Tag: congress

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” – February 2024

Federal Outlook

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

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

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

House Impeaches Homeland Security Secretary Alejandro Mayorkas

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

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

State Outlook

It’s All About the Benjamins

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

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

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

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

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

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

State Recap

HCA Holds State House Advocacy Day

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

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

Governor Healey Proposes Increasing FY25 Budget by Over $2.1 Billion

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

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

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

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

Joint Rule 10 Deadline Extended for Select Committees

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

Infectious Disease Bill Sent For Study

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

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

Did You See That? – 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.

Home Care Alliance Signs onto CMS Letter to House and Senate Leadership

The Alliance signed onto an advocacy letter written by the National Association for Home Care and Hospice (NAHC) to House and Senate leadership asking for their support in suspending the implementation of CMS’s final for the Home Health Prospective Payment System (HHPPS).

This week, the Alliance signed onto an advocacy letter written by the National Association for Home Care and Hospice (NAHC) to House and Senate leadership asking for their support in suspending the implementation of CMS’s final for the Home Health Prospective Payment System (HHPPS). As a reminder, CMS’s final rule if implemented would reduce Medicare payments for home health services by $635 million in 2023 and trigger an estimated $18 billion in payment reductions over the next decade.

The Alliance joined 49 other home care associations across the nation in signing this letter. The letter highlights the immense impact that the final rule would have on the agency across the country, noting that “the impact of those payment cuts would exacerbate the ongoing dismantling of this essential benefit that serves over 3 million of the most vulnerable Medicare beneficiaries, providing them with exceptional care quality in their own homes, preventing high-cost hospitalizations, and offering an alternative to life-changing institutional care while saving Medicare billions in spending every year.”

NAHC is currently working with key sponsors and co-sponsors of the CMS bill (S.4605/H.R.8581)that was introduced in August, to re-write the bill in response to CMS’s final ruling. The exact details of the revision of the bill have not yet been determined, but once they are the Alliance will re-engage with the Massachusetts delegation to update them on the changes and to garner their support for the new version of the bill. We will also be asking our members to once again reach out to their member of Congress to support the new version of the bill.

PDGM Fix Introduced, Advocacy Needed

Last week, a bipartisan group of senators, led by Sen Susan Collins (R-ME)  introduced what will be a most important legislative priority for HCA of MA this year.  Senate bill (S.433) will curtail the so-called $1 billion “behavioral adjustment” cut under the Patient Driven Groupings Model (PDGM) to which all of home health is transitioning in 2020.  Among, many other changes, PDGM will move home health from a 60 to a 30 day payment unit. This is the most significant change to home health payment since the Prospective Payment System was introduced in 2000.

The Congressional action that called for a home health payment overhaul required that the new payment model be budget neutral against current spending levels. However,  the legislation also allowed that CMS to consider “behavioral  adjustments” defined as industry actions that would be taken to increase payment under the new model, unrelated to patient case mix changes. CMS has used this authority very broadly to institute a payment adjustment in the first year of PDGM based on “assumptions” of behavioral changes, and that adjustment calls for a 6.42% base rate reduction, or a possible $1b reduction in payments.

S 433 would prohibit CMS from making any pre-rate change reductions based on assumptions and instead to phase in any adjustments (either up or down) based on observed evidence (i.e., data supported) changes in provider behavior. The objective would be to achieve budget neutrality by 2029. This later piece addresses concerns the Congressional Budget Office (CBO) expressed regarding whether a similar bill introduced last session was truly budget neutral. S.433 also would allow Medicare advantage plans and Center for Medicare and Medicaid Innovations (CMMI) to waive the “confined to home”  provision when in the best interest of a Medicare beneficiary.

Regardless of the “behavioral adjustments,” the PDGM model is expected to have a tremendously varied impact state by state and agency by agency.  A significant amount of this impact is related to a Congressional  requirement that the payment model no longer use the volume of therapy as a payment level determinant.  (Something MEDPAC has been calling on CMS to do for years.)   The state of Florida, where therapy visits average 10.45 per episode of care is set to “lose” the most – projected at $141 million.  California on the other hand, where the average therapy utilization per episode was 5.76,  will be the largest gainer.  MA (need numbers from Tim)  Note: S 433 does not seek to make changes to the structure of the payment model that produces these changes.

It is important to reflect on CMS’ proposal in 2017, Home Health Groupings Model (HHGM) and how we arrived to where we are today. At the time, HHGM represented similar changes to the payment model, without soliciting industry feedback and some estimates predicting a 15% reduction in payments. As a result, the industry unified itself behind one message: that CMS withdraw its proposal and engage stakeholders to come up with an alternative. Upwards of 13,000 emails were sent to Congress from the industry, 49 members of the U.S. Senate and almost 160 members of the U.S. House of Representatives signed onto letters to CMS echoing the request to withdraw HHGM. This was a remarkable show of mobilization by the industry and we’ll need it again to make modifications to PDGM.

At present there is no bill in the House, but it is expected that one will be forthcoming.  Strong early sign on support is critical to keeping this bill moving and HCA of MA will be urging members to contact the MA delegation to support S.433 and the companion house legislation to be introduced. Stay tuned for these advocacy alerts in our weekly newsletter and advocacy messages in the coming weeks.

HCA will also be hosting a number of member events to prepare for the payment transition.  While the full day PDGM programs in March in Northampton are sold out, there will be a high concentration of sessions on PDGM at the New England Home Care Conference and Trade Show in on June 5 -7 inn Falmouth. Watch here for more details.

In the meantime, send a message here to Senators Warren and Markey about the need for their support on this issue. 

Let’s do this home care – we cannot sustain $1 billion in cuts based on assumptions, not facts!