Tag: Government Shutdown

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.