Tag: CMS

Centers for Medicare & Medicaid Services

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 47th 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 31st. 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! – 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 1st marked the continuation of a new tradition in Massachusetts. For the 14th 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 1st 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?!? – 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 4th 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 56th 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 3rd, 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.

Did You See That? – October 2023

Federal Recap

Making History Isn’t Always a Good Thing

So……. Who had the U.S. Congress ousting Speaker McCarthy on their 2023 bingo board? In a crazy turn of events, in a historic vote, the U.S. House of Representatives voted 216-to-210 to oust Republican Speaker Kevin McCarthy, marking the first time a speaker has been removed from their position. The vote was forced by a contingent of hard-right conservatives, led by Rep. Matt Gaetz of Florida, who called for a motion to vacate McCarthy earlier this week. In the end 8 Republicans joined all Democrats in voting to removed McCarthy as speaker, throwing the House and its Republican leadership into chaos.

To make matters worse, apparently, the Problem Solvers Caucus is close to collapsing because of the Speaker drama. The Problem Solvers Caucus is made up of moderate Republicans and Democrats, whose main goal is to find common ground on many of the key issues facing the nation. According to Politico, Democrats in the Caucus proposed a possible arrangement whereby a bloc from their party would vote to save McCarthy in return for a more expansive role in operating the House. Some ideas included giving the two parties an equal number of seats on the powerful Rules Committee and changing the rules of the House to make it harder for a splinter faction to eject a speaker. Democrats asked McCarthy to delay the vote, in order to continue negotiations, as well as a clearer promise that he would be willing to actually work across the aisle. Republicans in the Caucus believe that the Democrats were negotiating in bad faith since the rest of their party had decided to vote to oust McCarthy because it would thrust the GOP into chaos. In the end, the roughly 30 Democrats in the Problem Solvers stuck with House Minority Leader Hakeem Jeffries and voted to oust McCarthy. Republican Caucus Chair Rep. Brian Fitzpatrick (R-Pa.) told Fox News that he asked a group of Dems to vote present on a procedural vote, allowing Republicans to temporarily kill Rep. Matt Gaetz’s move against McCarthy. Gaetz (R-Fla.) would surely have tried again, he noted. Rep. Fitzpatrick and over 10 Republicans in the Caucus have said that they are now considering breaking up the group in frustration, due to the lack of cooperation during the speaker fight.

I mean come on. At some point we have to put the good of the country above politics and optics. While we all may not agree with McCarthy’s politics, we can all agree that it only weakens our country overall when we continue to have such disarray in Congress. Congress only has a month and a half to pass a spend bill, which will need to include not only aid for Ukraine, but aid for Israel. At the rare everything is going, there is little chance that Congress will succeed in coming to any sort of agreement. This is like expecting a football team to play well without a head coach. Please tell a time when any sports team/country/company, literally any operation succeeded with a power vacuum at the top.

In the meantime, Rep. Patrick McHenry, Majority Deputy Whip, takes over as interim Speaker until a new one is named. In a closed-door meeting, Republicans elected House Majority Leader, Steve Scalise to be their candidate for Speaker. Scalise won the election 113-99 over House Judiciary Committee Chair, Jim Jordan. The vote came after Republicans killed a proposal to change the nominating process that was intended to avoid a messy floor fight. Though Scalise won the GOP speaker election, at the moment he does not have the votes to win the entire House vote, if all Democrats vote against Scalise, like they did during the McCarthy Speaker election. Scalise needs to win a majority from the full House.

Senate Finance Committee Hold Hearing on Importance of Home Care

On Monday, the Senate Finance Subcommittee on Health Care held a hearing on home health and the vital role of home health in access to care. This hearing was unlike most hearings I have watched over my career. Usually, you see committee members battle each other over their opposite beliefs on the subject of the hearing. that was not the case this time. Senators on both sides of the isle seemed to agree on one major topic, the importance of home-based care, and the need for more investments.

Witnesses for the hearing included: William A. Dombi, the president of the National Association for Home Care & Hospice; Carrie Edwards, the director of home care services at Mary Lanning Healthcare; Judith Stein, the executive director of the Center for Medicare Advocacy; and David Grabowski, a professor and researcher at Harvard Medical School.

The main topic of the hearing was CMS’s proposed rate cut to home health repayment rates. Witnesses were given the opportunity to share how these proposed cuts will be detrimental to the industry. They were also able to discuss the dangers of skyrocketing referral rejection rates, the impact of further Medicare Advantage (MA) penetration and the issues the provider community takes with Medicare Payment Advisory Commission’s (MedPAC) reports on home health care.

If you would like to watch a recording of the hearing, use this LINK.

Look Ahead

Always About the Dolla’s

I’ll keep this short. The only thing that Congress will be working on for the next couple months, outside of picking a House Speaker, is trying to pass a full-year budget. On October 1st, President Biden signed a continuing resolution (CR) that funds the government until November 17. The next Speaker, whoever it is, first task will be to pass a CR to allow for more time for a final spending package to be passed, because the odds that both chambers can come to an agreement on a final spending package are as low as my chances of getting a date with Margot Robbie.

This budget will be even more contentious given the recent war that broke out in Israel and the ongoing Ukraine war. Democrats will be looking to provide federal aid to both countries which will likely cause a massive battle with their Republican counter parts. While support for Israel is coming from both sides of the isle, support for Ukraine is lacking in House, which will likely hold up much of the negotiations on a budget. The House GOP under former Speaker Kevin McCarthy did not include any aid to Ukraine in their spending package, which differed from the Democrat led Senate budget proposal. This stalled the last budget negotiations until a CR was agreed upon which included no aid to Ukraine.

In the end, it’s going to be a lot of late nights in DC for staffers, as they try to hammer out an agreement on a CR. Lets hope they can finally get something done, though I’m not gonna hold my breathe.

State Recap

Massachusetts Takes First Steps towards Passing Salary Transparency Legislation

Massachusetts is on its way to becoming the 9th state to pass salary transparency laws. Today, the House of Representatives passed H.4109, An Act Relative to Salary Rance Transparency, which mandates any public or private employer with at least 25 employees include a projected salary or wage alongside any job listing and requires employers with 100 or more full-time Massachusetts employees to submit wage data reports. The Executive Office of Labor and Workforce Development will publish aggregate wage data on an annual basis. The passing of this bill comes after House Speaker Ron Mariano’s office said the chamber’s top Democrats were making it a priority to bring forward salary transparency legislation.

Rep. Josh Cutler of Duxbury and Sen. Patricia Jehlen of Somerville, co-chairs of the Joint Committee on Labor and Workforce Development, proposed the bill as a way to build on the state’s equal pay law by better empowering workers. They dubbed the bill the Frances Perkins Workplace Equity Act, commemorating a Massachusetts native who was the first woman to serve as U.S. labor secretary. HCA will provide updates as the Senate takes up the legislation.

Governor Healey Signs Tax Relief Package

Today, Governor Maura Healey signed a $1 billion tax relief plan that aims to put more money in taxpayers’ wallets and make Massachusetts more competitive. The signing of the bill marks the first Massachusetts tax cut in over 20 years. Twenty months elapsed between Republican Gov. Charlie Baker using his final State of the Commonwealth address in January 2022 to ignite debate about slashing taxes and the final enactment of the package. Legislative leaders said the total impact of the measure for fiscal year 2024 will be $561.3 million. By 2027, when the changes are fully phased in, they say the total impact will be $1.02 billion.

The package will beef up tax credits for caregivers, renters, and seniors, and appease the business community as well. The package’s largest item, worth about $165 million this year and up to $307 million once fully implemented, is an overhauled child and dependent tax credit. To relieve pressure on individual taxpayers, the package would more than double a tax credit available to parents, those who care for dependent seniors, and those who care for a disabled dependent. That credit would rise from $180 per dependent to $310 per dependent in fiscal year 2023, then again to $440 per dependent in fiscal years 2024 and beyond. More than 565,000 Massachusetts families would qualify for the credit, according to a bill summary. Changes to the senior circuit breaker tax credit could save some taxpayers up to $1,200 per year, while renters are in line for an extra $50 annually thanks to an increase to the maximum rent deduction. Additional reforms include changes to the estate tax threshold, and short-term capital gains tax rate.

Joint Committee Holds Hearing on Raising State Minimum Wage Bill

On Tuesday, the Joint Committee on Labor and Workforce Development held a hearing on a number of bills that pertain to minimum wages. These bills covered wages for everything from state minimum wage, the minimum wage for workers who also earn tips, to wages for overtime work, and more. The headline bill that was raised in front of the committee was An Act Relative To The Minimum Wage (S.1200 / H.1925), which would increase the state minimum wage by $1.25 per year until it reaches $20 in 2027 and index it to inflation. It would also increase the sub-minimum wage for tipped workers to $12 by 2027 and set it at 60 percent of the full minimum wage in future years, and stipulate that the minimum wage applies to municipal workers.

This hearing marks the reopening of discussion as to what is considered a livable wage in Massachusetts. It is important to note that the state minimum wage was increased to $15 an hour in 2023. Proponents for raising the minimum wage argue that with rising inflation and housing prices, that not only is a $15 minimum wage not a “liveable wage”, a rise to $20 an hour would still not be making a “living wage.” MIT’s Living Wage Calculator estimates that an adult with no children would need to make $21.35 per hour to support themselves in Massachusetts. For an adult with one child, the living wage would rise to $45.57 an hour, and two working adults would each need to make $24.72 an hour to support themselves and one child in Massachusetts. National Federation of Independent Business Massachusetts state director argues that “raising the base wage to $20 is not only unsustainable for Massachusetts employers who are already raising compensation to counteract the state’s labor shortage and attract workers into the workforce, but additionally, these types of one-size-fits-all mandates hurt smaller, Main Street businesses that cannot absorb the cost the most.” HCA will be sure to provide updates on the minimum wage legislation as it progresses.

Look Ahead

All For The Headlines

After successfully passing a tax relief package, the legislature has a new target in their sights, gun reform. For the last couple of years, legislatures and party leadership have been discussing sweeping gun reform legislation. Last week, House Democrats re-introduced/re-drafted an old gun reform bill that previously caused intense infighting. An Act Modernizing Firearm Laws, HD.4607, seeks to rein in the spread of untraceable “ghost guns,” update the state’s assault weapons ban, limit the presence of firearms in certain public spaces and streamline the licensing process.

House Speaker Ron Mariano said the latest bill penned by Judiciary Committee Co-chair Rep. Michael Day is “significantly different” than one he unsuccessfully tried to advance over the summer, when gun owners groups mounted vociferous opposition and some representatives appeared to balk.

This is not going to be an easy package to pass. At a House hearing on gun reform, gun control and gun safety groups threw their support behind the bill. While gun owners contended the legislation represents an unconstitutional infringement on their Second Amendment rights without offering much, if any, upside to public safety. History has shown that the two sides could not be farther apart on beliefs than when it comes to gun control. The gun lobby is going to fight this bill hard, as they do in every state that tries to pass gun reform legislation.

The gun reform legislation is just the beginning as the state government looks to pass big ticket legislation after basically doing nothing for the first 10 months of the year. The legislature has signaled that they are also looking to pass a climate package and salary transparency legislation. I believe the sudden urgency is a result of the continuous crap that the press has been giving leadership for the lack of legislation that has been passed this session. Hell, it took a record amount of time for them to agree on a budget. I personally find it to be very frustrating and a little patronizing for the legislature to think its okay to just bulldoze through big ticket items and forget about “smaller” less significant legislation like the home care licensure bill. They are supposed to be passing legislation regularly, not just when they are called out for not doing anything. This is exactly what annoys people about politics, when politicians only do their job when it’s most beneficial for them.

Did You See That? – September 2023

If politicians at the state and federal level have all of August off, why can’t I! rather than cover very little news in the August version of the rundown, I decided to take a break like everyone else in politics did, to re-group, recharge my batteries and watch my Mets season completely fall apart.

The Rundown is back under a new name “Did You See That?!?”, which I think is a better title my original choice which sounded like an 80s Sylvester Stallone action movie. This edition will be shorter than usual due to the lack of political news over the last month. But hey…. At least I’m here.

State Recap

Governor Healey Signs FY24 State Budget, Over a Month Late

Shockingly, August started off with some actual business being done. On August 10th, Governor Healey signed a $56 billion annual state budget for fiscal year 2024, marking her first annual budget signing since taking office in January. The signing of the annual budget comes over a full month into the fiscal year it covers, making Massachusetts one of the last states to pass a FY24 budget. This budget is the budget the second latest to land on a governor’s desk in 22 years. The budget will increase spending by 7% compared to FY23 budget, and for the first time, distribute at least $1 billion in revenue raised from a new tax on the state’s wealthiest residents.

The spending plan includes many policy provisions such as, making a pandemic-era program providing free school meals to all students permanent, supports in-state tuition and financial aid at public colleges and universities for undocumented immigrants, and offers assistance to help Bay Staters ages 25 and older attend community college for free. Due to substantial rate increases for home care services, unlike the FY23 budget, this budget does not include funding for the Enough Pay to Stay rate add-on.

Overall, Healey gave her approval to 103 of 112 outside policy sections, returned eight with amendments, and vetoed one authorizing the use of $205 million in one-time funding. She also reduced the budget’s bottom line by the same amount.

AG Campbell Confirms, these are Not Dumb Questions

Attorney General Andrea Campbell’s office said this week that it had certified almost all of the 42 potential election ballot questions (proposing 38 laws that could be decided at the 2024 ballot and four constitutional amendments that could be decided in the 2026 election) that had been filed by the August deadline. Thirty-four proposals (in some cases representing multiple proposed versions of a potential question) were certified, seven were not certified and one was withdrawn by its sponsor, according to Campbell’s office.

Some key ballot questions revolve around rights and benefits for Uber drivers, rent control, voter identification and the auditor’s ability to audit the state Legislature. The latter being the most interesting in my opinion. Auditor Diane Dizoglio, who is a former state Rep and Senator, has been in a consistent battle with the state legislature to have them open up their books to show exactly how much every state legislator makes.

Dizoglio filed a ballot question that would establish a state law explicitly permitting the auditor’s office to audit the Legislature. Top Democrats have resisted, arguing she does not have the authority and that doing so would violate the “separation of powers” required by the Constitution. In late July, DiZoglio appealed to Campbell for the attorney general’s support in a move toward litigation.

How is the STATE AUDITOR overstepping their authority when they are auditing the state, which is literally her job. That is like saying a chef cannot make food for staff because their job is to make food for customers. It just makes no sense.

Look I understand the concept of separation of powers, but we have seen over the years corruption, and just common bad practices by legislators not only in Massachusetts has increased to Whitey Bulger setting levels. We need our legislators and government officials to be held to a higher standard, and the best way for that to happen is for everyone to see what they are doing/what they have done.

Also, I’m not a detective, but it’s suspicious how aggressively they are trying to keep their books closed. I mean this is the same state leadership that literally changed term limit rules to allow the Karen Spilka to keep her leadership position of Senate President, even though her term limit ran out. Also, it says a lot that a person who was both a state representative and a state senator is so keen on auditing their books, I only imagine, she knows exactly what’s in their books, that needs to be released to the public.

HCA Submits Comments to CMS Proposed CY2024 Home Health Payment Rule

In late August, HCA submitted comments to CMS’s proposed CY2024 Home Health Payment Rule. In June, the Centers for Medicare & Medicaid Services (CMS) released their annual proposed rates for Medicare home health services, which would reduce net home health payments by an estimated $375 million, or -2.2%, in calendar year 2024, compared to 2023 rates. With home care providers already facing an unprecedented workforce shortage, leading many to turn away patients due to lack of staff, inflation, and exceedingly high gasoline prices, now is not the time to cut payment rates.

Look Ahead

As I have written before, this state legislature has been one of the least active legislatures in years, and they seem to be keen on keeping that reputation. The state legislature is taking a slow approach to coming back from the Cape and isn’t planning on bringing up any major legislation anytime soon. I will keep everyone posted, when big pieces of legislation come up.

Federal Recap

August is an aggressively slow month on Capitol Hill, as members of Congress and their staff head back to their state/districts for some “needed R&R”. I put needed R&R because I honestly think its ridiculous that in modern times members of Congress basically get a full month off of work like they are teachers. It made sense when they had to go back to plant/harvest crops and tend to their local businesses in the 1800’s. But in a time when you can get from DC to San Diego in less than 6 hours, I don’t see why they need a full month off from passing bills (which they rarely do). Its just infuriating the more and more you think about it. But I digress.

The only noteworthy news event in August that pertains to the federal government, is that the first Republican primary was held. But honestly for everyone’s sake, and mainly for my sanity/respect for other people/my job. I’m going to bite my tongue and not share my opinion on that matter.   

Look Ahead

Heading to the Swamp

HCA will be heading to the D.C. swamp on September 20th with some member agencies to speak with members of the Massachusetts congressional delegation to educate them on the impact of the proposed rate cut and how they can help to stop CMS from implementing the proposed cuts. We will be asking these offices to sign onto The Preserving Access to Home Health Act of 2023, which would prevent CMS from implementing their cuts.

You can help our advocacy efforts by reaching out to your member of Congress urging them to sign onto the bill, by using this ACTION ALERT to write directly to them.

The Rundown – July 2023

State Recap

HCA Provides Testimony at Elder Affairs Hearing

On June 19th, HCA provided verbal testimony (Add Testimony HERE) at a Massachusetts state Elder Affairs Committee Hearing. HCA provided testimony on H.640/S.397, An Act to Improve Infection Control in Massachusetts Home Care, which would direct EOHHS to establish a mandatory infection control training program for personal home care attendants and all home care employees.

During the hearing we made it clear that we do not support the bill and raised our concerns with bill as drafted. We explained that this bill would prove to be duplicative with existing infection control requirements established at the federal level and in ASAP contracts. In addition, we strongly encouraged that the bill be re-written so that the text clearly clarifies that home care agencies should be allowed to conduct the training, if infectious control training is required.

If you would like to submit your own written comments on the bill, testimony may be submitted to the Committee via email to committee joseph.russo@mahouse.gov and victoria.halal@masenate.gov.

Budget, What Budget? No Movement on State Budget

I think state legislators are taking The Kink’s song “Sunny Afternoon” a little too seriously. Once again state legislators failed to pass an annual state budget for FY24 by the June 30th deadline, resulting in the state legislator passing a supplemental budget to fund the government through July. This has become a common practice for the legislature, as they have not passed an annual budget on time since 2011. For reference of how long ago that was the last Harry Potter movie came out that year, Instagram had just come out, and Osama Bin Laden was killed. to summarize, THAT’S A LONG TIME AGO. Hell, I was still in school in 2011, I won’t say what level of school, but I’ll just say that I was 4 inches shorter in 2011 than I am now.

The legislature has taken a more relaxed approach in recent years with the budget usually being passed in mid-late July. Last year, the annual budget was not formally signed into law by then Governor Charlie Baker till July 28th. Legislators are still ironing out key discrepancy between the House proposal and the Senate proposals. At the rate they are at, I don’t expect a budget to be agreed and passed till late July at the earliest.  

Look Ahead

Joint Health Finance Committee to Hold Hearing on Rate Setting Legislation

The Joint Health Finance Committee plans to hold a hearing on Tuesday, July 25th, on numerous bills that pertain to home care services. One of the bills that is being considered is H.1195/S.755 – An Act Clarifying Rate Setting Processes for Home Health and Home Care Services. As a refresher, this bill would clarify the rate setting processes that are already in place for both home health and home care services. It would NOT set the rates or dictate the amount for future rates set by Mass Health and EOHHS. It does make the rate setting process more transparent and ensures rates set by the state follow the rate setting laws and reflect the actual operating costs incurred by home health and home care providers. In addition, it articulates the cost factors that should be included in the methodology and rate setting process including new regulatory costs and governmental mandates. Recent examples include changes in the state’s minimum wage, the Paid Family and Medical Leave Act, health insurance, employee benefits and training, and increased technology costs.

This bill has been a major focus of our advocacy efforts for the last couple years, and we would like everyone to provide testimony if possible. In all seriousness, it will only take 3 minutes of your time. I will draft a template for members to use to write their testimony to either send to the committee or to provide verbally on the day of. The more people the provide testimony, verbally or written, the stronger our voice. I will be there in person to speak to the committee on behalf of the association and if anyone would like to join me, please email me at hccollins@thinkhomecare.org.

House Proposes Nearly $700 Mil in Supplemental Spending (State House News)

House Democrats are preparing to bring forward a $693 million spending bill that would steer financial support to vulnerable hospitals, allow state energy regulators to update contracts related to a key hydroelectric transmission project in Quebec, and extend horse race simulcasting for another half-decade.

The House Ways and Means Committee on Wednesday morning opened a poll on a redrafted supplemental budget (H 3869), one day before the chamber is set to meet in its first formal session since April 26.

Of note, House Speaker Ron Mariano’s office said the bill calls for spending $180 million to support hospitals still facing pandemic-related impacts, including those that serve a high percentage of Medicaid patients.

Mariano’s office said the bill would also give the Department of Public Utilities the flexibility to approve amended transmission contracts related to the New England Clean Energy Connect (NECEC) project, which would carry hydroelectric power generated in Quebec through Maine to end points including Massachusetts.

Representatives on the House Ways and Means Committee were given until 11 a.m. Wednesday to indicate their support or opposition for the spending bill. The bill is a supplemental budget for fiscal year 2023, which ended June 30. House and Senate negotiators have not come to terms on a compromise annual budget for fiscal year 2024, which began July 1.

Federal Recap

CMS Proposes Massive Cuts to Home Health Payment Rates

On the last Friday of June, CMS published its FY 2024 home health proposed payment rule. First before I get into the proposed rule, I have to vent really quickly about how annoying it is that both federal agencies tend to release major regulations/proposed rules on Fridays, especially before holiday breaks. CMS released their proposal (though it was accidentally leaked early) in the afternoon on the FRIDAY BEFORE JULY 4th WEEKEND. Not only did this ruin my plan to leave work a little early to get a jumpstart of the long weekend, but it ruined the entire weekend because I had to read and analyze the entire proposal. Listen I understand that they do this because they want to bury proposals like this so that it doesn’t get major new coverage, but for us professionals, whose entire job are affected by these releases, it is such a slap in the face. I don’t pay my taxes that help to pay CMS staffs salaries for them to turn around and basically pull a beer out of my hand and throw a big regulatory rule at my face. It’s rude, inconsiderate, and ill argue it hurts the economy by keeping my hard-working (relative) people stuck inside reading, rather than out spending money at bars, restaurants and stores. It should be legally required that federal agencies have to release regulations/proposed rules on Mondays or at least 5 business days before a holiday break.

Alright, back to the proposal. CMS is proposing a 2.2% decrease aggregate home health payments, or an estimated $375 million less compared to 2023 levels. The proposed update would bump payments 2.7%, or $460 million, but that is completely undermined because home health agencies are being forced to absorb a 5.1% decrease, or a decrease of $870 million. As a refresher, last year CMS originally proposed a 7.85% permanent rate adjustment based on the conclusion that HHAs were overpaid in 2020 and 2021 due to provider behavior changes in coding and services provided. In the end, CMS only applied a 3.925% permanent rate reduction after objection from agencies and home care associations. At the time, CMS explained that the lower adjustment would be applied because “we recognize the potential hardship of implementing the full -7.85 percent permanent adjustment in a single year.” The 5.1% proposed rate reduction represents the remainder of the original 7.85% rate reduction that CMS calculated as warranted under its methodology for 2020 and 2021 along with an additional 1.636% for 2022, totaling 9.36% overall from the beginning of PDGM.  An early analysis indicates that the additional 2022 element to the proposed permanent adjustment is due to further visit decreases in a 30-day episode, particularly with therapy services. For an in-depth summary of the proposal rule, CLICK HERE.

CMS will accept comments on the proposed rule through Aug. 29. HCA will be submitting comments, and we strongly encourage members to submit comments as well. We will provide further updates as they develop on the proposed rule.

NAHC Files Lawsuit Against CMS and HHS

After the CMS proposed rule was released, The National Association for Home Care and Hospice (NAHC) filed a lawsuit against the Centers for Medicare and Medicaid Services (CMS) and the United States Department of Health and Human Services (HHS) challenging the validity of a change in Medicare home health payment that reduced rates by 3.925% in 2023 with significant additional cuts expected over the next several years. The lawsuit, which was filed in the District of Columbia, comes just a couple days after CMS released their proposed rule for 2024 which includes an addition additional 5.653% permanent rate cut in 2024.

In the lawsuit, NAHC argues that the methodology used to calculate the rates is flawed, and that the rate adjustment will worsen home care staffing shortages and patients’ access to care. In a statement released today by NAHC Until recently, nearly 3.5 million Medicare beneficiaries received home health services annually. Since the new payment model began in 2020, over 500,000 fewer Medicare patients have accessed home health services. According to a statement released by NAHC, they are seeking declaratory and injunctive relief including a reversal of the rate adjustments in the 2023 rule and requirement that Medicare implement the budget neutrality mandate consistent with the law. It should be noted that it could take months for the case to be heard with no timetable set. HCA will be closely following the court case and will provide updates as they unfold.

Look Ahead

With August recess right around the corner, July is usually a slower month where Capitol Hill wraps up last minute things before takin a month break. But not this year, Congress decided they wanted to set off some last second fireworks before everyone left. The big piece of legislation that everyone is talking about is the NDAA, the National Defense Authorization Act. The NDAA is a massive $886 billion must-pass bill that details the annual budget and expenditures of the U.S. Department of Defense. The NDAA is one of few pieces of legislation that usually passes with bipartisan support, and with minimal debate, but this year is very much different.

House Republicans have chosen the NDAA as the next battle ground in the culture war. Far Right Republicans have been adding countless poison pill amendments that risk driving away any chance of Democratic support. The most controversial amendment being Rep. Ronny Jackson (R-TX) proposal that would remove a Pentagon policy that allows service members to take up to three weeks of leave to travel out of state for an abortion and other “non-covered reproductive health care services.” The policy also states the Department of Defense will reimburse members for any expenses related to that travel. This rule was established in the wake of the Supreme Court decision that stripped abortion rights and left them up to individual states. Republicans argue that the new rule circumvents laws barring taxpayer money for the procedure in most cases, but language to undo this new policy could be a red line for Democrats. The abortion rule has been a major sticking point for Republicans in both the House and the Senate. In the Senate Sen. Tommy Tuberville (R-AL), who looks like the human version of Squidward, has been holding up high level defense appointments until the rule is taken out, leaving many key positions unfilled.

Other poison pill provisions revolve around Ukraine, NATO, sea-launched cruise missiles, and Buy American provisions. House Democratic leadership has signaled that if Republicans choose to move forward with any or some of these amendments (especially the abortion proposal) they would pull their support for the bill. that would leave Republicans with little wiggle room to pass the bill.

In the end the NDAA will be the central focus till they leave for August recess, with the Senate needing to pass the NDAA once it finally moves through the House. So there is still an opportunity for these people to say stupid stuff, like that being a white nationalists doesn’t make you racists, that will get everyone on Twitter and Thread (what ever that is) into a frenzy.

The Rundown – April 2023

Federal Recap

HCA Travels to DC to advocate for Home Care

To end the month, HCA along with member agencies, Care Central VNA & Hospice and Seraphic Springs Health Care Agency traveled to DC to meet with members of the Massachusetts congressional delegation. HCA updated congressional staff about the ongoing worker shortage that the industry is currently facing and the immense impact that further cuts by CMS for home health rate would have on the industry. We noted that if any further cuts are applied it could result in up to 50% of home health agencies across the country having a net margin below zero.

HCA would like to say a special thank you to Care Central VNA & Hospice and Seraphic Springs Home Care Agency, and Renee Walsh for taking the time to come down to DC to advocate for our industry.  HCA will continue to work with the Massachusetts congressional delegation to help prevent CMS from applying further cuts to home health rates. If you would like to join HCA on any future advocacy efforts in DC or at the state house, please reach out to Harrison Collins, hcollins@thinkhomecare.org. 

SVB Collapse

The month started slowly with the usual twitter beefs between members of Congress and the media continuing to speculate who will run for President in a year, and then…. Suddenly….. All HELL BROKE LOOSE!! Out of what seemed like nowhere, in a matter of 48hours, Silicon Valley Bank (SVB) collapsed, marking the biggest bank failure since 2008, and the second largest of all time. At the time the bank collapse, SVB’s total assets were over $220 billion, making them the 16th largest commercial bank in the US. Which was honestly more shocking to hear than the news that they collapsed. Learning the news that a bank that I barely knew about was that large was like finding out that the 16th biggest food chain in the US is Tatte Bakery & Cafe! And at-least they have delicious pastries.

for a quick rundown, SVB was originally founded over a poker game, wild story, in 1983, Silicon Valley Bank became the go-to lender for tech startups that appeared too risky in the eyes of larger, more traditional banks. Eventually, Silicon Valley Bank would come to do business with nearly half of all U.S. tech startups backed by venture capitalists, including businesses such as Spotify, Pinterest, and Fitbit. SVB grew and grew and looked unstoppable. During the beginning of the pandemic with interest were low and egg cartons only cost $1.50, tech stocks exploded, which led to a surge in deposits at the bank, which then invested a large chunk of the cash into long-term U.S. government securities. But when interest rates started to sky rocket last year, not only did egg prices jumped up to $3.50, the huge amount of bonds they bought became worthless high, resulting in a 1.8 billion loss. The increase interest rates also resulted in a contraction in funding for startups, pushing startups to withdraw more and more money from their accounts to pay their debts. This meant that SVB had to cover the money for startups to withdraw, this pushed SVB to announce that they were selling $2.25 billion in new shares to plug the hole in its finances, and that they were holding a new funding round, which is not usual for big time banks. This made people LOSE THEIR MINDS. On a Wednesday March 8th, startups, and venture capital firms in droves started to withdraw all their money from SVB, fearing it was the 2008 bank collapse all over again, causing SVB stock to drop 60% on Thursday, March 9th. By Friday, March 10th, trading in SVB shares was halted and it had abandoned efforts to raise capital or find a buyer. California regulators intervened, shutting the bank down and placing it in receivership under the Federal Deposit Insurance Corporation, which typically means liquidating the bank’s assets to pay back depositors and creditors. In the matter of 3 days one of the biggest banks in the US failed, mainly because they failed to watch the Big Short. If only they watch past the scene with Margot Robbie in the bathtub, they would have learned NOT TO PUT ALL YOUR EGGS IN ONE BASKET.

Democrats were quick to point the blame at President Trumps for lifting of bank regulations during his administration, and the Feds failure to prevent the collapse. In a speech right after the collapse Massachusetts own, and vocal advocate for banking reform, Sen. Elizabeth Warren, called out former President Trump, for rolling back parts of Dodd-Frank act, which provides oversight over banks. One part of the act that was rolled back is the minimum amount banks had to keep on hand at any one time, which would give banks more money to invest and spend. Warren argues that this led to SVB to pump more money than they should have been able to into long-term U.S. government securities, which eventually collapsed. Sen. Warren and California Rep. Katie Porter, introduced a bill that would re-instate the parts of the Dobbs-Frank act that were rolled back.

Republicans, were also quick to blame federal regulators, but for the opposite reason, going to far. Some prominent Republicans including President Trump, slammed the Fed for stepping in to ensure that depositors – including the nearly 90% of whom had funds in SVB that exceeded the $250,000 limit of what is insured by the Federal Deposit Insurance Corporation (FDIC) – would have access to all of their money on Monday. The move represents the biggest federal intervention in the financial market since the 2008 economic collapse. GOP members believe that the government shouldn’t be in the act of bailing out banks for their bad practices, especially if those practices are “woke” polices. Likely presidential candidate Florida Governor Ron DeSantis used the news of SVB’s failure to further criticize corporations so called “woke” policies. DeSantis said “I mean, this bank, they’re so concerned with DEI and politics and all kinds of stuff. I think that really diverted from them focusing on their core mission,”. I don’t know about you, but I don’t know how having diversity in your business can lead to a bank spending too much money on government securities, but that’s just me.

President Trumps Arrest

Things continued to go off the walls when a week and a half later it was released that the Manhattan District Attorney Office invited President Trump to testify to the grand jury for his alleged role in the 2016 hush money payments to former porn star Stormy Daniels, which legal experts said was a sign that he would be indicted. This obviously send obviously sent the twitter world and Truth Social into a frenzy! President Trump jumped what I can only assume is an old blackberry to say on Truth Social, that he expects to be arrested on March 21 and calls on his supporters to protest (obviously in all caps), even though he hadn’t been notified that he would be. He later went on to warn of potential “death and destruction” if he is charged with a crime. All news coverage quickly changed to exclusively following the Trump potential arrest. And then finally on March 30 it was made aware that the President had indeed been indicted. This marked the first time that a former president was indicted for criminal charges. Which is honestly shocking if you look back at all our presidents including, Nixon, Clinton, Harding, and VP Spiro Agnew.

Maybe it’s just me but while I know its huge news that a former President was indicted is massive news, it just doesn’t feel like it really is. After how crazy the world has been for what feels like 20 years but has really only been 7, I just feel numb to all big news. I mean a former president is charged with a crime and it weirdly felt like less of a big deal than when a rival team loses their starting QB.

Look Ahead

Congress is out of session for the first two weeks of April for Easter Recess. In the meantime, and even when they get back all the focus will be President Trumps criminal probe and his arrest. Now since his actual arrest happened in April, I will cover his arrest in further detail in the next rundown. But other than that, there is not much else to look ahead for over the month of April at the federal level

State Recap

Traveling Nurses

The Health Policy Commission reported in late March that an increasing reliance on travel nurses is contributing to high turnover rates among nurses in Massachusetts.  The report even prompted the Health and Human Services Secretary Kate Walsh, to say that the hospital industry has to “get rid of these usurious travel agency contracts that hurt everybody,” and the attorney general has put temporary nursing agencies on warning of violating rate payment rules. Registered nurse vacancy rates in Massachusetts hospitals doubled from 6.4% in 2019 to 13.6% in 2022, with especially high vacancy rates in community hospitals, the HPC report says.

The report also showed that the widespread industry shortage does not appear to be caused by fewer people wanting to become nurses, but rather nurses leaving the field after they had already begun working. The number of people completing nursing programs did not change during the pandemic and, in fact, there was an increase in the number of people earning advanced nursing degrees in 2020. As of 2021, contracted workers (travel nurses) represented about 5% of hospital patient care labor costs in the state, the report says. Across Massachusetts, health care facilities paid $1.5 billion to these workers in fiscal 2022 — a 154% increase over the previous year.

The increase of traveling nurses has had an impact not only on Hospitals but on home care agencies. With more and more nurses choosing to work for hospitals for short contracts for more pay, it has left the pool of potential nurses for home care agencies scarce. HCA has been working to increase nurse reimbursement rates to attract more people to the home care sector.

HCA Spends Week at State House Advocating for Legislative Priorities

Last week, HCA spent the week at the State House with HCA member agencies to meet with their state legislators to advocate for our legislative priorities. HCA talked to legislators about two bills that we strongly support, H.649/S.380, 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. Both bills will help aid in improving the home care industry and help to bring stability to our sector as a whole. HCA wants to say a special thank you to Maxim, Bayada, and Visiting Angels for taking the time to come to the state house to advocate for these vital pieces of legislation. If you too would like to participate in state legislative meetings, please reach out to Harrison Collins, hcollins@thinkhomecare.org.

Look Ahead

Elder Affairs Committee to Hold Hearing on Licensure

On Monday, April 10, at 9:30am EST, the Joint Committee on Elder Affairs will be holding a public hearing on several pieces of legislation, including H. 649/S.380, An Act to Improve Massachusetts Home Care. H.649/S.380 would create a licensure system 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. This hearing will give member agencies the change to persuade legislators as to why they should pass this bill and the benefit it would have for the industry.

If you would like to listen in on the hearing use the link HERE. HCA will be testifying in person, if you would like to testify for the hearing, either in-person or virtually, please use the link HERE to sign up to testify. HCA will also draft a template for agencies to use to submit written testimony for hearing. please let me know if you plan to testify for the hearing by emailing me at hcollins@thinkhomecare.org.