and self-determination, according to the administration, which also says the new name will help the agency reach more people. The proposal would remove language — including the terms “elder,” “elderly person(s)” and “handicapped” — and replace those terms with “older adult(s)” and “adult with a disability,” in addition to using gender-neutral language, Healey’s office said.

Mayor Wu Looks to Push Through Tax Plan

After meeting with Boston’s delegation of state legislators Monday, Mayor Michelle Wu said she’s holding out hope that her plan to shift the city’s property tax burden to avoid a residential tax hike could pass through the State House before a quickly approaching deadline.

“Most likely there will be a hearing next week on this,” Wu said during the “Ask The Mayor” segment of GBH Radio’s “Boston Public Radio” on Tuesday. Wu’s plan — which got approval from the City Council and now sits before the Joint Committee on Revenue as a Rep. Rob Consalvo bill (H 4805) — seeks permission to tilt a bit more of the city’s property tax burden onto commercial owners instead of residential owners for a few years. The mayor says her plan would protect residential property owners from larger increase in taxes due to declining commercial values.

The Wu administration wants to get approval for the tax change before it has to send tax bills out to residents. And since there has been some controversy around the idea, Wu likely wants to see it passed in formal sessions — which end July 31 — before any single lawmaker’s objection could block the plan from moving forward during informal sessions in the final five months of 2024.

“Did You See That” – May 2024

Federal Outlook

Tariffs? We are Talking About Tariffs?

This topic has absolutely nothing to do with health care in any way, but it could have an surprising impact on the presidential election race.

President Biden announced recently that United States Trade Representative (USTR) plans to increase tariffs significantly on $18 billion on imports of clean-energy goods from China. The increases will apply to imported steel and aluminum, legacy semiconductors, electric vehicles, battery components, critical minerals, solar cells, cranes, and medical products. The new tariff rates – which range from 100% on electric vehicles, to 50% for solar components, to 25% for all other sectors – will be implemented over the next two years.

As a refresher, because 2018 feels as close as to when the pyramids were built, in 2018 President Trump implemented sweeping tariffs, up to 25%, on over $300 billion in goods from China. These products stretched from washing machines, to apple chargers, to steel and aluminum. Trump’s goal was to pressure US manufacturers to move their supply chains out of China back to the US.

The Biden administration came to their decision after “reviewing” Trumps tariffs on China. I put “reviewing” in quotes because from my experience, the word “review” means nothing. The call for increases also came after signs that China is looking to increase production and exportation of their clean-energy goods, which has been a focal point of the Biden administration. Over the last 4 years, the Biden administration has handed out hundreds of millions in grants to increase production of EV vehicle and charging stations in the US. The early results are as good as my blood pressure after stepping on a Lego barefoot, pitiful. Demand for EVs has steadily dropped over the years, Multiple EV startups have gone under due to lack of sales, multiple automakers have rolled backed their EV development, and Tesla, the leading charging station producer, announced plans to drastically roll back their production of charging stations.

In response to Bidens tariff announcement, Trump, who calls himself the “tariff man”, said at a rally in New Jersey that if he was reelected, he would increase tariffs “200% tax on every car that comes in from those plants.” Trump would not only increase tariffs on Chinese automakers, but all cars coming imported into the US.

This sets up trade wars being a potential hot topic on the campaign trail for both Biden and Trump, who both believe in increasing tariffs on foreign goods. Now the one thing that both these men fail to realize is that the tariffs, for the most part, have not had the affect they hoped. US producers have not moved their supply chains out of China and back to the US. At best they have moved production to other countries like India; Or they passed on their increased costs of production to consumers, which hurts the consumer the most.

Alternative ideas that they should look at is creating additional tax breaks for companies that open plants in U.S., especially those that are moving production back to the US. Give out grants to teach workers to work in these types of plants, that can be making multiple products in one facility. Look to offset China’s currency manipulation by buying the Yen, making the Yen buying power stronger and the US dollar weaker, and in turn making US good cheaper and Chinese goods more expensive. Lastly, the U.S. should go back to embracing truly free trade. Free trade helps our economy grow, increases access to higher-quality, lower-priced goods, improves efficiency and innovation, and increases competition.

Federal Recap

Medicaid 80/20 Rule

Well after over a year of speculation, the Biden Administration announced their plans to make major change to the home and community services under Medicaid. CMS released their final Medicaid access rule in late April, which includes substantial changes to many Medicaid services. Some of the changes are positive, including creating a new HCBS quality reporting system and increasing payment rate transparency. But on the other side, the rule including language would require home-based care providers to use 80% of the Medicaid reimbursements they receive toward direct care worker compensation. It’s like finding out that you must work overtime the whole week for no extra pay, but at least your boss throws you a pizza party.

CMS originally released their proposed rule in April of 2023, in response to massive home care workforce shortage across the country, that have led to long wait times, with nearly 700,000 Americans languishing on waiting lists every year since 2016 according to one estimate. The rule would apply to direct care workers that provide homemaker, home health aide; personal care services, that fall under select Medicaid 1915 waiver services (MA Frail Elder Waiver & the MA Community Living Waiver) and the 1115 waiver services (MassHealth). CMS defines a direct care worker as a worker that:

Provide nursing services
Assist with ADLs and IADLs
Provide behavioral supports, employment supports, or other services to promote community integration.

Specifically includes:

Nurses (RNs, LPNs, NPs, Clinical Nurse Specialists) • Licensed or certified nursing assistants
Direct support professionals
Personal care attendants
Home health aides
“Other individuals” paid to directly provide Medicaid services that address ADLs/IADLs, behavioral supports, employment supports, or other services to promote community integration, including nurses and other staff providing clinical supervision.

CMS defines compensation as:

Salary;
Wages;
Other remuneration as defined by the Fair Labor Standards Act;
Benefits: health and dental benefits, life and disability insurance, paid leave, retirement, tuition reimbursement.
The employer share of payroll taxes for direct care workers, specifically including FICA taxes, unemployment insurance, and worker compensation.

The final rule allows providers up to 6 years to demonstrate compliance with the new rules, an increase from 3 from the proposal, and states have the option to offer “hardship exemptions” and give small providers a lower threshold than the 80% mandate. CMS hopes that the new rule will help to lure workers to the field and bring stability to the workforce.

HCA, along with providers across the nation, could not disagree more with the proposed 80/20 rule. HCA, along with others, submitted comments to CMS highlighting the dangerous effect that the proposed rule could have on already strapped agencies across the country. “This is a misguided policy that will result in agency closures, force providers to exit the Medicaid program, and will ultimately make access issues worse around the country. As NAHC and our partners across the home care industry have demonstrated, such a provision is not only unworkable due to the varied nature of Medicaid programs across the country, but CMS also lacks statutory authority to impose this mandate.” Said The National Association for Home Care and Hospice (NAHC). Jennifer Sheets, co-chair of the NAHC Medicaid Advisory Council (MAC) reiterated the same sentiment about the rule, “We know that CMS has good intentions and a desire to improve the lives of workers, but this policy is ill-advised and will have serious negative impacts on providers and their clients around the country.”

Swiftly after CMS released the 80/20 Medicaid access rule, Congress moved to introduce legislation that would block implementation. Rep. Cammack (R-FL-3). The bill would prevent the Department of Health and Human Services from finalizing the “80/20” rule and to prevent the Department from promulgating, implementing, enforcing, or giving effect to any substantially similar rule requiring a minimum percentage of Medicaid spending on home and community-based services (HCBS) providers be spent on compensation for direct workers. Click the link HERE like to write to your Representative urging them to support HR.8114.

State Outlook

A Billion Here, A Billion There

Budget season is officially upon us. The House recently passed their proposed$58 billion budget for FY25, that invests in K-12 education, childcare and public transit. The House proposal does not call for tax increases, seeks to push overall state spending up by about 3.3 percent, or $2 billion, and aims to drive up the state rainy day fund balance to nearly $9 billion.

Two weeks later Senate leadership released their proposed $57.9 billion budget bill for FY25. The Senate budget is similar to the House’s proposal in many ways, but also stretches to propose a pair of novel ideas: free community college and regional transit authority trips. The Senate proposal would cover another year of free school meals, pay for another year of the multi-year K-12 funding law known as the Student Opportunity Act, and direct more money to strained emergency family shelters without seeking additional systemic reforms.’ All three budget proposals — Healey’s, the House’s and the Senate Ways and Means Committee’s — seek $325 million for the emergency family shelter system. That amount would level-fund the line item compared to fiscal 2024, though Beacon Hill already agreed via a bill Healey signed in April to allow the use of $175 million from savings on shelter costs in fiscal 2025.

The Senate proposal calls for $100 million less in spending than the final $58 billion House-approved budget. That annual rate of growth would rank close to the bottom over the past decade, and it represents a marked shift from the spending spree Democrats enacted in the past two years — 9.1 percent spending increase in fiscal 2023, 6.9 percent in fiscal 2024 — with the support of Republican Gov. Charlie Baker and then Healey. The fiscal conservation comes after months of lacking revenue collection for the state.

HCA is working with our legislative champions to insert the rate clarifying bill language in the outside section of the Senate budget proposal through the amendment process. Please use THIS LINK to write to your State Senator, to urge them to co-sponsor Amendment #535, Clarifying Rate Setting Processes for Home Health and Home Care Services.

An amendment was submitted that would require quarterly reporting on wages provided through the chapter 257-line item, 1599-6903. HCA is working with our legislative champions and the Senate Ways and Means committee to block the amendment from being passed.

State Recap

HCA Licensure Bill Moved to Health Care Financing

HCA Licensure bill that would create licensure system for non-medical home care services was voted our favorably by the Committee on Rules and was sent to House Health Care Financing. HCA has continued to advocate to committee staff for the importance of passing this bill this session. HCA will provide further updates as the bill progresses through the legislative process.

State House Unveil Expansive Hospital and Industry Reform Bill

In the wake of the ongoing Steward Hospital fiasco, on Tuesday, House leadership unveiled their highly anticipated hospital oversight and industry reform bill. The Legislature’s Health Care Financing Committee on Tuesday moved to advance a redrafted, 97-page proposal that combines lessons learned from the Steward Health Care crisis, major changes to how state regulators work to contain health care spending, and new tools to deal with facility expansions and closures. Officials in House Speaker Ron Mariano’s office pitched the wide-ranging bill as the biggest effort to contain health care costs since the 2012 law that established the Health Policy Commission, the Center for Health Information and Analysis and an annual benchmark representing a goal for spending growth.

A key component of the bill aims to strengthen data-reporting requirements and consequences. Hospitals would need to disclose audited financial statements about out-of-state operations for their parent organizations, certain private equity investors, real estate investment trusts, and management services organizations. They would also face much higher fines for falling short of those requirements, boosted from $1,000 per violation to $25,000 per violation with no maximum cap. The bill additionally empowers DPH to block certain licensure or expansion approval against a system that has failed to submit appropriate financial data to the state. The redrafted legislation would also overhaul health care cost containment and management at the state level, including by changing the existing one-year benchmark to a three-year cycle. Mariano’s office said a longer time period would better account for dips and spikes in spending by individual entities.

Senate President Karen Spilka did not commit to taking up the bill in the Senate. The Senate will likely look to expand upon the proposed bill or propose their own bill that would include more prescription drug legislation and/or strengthen the Health Policy Commissions authority.

“Did You See That” – March 2024

Federal Outlook

America is Having a Severe Case of Déjà Vu

As we know, history tends to repeat its self-time and time again. Many of you may have heard about the weird parallels between Lincoln and JFK, such as that both presidents were shot in the back of the head, on the Friday before a major holiday, while seated beside their wives, who both married socially prominent twenty-four-year-old woman who spoke French fluently, the list goes on and on. The same may be happening for 2020 and 2024. The Super Bowl in 2020 was between the 49ers and the Chiefs, same as in 2024, where the Chiefs won both games, Taylor Swift won Grammy awards in both 2020 and 2024, both years were leap years, and just like in 2020, we will see the same two candidates face off during the presidential election.

I am going to take a second to say, to be crystal clear, that I do not care who you vote for. That is your business, and it is your right as an American to believe what you want and vote how you want. Okay now back to the mess at hand

President Joe Biden, who was born before the invention of duct tape, penicillin, and the color TV, will once again face off against former President Donald Trump, whose skin looks like what happens if you eat too many carrots. I think we can all agree that this was the last matchup that we wanted to see, but here we are. This is the first presidential election rematch since 1956, which saw then President Dwight Eisenhower defeat for a second time in a row Democratic candidate, Adlai Stevenson, who could put a rock to sleep.

While it may be the same matchup, the sentiment around the election is very different. For one, we are no longer experiencing life as it was during COVID, where we saw state by state lockdowns, high unemployment numbers and a dire lack of live sports to watch. Contrast to the current climate we are living in, a world of high interest rates, unaffordable housing, and multiple military conflicts across the globe, and more sports betting than ever before.

The candidates, their political parties, the media, and really everyone are really focusing on one aspect when it comes to electability of the candidate, who is more “fit” to hold the office. I put fit in quotations because how that word is defined is different depending on who you ask. When it comes to President Biden “fitness” for office, people argue that he is too old to be president. Biden is 82 years old, which already makes him the oldest president in our history. If Biden were to win the election, he would be 86 when his term is over, which is even high for a golf score for a professional. Many have questioned his mental fitness at his current age, and are doubly concern that it will get worse as time goes on. Even the special counselor assigned to a case involving Biden’s storing classified documents after he was VP, expressing concern for his memory. Saying that he could not convict Biden beyond a reasonable doubt because “Mr. Biden would likely present himself to a jury, as he did during our interview of him, as a sympathetic, well-meaning, elderly man with a poor memory.” That report also comes after 4 years of President Biden mis-saying names of countries and people, on a weekly basis. There are countless examples of Biden having mental gaffes. It shows something that people were genuinely happy to hear that Biden got it right at a town hall when he said he was president of the U.S. and not another country. people are also worried that with his “advanced age” he can’t relate with younger populations and their concerns. I mean we come from two different times, Biden grew up when a fun activity as a kid was playing with string and skipping rocks, while my generations and people younger than me idea of fun is killing zombies in a video games and catfishing people online.

When it comes to former President Donald Trumps “fitness” for office, the considerations are less around his mental state, but more around his actions as president and his belief on the power of presidency. People especially his actions surrounding the January 6^th insurrection and potential election interference. The former president has been indicted by a special counsel on felony charges for working to overturn the results of the 2020 election in the run-up to the violent riot by his supporters at the U.S. Capitol on Jan. 6, 2021. The four-count indictment includes charges of conspiracy to defraud the United States government and conspiracy to obstruct an official proceeding: the congressional certification of Joe Biden’s victory. by saying that the election was stolen and trying to persuade state officials, then-Vice President Mike Pence and finally Congress to overturn the legitimate results. He was also indicted in Georgia along with 18 others, for violating the state’s anti-racketeering law (RICO) by scheming to illegally overturn his 2020 election loss. RICO charges are better known for being used by law enforcement to down the Mafia in the 80s and 90s. It is important to note that the former President is yet to be convicted of any charges. People are also concerned because Trump has shared his belief publicly that a president should have immunity from any actions they take as president, which many believe goes against the original intent of the constitution and the separation of powers. Trump said on Truth Social in all-caps “A PRESIDENT OF THE UNITED STATES MUST HAVE FULL IMMUNITY, WITHOUT WHICH IT WOULD BE IMPOSSIBLE FOR HIM/HER TO PROPERLY FUNCTION”. Trump is effectively arguing that a president can do whatever he wants while president and cannot be held liable. This is response to charges that were filed against him for illegally holding onto classified documents and allegedly trying to move/destroy evidence. People are concerned that a candidate that has allegedly worked to fix and overturn an election, as well as believes that a president should have full immunity to do whatever they want while president, is not “fit” to hold the country’s highest office.

In the end, we can all agree that this election season is going to be exhausting. Thank god we have the Olympics to distract us for parts of it.

Federal Recap

Biden Unveils Budget Proposal for FY25

On Monday, President Biden unveiled his proposed budget for FY25, which looks to cut the deficit by $3 trillion over a decade, by increasing taxes for companies and the wealthy. The proposals calls for raising the corporate tax rate to 28 percent from 21 percent, which is the level that was set by the 2017 Tax Cuts and Jobs Act. It also calls for increasing what’s known as the corporate minimum tax to 21 percent from 15 percent. That tax, which was passed by Democrats in 2022, applies to corporations that report annual income of more than $1 billion to shareholders on their financial statements but use deductions, credits and other preferential tax treatments to reduce their effective tax rates well below the statutory 21 percent. In addition to quadrupling a 1 percent surcharge on corporate stock buybacks to 4 percent. White House economists estimate increasing the tax could yield $137 billion in new tax revenue over a decade.

For taxing the wealthy, the proposal includes language that would raise the capital gains tax rate for earner who make more than $400,000 a year to 39.6 percent, and close the so-called carried interest loophole that allows wealthy hedge fund managers and private equity executives to pay lower tax rates than entry-level employees. The most progressive policy included in the proposal would create a 25 percent “billionaire tax” on individuals with wealth, defined as the total value of their assets, of more than $100 million, with the goal is to prevent the wealthiest Americans from employing tax strategies that allow them pay lower tax rates than those of middle-class households.

Last Thursday, before the President’s State of the Union Address, House Republicans advanced their FY25 budget proposal, which would take a vastly different approach to balancing the budget, by cutting over $14 trillion in federal spending in such areas as green energy subsides and student loan forgiveness while reducing taxes. The House Budget Committee adopted the blueprint in a 19-15 party line vote last Thursday, with Budget committee chairman Jodey Arrington saying that the budget plan would reduce the federal debt, which stands at over $34 trillion, create a $44 billion budget surplus in fiscal 2034 and stir economic growth by lowering taxes. The budget postpones severe spending cuts until fiscal 2026, after the November election that will determine control of the White House and Congress. Committee documents show 2026 basic discretionary spending falling by more than $100 billion to $1.5 trillion.

To put it mildly, FY25 budget negotiations are expected to be turbulent, like a flight trying to fly through a hurricane. HCA will be watching the budget process closely as it unfolds.

Government Avoids Partial Government Shutdown, Still More to Do

Late on Friday, the Senate passed a government funding bill, funding roughly 30 percent of the federal government for the next six months, mere hours before the deadline. The legislation — which passed by a 75 to 22 vote — devotes $459 billion to the departments of Agriculture, Commerce, Energy, Housing and Urban Development, Interior, Justice, Transportation, and Veterans Affairs, as well as the Environmental Protection Agency and Food and Drug Administration, for the rest of the fiscal year, which ends Sept. 30. President Biden signed the packaged shortly after it cleared the Senate. Biden thanked Congressional leadership for working together to avoid a partial shutdown. The passing of the funding package came more than five months into the current budget year after congressional leaders relied on a series of stopgap bills to keep federal agencies funded for a few more weeks or months at a time while they struggled to reach agreement on full-year spending.

Through the funding package, non-defense spending will remain relatively flat compared with the previous year. Supporters say that’s progress in an era when annual federal deficits exceeding $1 trillion have become the norm. But many Republican lawmakers were seeking much steeper cuts and more policy victories. The funding packaged also includes over 6,000 earmarks requested by individual lawmakers with a price tag of about $12.7 billion. Earmarks, which were previously banned in 2011, but was recently voted to reinstate earmarks in 2021 by Democrats, with Republicans soon following suit.

Congress still needs to tackle tricker funding packages for remaining departments, including the Departments of Defense, Financial Services and General Government, Homeland Security, Labor-HHS, Legislative Branch, and State and Foreign Operations. Those bills are typically much more controversial and are at greater risk of failure than the bills that passed this week.

State Outlook

Where The Money At?

For the 9^th straight month, state tax collections fell short once again in February. This extends what was already the longest streak of below-benchmark months in more than two decades, tax revenue remains down compared to a year ago. State House News reported that the Department of Revenue reported Tuesday that it collected $2.007 billion last month — $27 million or 1.3 percent more than actual collections in February 2023 but still $11 million or a slim 0.6 percent shy of the administration’s revised monthly benchmark of $2.018 billion. The Healey administration in January lowered the monthly benchmark for February from the $2.137 billion it originally projected for the month prior to the governor’s fiscal year 2024 revenue downgrade. The last time tax collections came in at or above the administration’s monthly benchmark was June 2023, nine months ago. The Healey administration didn’t establish fiscal 2024 benchmarks until August last year, so there was no official expectation set for July 2023. But each month since — now seven in a row — has seen collections fall short of the administration’s projections.

The Executive Office of Administration and Finance said the administration is not planning to make additional budget moves in connection with the below-benchmark February revenue report. A spokesman said the budget office’s outlook on fiscal 2024 has not changed. DOR is due to report revenue collections for March by Wednesday, April 3. The monthly benchmark for March, which DOR said is usually “a mid-size month for revenue collections, ranking sixth of the 12 months in eight of the last 10 years,” is set at $3.935 billion. That would be $52 million more than what was collected in March 2023.

State Recap

Massachusetts Health Care Costs Rose in 2022

The Center for Health Information and Analysis (CHIA), created under a 2012 cost containment law, released its annual report Wednesday examining health care spending trends in 2022. The detailed report covers a year that started with record-high reporting of COVID-19 cases, followed by gradual decline throughout the year.

The 2022 growth in health care spending was below both the rate of growth in the Massachusetts economy broadly (7.2 percent) and regional inflation (7.1 percent), CHIA said, but outpaced growth in both national wages and salaries (5.1 percent) and national health care spending measured by the Centers for Medicare & Medicaid Services (4.1 percent). The largest contributors to the 2022 expenditure increases were pharmacy spending and non-claims payments, CHIA said.

Other medical services, which includes long term care and home health services, was the largest component of MassHealth spending, totaling $3.4 billion in 2022. Other medical services spending increased 10.1% overall, but only 0.8% on a PMPM basis. Its important to note that the CHIA report does not specifically mention how much was spent on home health services amongst the “other medical service” category.

MassHealth Proposes Significant Increase to CSN Rates

In February, MassHealth released their proposed rates for CSN services. In summary, MassHealth proposed a 32.4% increase to RN weekday rates, and an 11% increase to LPN rates. They have also added a high-tech rate for members with Trachs/Vents/Central lines, these rates have a $2/unit ($8/hr) add on/UA modifier, as well as increased the rate for the 60-day supervisory visit of CCA services by 32.4% as well. If these rates take effect, we will have realized nearly 100% rate increases to this program since 2017 when HCA’s members and CCM Families teamed together on advocacy efforts. An incredible feat.

HCA provided verbal testimony in favor of the rate increase at a public hearing last week, in addition to submitting written testimony.

Massachusetts Health Care Costs Rose in 2022

CHIA’s annual report estimated total health care spending in Massachusetts at $71.7 billion in 2022, and a per capita health care expenditure of $10,264 per resident. Total health care spending was up $3.9 billion (up 5.8 percent on a per capita basis) over 2021’s level — well in excess of the state’s 3.1 percent benchmark for health care cost growth. CHIA said the 5.8 percent growth rate in 2022 represents the largest one-year jump since measurement began in 2012, aside from the “anomalous spending growth in 2021 driven by the pronounced effects of the pandemic.” Health care spending shot up 9 percent in 2021 after posting a 2.3 percent decline in 2020. The 2022 growth in health care spending was below both the rate of growth in the Massachusetts economy broadly (7.2 percent) and regional inflation (7.1 percent), CHIA said, but outpaced growth in both national wages and salaries (5.1 percent) and national health care spending measured by the Centers for Medicare & Medicaid Services (4.1 percent).

Other medical services, which includes long term care and home health services, was the largest component of MassHealth spending, totaling $3.4 billion in 2022. Other medical services spending increased 10.1% overall, but only 0.8% on a PMPM basis. It’s important to note that the CHIA report does not specifically mention how much was spent on home health services amongst the “other medical service” category.

“Did You See That” – February 2024

Federal Outlook

Senate Passes $95.3 Billion Foreign Aid Bill, DOA in House

The Senate passed a $95.3 billion foreign aid bill with assistance for Ukraine and Israel, setting up a showdown with the House. The foreign aid package includes billions of dollars to support Ukraine and for security assistance for Israel, as well as humanitarian assistance for civilians in Gaza, the West Bank and Ukraine, among other priorities. The Senate vote was 70 to 29 with 22 Republicans voting in favor, including Senate Minority Leader Mitch McConnell. “History settles every account,” McConnell said in a statement following the vote. “And today, on the value of American leadership and strength, history will record that the Senate did not blink.” The bill includes $60 billion to support Ukraine in its fight against Russia, $14.1 billion in security assistance for Israel, $9.2 billion in humanitarian assistance and $4.8 billion to support regional partners in the Indo-Pacific region in addition to other policy provisions, according to the Senate Appropriations Committee.

The bill passed the Senate despite Speak Mike Johnson’s, who looks like the type of person that would side with the parents that banned dancing in footloose, criticism of the legislation and former President Donald Trump signaling opposition to the bill by arguing the US should stop providing foreign aid unless it is in the form of a loan. Johnson has said that he has no plan to take up the bill currently. “Right now, we’re dealing with the appropriations process, we have immediate deadlines upon us and that’s where the attention is in the House in this moment.” Johnson also said that we, Congress, need to focus on the border first, and not on foreign aid. Johnson has said in the past that he would not support a foreign aid package unless the House’s hardline border bill is attached, which Senate leadership on both sides of the aisle have said in the past is a nonstarter. The Senate previously announced that they have agreed on a border bill that has bipartisan support, but the House and Speaker Johnson argue that it does not go far enough. But what the House did not say is that presidential candidate Donald Trump has pushed for Congressional republicans to block any border deals so that democrats cannot campaign on the border during the upcoming election cycle. President Joe Biden called on House Republicans to hold a vote on the bill in remarks from the White House, saying that a “minority of the most extreme voices in the House,” should not be permitted to block the bill.

House Impeaches Homeland Security Secretary Alejandro Mayorkas

After an embarrassing failure in January, the GOP led House succeeded in impeaching Homeland Security Secretary Alejandro Mayorkas for his handling of increased migration at the southern border, making him the first cabinet secretary since 1876 to be impeached. The vote tally was 214 to 213. Three Republicans voted with Democrats against the measure. Speaker Johnson said Homeland Security Secretary Alejandro Mayorkas needed to be impeached because he refused to do his job. “From his first day in office, Secretary Mayorkas has willfully and consistently refused to comply with federal immigration laws, fueling the worst border catastrophe in American history,” Johnson said in a statement after the impeachment vote Tuesday. Johnson accused Mayorkas of undermining the public’s trust “through multiple false statements to Congress.” He also said the homeland security secretary “obstructed lawful oversight of the Department of Homeland Security, and violated his oath of office.” Constitutional experts have said the evidence does not reach that high bar of impeachment and three Republicans voted with Democrats against the resolution.

Republican Rep. Ken Buck voted against the impeachment of Homeland Security Secretary Alejandro Mayorkas last week — and did so again tonight. Buck said he did not reconsider his vote because he does not believe that the circumstance qualifies as a high crime and misdemeanor. “You can try to put lipstick on this pig, it is still a big, and this is a terrible impeachment. It sets a terrible precedent,” Buck told CNN on Tuesday after the vote. Sen. Ken Cramer (R-N.D.), an ally of former President Trump, slammed House Republicans actions, calling it “the worst, dumbest exercise and use of time.” The impeachment now moves to the Senate where Democrats have a majority, all but killing any GOP hope of Mayorkas being fully impeached. The Senate is required to hold an impeachment trial, Senate Majority Leader Chuck Schumer’s office said House impeachment managers will present the articles of impeachment to the Senate following the state work period. Senators will be sworn in as jurors in the trial the next day. Senate President Pro Tempore Patty Murray will preside. The key part of the trial is that during an impeachment trial in the Senate, no other official business can be done till the trial is completed. It is widely expected for the Senate to push through the trial to acquit Mayorkas as quickly as possible so they can get back to budget negotiations for a full year budget.

State Outlook

It’s All About the Benjamins

In a crushing blow for Governor Healey’s budget plans, for the seventh straight month Massachusetts failed to hit projected tax revenue. This comes on the heals of Governor Healey implementing emergency 9c cuts of up to $375 million and the Healey administration significantly lowering monthly tax revenue benchmarks. State House News reported that The Department of Revenue reported collecting $3.594 billion last month (January) — $268 million or 6.9 percent less than actual collections in January 2023 and $263 million or 6.8 percent below the administration’s revised monthly benchmark of $3.858 billion. The Healey administration last month lowered the monthly benchmark for January from the $4.121 billion it projected for the month prior to the governor’s fiscal year 2024 adjustments.

Since fiscal year 2024 started in July, DOR has collected $21.460 billion, 1.2 percent less than what the Healey administration projected last month that it would have hauled in by this point in the calendar. The administration last month slashed the year-end revenue estimate by $1 billion after it was reported in December that tax revenue was running $769 million behind projections. Reducing the revenue estimate by $1 billion was meant to address the existing $769 million shortfall while also providing some breathing room for the second half of the budget year, when Administration and Finance Secretary Matthew Gorzkowicz said he expected additional months of below-benchmark collections. The administration also said it thought its January actions would be enough to avoid further 9C cuts this year. Now, after the governor cut $375 million in spending and newly tapped $625 million in non-tax revenues to account for the $1 billion revenue downgrade, the state still finds itself in a hole. Gorzkowicz told reporters that the administration does not have any plan to implement any additional 9c cuts to account for lowering tax revenue.

Lagging tax revenue is a major problem for Governor Healey, who has lofty goals for 2025, and the legislature as they try to craft a FY’25 budget. In late January, Governor Healey released her proposed $58.15 billion budget for FY2025, an over $2 billion or 3.7% increase when compared to the final FY2024 budget she signed back in August. The proposed budget suggests that she and her budget team expect a growth in revenue compared to last year. The bill does not propose any new tax increases to generate additional revenue, nor does it recommend tapping into the state’s more than $8 billion “rainy day” savings account. Further details on her proposed budget can be found below.

With lagging tax revenue and Governor Healey laying out an ambitious budget proposal in January, the legislature is left to be the bad guy. Governor Healey said in her State of the Commonwealth address that she wants to continue to pay for the migrant crisis, increase spending on infrastructure, such as the T, address the housing crisis and expand access to free community college for Massachusetts residents. All these things will cost an exuberant amount of money to be done properly. Want to know how much? So much so that I had to check a thesaurus to find a better word for a “crap ton”. But in all seriousness, they will all cost billions of dollars. It has been reported that to properly address the migrant crisis it could cost over $2 billion a year. That’s more than what the state spends on free school lunches, free community college, and energy and environmental affairs combined. It’s going to be tough for the legislature to look at current revenue trends and propose a budget that could further exacerbate the ever-growing revenue dilemma and result in an unbalanced budget half-way through the fiscal year.

This concerns me especially because we have already seen the health care sector be cut by Governor Healey when she implemented her 9c cuts to balance the budget. The largest cut proposed by Governor Healey was a $294 million cut to MassHealth fee for service. The explanation that was given for why they can afford to cut $294 million was due to “members using fewer services than we had originally budgeted.” This leads me to worry that the legislature will look to make cuts to the health sector and home care specifically to offset additional spending for Governor Healey initiatives. HCA is closely tracking the legislature’s budget process and has already spoken with the House about the importance of properly and sufficiently funding home care line items in the FY25 budget. HCA plans to continue outreach to the Senate side as the budget process moves along.

Now, like a weatherman, my prediction could be completely wrong. We have seen in the past many times that governments can basically create money out of nowhere and make a budget shortfall go away while also increasing spending, look at Congress every year. But HCA won’t take that chance that they will continue their trend of higher spending till proven otherwise and will continue to fight for funding for home care.

State Recap

HCA Holds State House Advocacy Day

HCA along with members of the Enough Pay to Stay Coalition (EPTS), held a highly attended State House Advocacy Day at the Massachusetts State House. Over 18 people from 8 agencies attended the State House Event. The day started with remarks from Jake Krilovich, Julie Watt Faqir, ED, Home Care Aide Council, and Betsy Cummings, ED, Mass Home Care, followed about remarks from some of our biggest legislative champions, Senator Patricia Jehlen, Representative Thomas Stanley & Representative Carmin Gentile.

Over a full day a meetings HCA members met with over 12 legislative offices, where we discussed the struggles agencies face on a day-to-day basis due to a workforce shortage and how passing H.1195/S.755 – An Act Clarifying Rate Setting Processes for Home Health and Home Care Services would help increase transparency of the rate setting process, as well as, update the rate setting methodology to account for all the costs of that go into providing these services, which will help to create a more adequate rate that will allow agencies to properly compete for workers. We also discussed the crucial need to pass H.649 – An Act to Improve Massachusetts Home Care, which would establish a licensure system for non-medical home care services that would establish baseline standards for agencies, to ensure a quality network of providers for consumers and keeping services affordable for those who rely on them. HCA would like to give a special shoutout to all the members that attended, their valuable insight into the importance of Home Care and what we need to do to grow the sector will go a long way to help pass these two key pieces of legislation. If you would like to read more about the event, check out State House News coverage of the event HERE.

Governor Healey Proposes Increasing FY25 Budget by Over $2.1 Billion

Governor Healey is proposing a $58.15 billion budget for FY2025, an over $2 billion or 3.7% increase when compared to the final FY2024 budget she signed back in August. The proposed budget suggests that she and her budget team expect a growth in revenue compared to last year. State House News reported that Healey’s team balanced their plan by trimming $450 million from various line items, proposing to prevent about half a billion dollars in other spending growth, and deploying $1.25 billion other available state resources. The bill does not propose any new tax increases to generate additional revenue, nor does it recommend tapping into the state’s more than $8 billion “rainy day” savings account. Cost controls include closure of the MCI-Concord medium security prison and changes at MassHealth, which typically reflects the largest share of the budget. The budget will propose “flat spending” for MassHealth’s personal care attendant (PCA) program.

Governor Healey proposed several increases in funding as compared to FY24, to line items that affect home care services. Including but not limited to:

1599-6903 – Chapter 257 and Human Service Reserve – $173,000,000 to $390,000,000.
9110-1630 – Home Care Services Provided Through ASAPs – $215,556,634 to $236,582,945.
4000-0700 – MassHealth Fee for Service Payments – $3,601,016,357 to $4,232,605,645.

In addition, unlike the FY2024 final budget, Governor Healey’s proposed budget did not include language for a pass-through requirement for Chapter 257 rates under line item 1599-6903. The pass-through requirement included in the FY24 budget amended the Chapter 257 Rate Reserve line item 1599-6903 as follows, by inserting after the words “any human service provider receiving revenue under said Chapter 257” the following: “, and any home care agency subcontracting with such human service providers to provide home care services,”. This language specifically requires home care providers under chapter 257 to comply with a 75% pass-through requirement that is stipulated in line item 1599-6903. We would like to note that this pass-through requirement is much broader than a pass-through amendment that SEIU tried to pass during the House budget debate, that HCA along with the Home Care Aide Council successfully blocked. Next, Governor Healey’s budget will be taken into consideration by the House and the Senate. The legislature is not required to include anything that is proposed by the Governor in her budget proposal. HCA will work with our legislative champions at the state house to make sure that no pass-through language is included in either of the proposed budgets from the House and the Senate.

Joint Rule 10 Deadline Extended for Select Committees

On Monday, The State House of Representatives voted to extend the Joint Rule 10 deadline, which is the deadline for committees to report on bills (favorable, non-favorable, or further study), was extended to May for select committees including the Committee on Advanced Information Technology, the Internet and Cybersecurity; the Committee on Agriculture; the Committee on Children, Families and Persons with Disabilities; the Committee on the Judiciary; and the Committee on Transportation. This does not affect the two bills (H.649 – An Act to Improve Massachusetts Home Care & H1195/S755- An Act Clarifying Rate Setting Processes for Home Health and Home Care Services) that were introduced by HCA along with the Enough Pay to Stay Coalition (EPTS Coalition). Both these bills are currently before the Joint Committee on Health Care Financing, whose deadline to report out bills is March 27^th. HCA will continue to provide updates as both bills move through the legislative process.

Infectious Disease Bill Sent For Study

The Joint Committee on Elder Affairs announced yesterday that it is recommending that H.640/S.397 – An Act to improve infection control in Massachusetts home, which would establish a mandatory infection control training program for personal home care attendants, be given a study order. A study order authorizes the Committee to sit during recess and study this measure and similar ones and file a narrative report of its findings. However, for the vast majority of bills sent to a study order, no further Committee activity takes place, it is mainly seen as a quiet way to kill a bill.

HCA does not support the bill. We raised our concerns about a bill during a hearing on a bill in June of 2023. HCA provided testimony in person that raised amongst other concerns that home care agencies under contract with Aging Service Access Points already have infection control requirements as part of their contracts in the home care program. These require training during employee onboarding and on an annual basis as part of their in-service requirements. In addition, federally certified home health agencies also have infection control requirements as part of the Federal CMS Conditions of Participation. We proposed adding an amendment that would exclude home care agencies contracting with ASAP entities and exclude home health agencies as defined in the Massachusetts general laws section 51K.

Did You See That?!? – January 2024

Quick Note

I hope everyone had a great holiday break! I know I did!! This may just be my negative winter northeastern mind kicking in, but I might be the only person who really doesn’t enjoy “year in review” look back segments. Weather its friends posting their year in photos on Instagram, CNN covering all the horrific news events of the year that made everyone sad, or ESPN replaying every winning play in sports, I think they are all kind of pointless and a waste of time. Other than Spotify yearly wraps. I personally find it really fun and interesting because I get to see firsthand how my wife’s love for Taylor Swift is so deep, that it affects my top 5 artists of the year.

Besides that! It’s 2024, it’s time to move on to the present and the future. So rather than rehashing for the 30^th time what happened in 2023, I’m going move forward and update everyone on what to expect in 2024.

*I would also like to say that all opinions raised in this piece are my own and do not represent HCA’s opinions and thoughts.*

Federal Outlook

Now We Have TWO BUDGET DEADLINES!!!

Congress loves budget season and the immense amount of press that comes with it so much, that they broke the yearly budget into two deadlines. For a small recap, (I know, the hypocrite I am) Congress previously failed to pass a full year spending package that would fully fund all 12 regular appropriations bills by the original continuing resolution (CR) November 17^th deadline, newly elected House Speaker Mike Johnson crafted and passed a two-step CR, with four of 12 appropriations bills expiring January 19, and the remaining eight expiring February 2. While this buys Congress time to discuss appropriation levels, it also creates a series of funding deadlines that, if not met, will shut down parts of the government.

Now the first deadline, January 19^th, is quickly approaching for Congress to pass four of 12 appropriations bills, which include budgets for the FDA, Energy and Water Development, Military Construction and Veterans Affairs, and Transportation, Housing and Urban Development. “The Hill” reported that there are four different avenues that Congress could take when it comes to dealing with the budget.

Option one: Congress passes all their funding bills by each deadline. Now this Option is looking less and less likely as days pass. “It’s going to be very difficult to get all of the appropriations bills we have to get done in time if we don’t have the [top-line] number, and we don’t have the number right now,” Rep. Tom Cole who heads the House subcommittee that crafts the annual funding bills for the departments of Transportation (DOT) and Housing and Urban Development (HUD). “So, we’re going to have to make some tough decisions in early January.” To date, the House has passed seven GOP-crafted spending bills while the Senate has passed a so-called maxibus of three bills. But the bills passed look vastly different between chambers, which means there is still a long way to go for Senate and House leaders when it comes to an agreement on a final package.

Option Two: Congress passes another stopgap for the budgets due on January 19^th. This is becoming the more likely option as discussions between lawmakers continue to stall. There have already been doubts raised by legislatures in the House and in the Senate before the Holiday break on Congresses ability to pass any budget pieces, with one saying that if a deal was not made before the break, the odds of any deal happening by the deadline were very slim. It is yet to be seen how a 3^rd CR would be drafted and when the next deadline would be. It is important to note that Speaker Johnson has said he will not push through another short-term stopgap. “A CR is simply unacceptable for a year,” Senate Minority Leader Mitch McConnell (R-Ky.) said before the Senate left for their end-of-year recess. “It’s devastating, particularly for defense, and we’ve got all of these wars going on. So, we need to reach an agreement on the top line and get about getting an outcome as soon as possible.”

Option Three: Parts of the government shut down as negotiations continue through the February 2^nd deadline. I personally believe that this will not happen, as it would be a major blow to Speaker Johnson reputation if he fails to pass any sort of a budget or a CR by the 19^th.

Option Four: Congress passes and omnibus spending package funding all budgets at once. This is something that hardline Republicans were trying to prevent when they pushed for the two-step CR. Former Speaker Kevin McCarthy, during his fight to keep his spot, promised conservatives he wouldn’t resort to a single massive spending package, and Speaker Johnson backed that vow, telling reporters in November that they “broke the omnibus fever — we call it the ‘omni fever.’”

But with limited options on the table, I would not put it out of the realm of possibility that the Biden Administration along with Senate Democrats propose a full year omnibus package to Republicans at the last minute that entices them to support rather than a government shutdown.

Regardless of which option comes to fruition, we can all agree that this will be an absolute shit show. It’s unbelievable to me that Congress continues to fail to recognize that literally no one wins when they fight over the budget, and it only pisses off the vast majority of the public. The public is forced to witness stupid cat fights between media hungry, empty-suit politicians that only care about themselves and only try to show that they care about leading when it’s best for them.

It’s the same dog and pony show every year, where one side demands X and the other demands Y, they both say they wont budge even though in the end they always do. I understand why Speaker Johnson broke up the appropriation budgets into different deadlines, but in the end won’t change how they negotiate overspending. We are already hearing discussions about a single omnibus budget being negotiated which basically makes the two deadlines useless. What holds up the budget process every year, isn’t mundane budget features such as payroll or resources. It always comes down to year specific budget proposals (i.e. border crisis, Ukraine aide, Israel aide, etc.) which cause the whole budget process to hault. These politicians walk around like there are no ramifications for delaying a budget or even failing to pass a budget resulting in a government shutdown. So many businesses, non-profits, charities, non-profits rely on government funding to survive and when they fail to advance the budget, they all get hurt. I think, every time there is a CR, members of Congress should not be paid for the extended amount of time, and if there is a government shutdown, they should owe money for every day it is not open.

Presidential Election

It’s the most horrible time of the year!!! With so much despair and with everyone crying, giving you great fear!!!! It’s the most horrible time of the year!!! (single with cadence of it’s the most wonderful time of the year by Andy Williams).

Yes, sadly it’s finally here. The race to be elected president is right around the corner, haunting us all like the Babadook in the shadows, with election day this November. I’m not going to spend much time on this because, as history has shown, no one can accurately predict what will happen. Right now, it is looking like we will have to live through the worst rematch in history between Donald Trump and Joe Biden. The only outside candidate that I believe has a shot to challenge either candidate is former South Carolina Governor Nikki Haley, who is the type of person that reminded her teachers when homework wasn’t collected. She has gotten the most support out of all the challengers to Donald Trump in the Republican primary.

As the year goes on Congress will become less and less active as the election day draws closer. So, I would plan for Congress to basically stop once August recess comes around.

State Outlook

Second Session Is Here

New year, same business. January 3^rd marks the beginning of the second session of the 193^rd general court of the Commonwealth of Massachusetts. The second session is when the legislature is usually the most active, with it being the last time to act on a piece of legislation that were introduced during the first session. This year, legislative leadership will have their handful with trying to pass legislation on hot button issues, such as gun control, climate, housing crisis and growing health care costs. The legislature will also need to pass a budget for FY25, which will come with its own headaches as Massachusetts looks to address the migrant shelter crisis.

HCA will be very active this year as we look to advance two key pieces of legislation that we filed, H.649 – An Act to Improve Massachusetts Home Care, and H.1195/S.755 – An Act Clarifying Rate Setting Processes for Home Health and Home Care Services. The licensure bill was recently voted favorably out of committee by the Joint Committee on Elder Affairs, referring the bill to the Committee on Health Care Financing. The Licensure bill will now move to the next step of the legislative process, which involves three occasions (known as “readings”) in each branch in which a bill is considered. The first “reading” will come from the from the Joint Committee on Health Care financing. Please use this ACTION ALERT to write to members on the Joint Committee on Health Care Financing urging them to give the bill a favorable report. HCA will provide updates on the licensure bill as they unfold.

We expect that H.1195/S.755 – An Act Clarifying Rate Setting Processes for Home Health and Home Care Services, will be given the same treatment soon as the deadline for the Joint Committee on Health Care Financing to report bills out of their committee is the fourth Wednesday of February.

Did You See That?!? – November 2023

Federal Recap

And the Winner Is!?!?!?!

After what has felt like an eternity, the House has finally elected a new Speaker of the House……. Rep. Mike Johnson (R-LA-4). Now I imagine that a lot of you said…. Who?!?!?! When he was elected. Well, you are not alone. After multiple weeks and several unsuccessful speaker bids from some more well-known republicans, such as controversial house member, Jim Jordan and Majority Whip Steve Scalise, the GOP seemed to be running out of people to choose from, in comes Rep. Johnson. Johnson, who is a relatively new member, only in his 4^th term, is not a very well-known member amongst people outside the beltway.

Johnson, who looks like a live rendition of the men’s bathroom sign figure, previously served as Vice Chair of the House Republican Conference. But Johnson is most well-known for his hardline stance on abortion, being a hardcore supporter of former President Donald Trump, and for not certifying the 2020 election. Many political pundits have noted that previous candidates, such as Jordan and Scalise, had something that Johnson did not. Political enemies within the GOP. Due to their very public personas and appetite for making media catching comments, Jordan and Scalise both have made a few hard-core enemies with the GOP, that have publicly said that they would never vote for them no matter what. Johnson seems to not have that problem; his biggest appeal was that he has limited beef with fellow GOP members. Mix that with support from Trump, voting fatigue, and I would hope some embarrassment, led to Johnson being named the 56^th Speaker of the House, which also makes him one of the most important GOP members in Congress.

CMS Releases Final Rule for Home Health Payments

A couple weeks ago, CMS released its CY 2024 home health final payment rule. The final rule institutes an estimated aggregate increase to 2024 home health payments of 0.8 % ($140M) compared to 2023 payments. This is a reversal from the proposed rule issued in June that would have cut home health payments in the aggregate by 2.2%. The 0.8% increase reflects a payment update of 3% and fixed dollar loss ratio (FDL) increase of 0.4%. These increases are offset by a -2.89% permanent behavioral assumption adjustment (which was originally proposed as a -5.1% cut).

All told, in the short term, this final rule offers significant relief to the industry for 2024. However, CMS and MedPAC continue to maintain their assertion that home health agencies were overpaid from 2020-2022 which leaves potential for future claw backs in the coming years.

The reversal of the proposed cuts would not have been possible without all of you. The Alliance is greatly appreciative of all the members that join our advocacy efforts over the last year, which include sending hundreds of advocacy emails to members of Congress and submitting comment letters to CMS proposed rule. We are especially grateful to the members that traveled with Alliance staff to Washington, D.C. twice in the last six months to participate in over 20 meetings with members of Congress and their staff. As proved by the final rule, your persistence and collective voice was heard. Obviously, there is more work to be done to prevent future cuts or claw backs – but for today, we breathe a sigh of relief.

House Subcommittee on Health Holds Hearing on Medicaid 80/20 Proposed Rule

Last Wednesday, the House Energy and Commerce Subcommittee on Health held a hearing on Medicaid 80/20 proposed rule and nursing home staffing requirements. As a refresher, in June, Centers for Medicare and Medicaid Services (CMS) proposed requiring at least 80% of Medicaid payments to home health agencies for personal care, homemaker and home health aide services go toward direct care workers, rather than company overhead or profits. The Subcommittee on Health held a hearing to examine the potential impact of the proposed rule.

Chairman Rep. Brett Guthrie (R-KY-2) lead the charge during the hearing, arguing that the proposed rule would cause an undue burden on agencies and in the end would impact patient access to vital care. “Biden’s unfunded mandates would restrict access to care for vulnerable population” said Chairman Guthrie. He went on to say that “finalizing the Access Rule would also force 93 percent of all home care agencies to reduce or limit their ability to accept new referrals.” Other committee members along with multiple witnesses that were brought in to testify before the committee, backed up Chairman Guthrie’s comments. Only a few committee members argued for the proposed rule, arguing that the rule would help to increase pay for workers thus encouraging more workers to come to the field. If you would like to see a recording of the hearing, please use this LINK.

Look Ahead

Time to Balance the Budget

Late on Tuesday night, in a surprising turn of events, the House of Representatives passed Speaker of the House, Mike Johnson proposed two-step continuing resolution (CR). The plan does not include budget cuts or aid for Israel. Under the two-step strategy — which Johnson and others have dubbed a “laddered CR”, would keep the government funded at current funding levels until Jan. 19, while the remaining spending bills would go on a CR until Feb. 2.

The passing of this bill marks a pretty big victory for the newly elected Speaker. But, while the bill garnered broad support from both sides of the isle, passing 336-95, with more Democrats voted for the measure than Republicans, some far-right members of the GOP voiced their frustration with the proposal. They are unhappy that Johnson worked with Dems and that the CR did not include the steep spending cuts and border-security measures they sought. These members are the same members that in September ousted former Speaker Kevin McCarthy after he made a similar deal with Democrats to fund the government through mid-November.

They’re not looking to oust Johnson over it. But some conservatives are privately entertaining other ways to retaliate. One tactic under discussion is the same one they used against McCarthy: holding the House floor hostage by tanking procedural votes. “There is a sentiment that if we can’t fight anything, then let’s just hold up everything,” said Rep. Ralph Norman (R-S.C.), one of several frustrated Freedom Caucus members who has huddled with the speaker multiple times this week.

The spending package now heads to the Senate, where Democratic and Republican leaders have voiced support. To prevent a shutdown, the Senate and Republican-controlled House must enact legislation that President Joe Biden can sign into law before current funding for federal agencies expires at midnight on Friday.

State Recap

Healey Administration Unveils Comprehensive Housing Plan

On Wednesday, Governor Healey unveiled a five-year, $4.12 billion housing bond bill. The Affordable Homes Act is filled with funding and policy reforms aimed at spurring much-needed production of new units, upgrading the aging and neglected public housing stock, and converting state land into housing-ready plots. Governor Healey previously campaigned on addressing the state’s growing housing crisis.

In a summary of the bill that was provided to reporters, the bill includes substantial investment to support the production, preservation and rehabilitation of more than 65,000 homes statewide, as well as 28 policy riders. One of the biggest changes it proposes is letting local officials charge transfer fees of 0.5% – 2% on property sale, that would be paid by the seller, which would be used fund affordable housing development. The threshold would be either $1 million or the median single-family home sales price for the county, whichever is greater. Healey’s office estimated the fee, if adopted, would affect “fewer than 14 percent of all residential sales.” In addition, the bill would create a new Homeowner Production Tax Credit, which aims to incentivize construction of homes targeted at potential middle- and low-income owners. It would also make permanent the Community Investment Tax Credit while boosting its cap on donations from $12 million to $15 million. Healey’s office estimated that all together the housing package could lead to creation of more than 40,000 new housing units, chipping away at a shortage that has previously been estimated at roughly 200,000.

Many of the plan’s key provisions will be controversial in the eyes of municipal governments that prize local control of zoning, as well as in some corners of the real estate community. It will need to navigate a gantlet of committees and leaders on Beacon Hill, many of whom have been skeptical of big-ticket housing reform in the past. Healey plans to complement the legislation with a trio of executive orders creating a housing advisory council, standing up a commission to examine streamlining housing production, and calling for a study to identify surplus public land that can be used for housing.

Look Ahead

Holiday Slumber

Yesterday marked the last day of formal session for 2023, which means that state legislators will go into their holiday slumber till 2024. After a pretty chaotic couple of months, with the state legislature acting like college students trying to cram for finals, legislators will now be in informal session until at least January 3^rd, 2024. Legislation is rarely passed during informal session, because under state rules, it only takes a single no vote for a bill to fail. During this time the legislature will continue their discussions on a supplemental budget package and a long term care bill focused around nursing homes and prescription costs.

HCA will use this time to educate members about our legislative priorities. HCA will be holding a State House Advocacy Day on January 30, 2024, where will be inviting legislators to meet with member agencies to learn about home care and the vital work that you all provide. If you would like to participate, please email Harrison Collins, at hcollins@thinkhomecare.org.

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