Tag: Trump

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.

The Rundown – May 2023

State Recap

EOHHS Releases Proposed Chapter 257 Rates for Certain Elder Care Services

On Friday, Executive Office for Health and Human Services (EOHHS) released their proposed Chapter 257 Rates for Certain Elder Care Services. We are happy to report that EOHHS proposed increasing Enhanced Community Options Program (ECOP) Direct Services from $749.47 to $976.08 per client per month and Home Care Program Services Direct Services from $326.35 to $424.34 per client per month, which amounts to about a 30% increase to the base rate for both ECOP and Home Care Program Services.

While a 30% increase on the surface seems high, that percentage does not consider the temporary rate add-ons (EPTS, ARPA, and DALA appeal settlement) that agencies have become accustomed to. After accounting for all, the percent increase is closer to 7%. EOHHS still plans to meet their deadline of July 1st, 2023, to implement the new proposed rates.

EOHHS also announced that they will be holding a public hearing on the proposed rates on Friday, May 19, 2023, at 9:00am EST. HCA will be providing testimony at the hearing and encourage everyone to provide testimony as well. We will be sure to send around our draft testimony before and we are happy to help anyone with their testimony as well.

House Passes Budget Proposal

The House voted unanimously (156-0) to approve their $56.2 billion state budget for FY24, sending their spending plan to the Senate. The over $56 billion budget plan included significant increases in spending for education, childcare, environmental agencies, transportation, and hundreds of millions in tax relief. Not included in the Houses budget is the Enough Pay to Stay (EPTS) rate add-on. This didn’t come as a surprise since it was not included in their initial proposal and with new rates set to be released soon, we did not expect the house to include fully funding a rate add-on at this time.

Knowing that the House would not be inclined to fully fund the EPTS rate add-on at this time due to the rate review, HCA along with the EPTS coalition did submit an amendment to the house budget proposal that would fund a rate add on for 3 months or one quarter of FY24. We filed this language because we were concerned if EOHHS would meet the July 1st, 2023, deadline to promulgate new Chapter 257 rates, and if they didn’t, we wanted to make sure there wouldn’t be a massive rate cliff since the EPTS and ARPA rate add-ons expire on the same date. The amendment was not included in the final house budget but did garner some co-sponsors during the amendment process. The budget process will now shift to the Senate.

Tax Relief Package

The House also passed their $1.1 billion tax relief package a month after Governor Healey released her $742 million tax relief package. The Houses tax package includes many of the same provisions that were included in the Governors tax relief package, such as;

  • Decreasing the short-term capital gains tax from 12% to 5%.
  • Combine the Child Care Expenses Credit with the Dependent Member of Household Credit to create one refundable $600 credit per dependent, while eliminating the current cap.
  • Increase Estate Tax threshold from $1 million to $2 million (Healey proposed $3 million).
  • Increase the rental deduction cap from $3,000 to $4,000.
  • Double the Senior Circuit Breaker Tax Credit from $1,200 to $2,400.

Two proposals included that were not in the Governor’s proposal were 1.) increasing the Earned Income Tax Credit (EITC) from 30% to 40% of the federal credit. 2.) establishing a single factor apportionment in Mass based solely on receipts matching what 39 other states currently do. The tax proposal would also alter Chapter 62f of general law which triggers a tax refund if the state has excess revenue to adjust the credit to an equal amount per taxpayer rather than based on percentage of what taxpayer paid the commonwealth. The House tax proposal will tag along with the House budget proposal to the Senate side to be debated and most likely changed before going to vote.

HCA Provided Verbal Testimony on Licensure Bill for Non-Medical Services

The Home Care Alliance provided verbal testimony during a hearing held by the Joint Committee on Elder Affairs on H.649/S.380, An Act to Improve Massachusetts Home Care, which would create a licensure system for non-medical home care services.

For many years, the Home Care Alliance and our members have advocated for home care licensure, as we believe that agencies should be held to a baseline set of standards that would protect consumers and workers. We believe that this bill has the framework to do just that, without overburdening providers, and driving consumers to seek services in the unregulated, underground market.

We need your help to get this bill over the finish line. Please Click this LINK to submit pre-written testimony to the committee. Submitting written testimony shows legislators and committee staff how much support this bill has amongst the industry and Massachusetts at-large. This increases the chance that the bill is voted out of committee and potentially be voted on and passed by the entire legislature. Your voice matters and we want to help you use it!

Look Ahead

Senates to Propose State Budget Proposal Soon

The Senate is expected to release their budget proposal next Wednesday, May 10th with a budget amendment deadline of Friday, May 12th. Since EOHHS released new chapter 257 rates that incorporate the EPTS, ARPA, and DALA settlement rate add-ons we do not expect the Senate to include an EPTS rate add-on.

We will still be keeping a close eye on their budget proposal and any amendments that are filed to the budget. During the House budget process an amendment was added that would require a 75% of rate payments to home care agency providers for the elder home care program be spent by such home care agency providers on direct care workforce wages and benefits. The amendment was not added to the House’s final budget proposal after HCA along with the EPTS coalition worked hard to educate legislators and committee staff about the issues with amendment and how the language is not needed. We will keep a close eye to see if the same amendment is added to the Senate budget proposal.

Federal Recap

CMS Proposes That 80% of Medicaid Payments for Home Care Go to Direct Care Workers

Recently, the Centers for Medicare & Medicaid Services proposed two rules surrounding access to Medicaid. Among the provisions is a requirement that at least 80% of Medicaid payments for personal care, homemaker and home health aide services be spent on compensation for direct care workers.

The two proposed rules are Ensuring Access to Medicaid Services (Access NPRM); and Managed Care Access, Finance, and Quality (Managed Care NPRM). The former, Access NPRM, also would call for the following related to home care and home- and community-based services:

  • Require states to publish the average hourly rate paid to direct care workers delivering personal care, home health aide and homemaker services;
  • Require states to establish an advisory group for interested parties to advise and consult on provider payment rates and direct compensation for direct care workers;
  • Require states to report on waiting lists in section 1915(c) waiver programs; service delivery timeliness for personal care, homemaker and home health aide services; and a standardized set of HCBS quality measures;
  • Promote public transparency related to the administration of Medicaid‑covered HCBS through public reporting of quality, performance, and compliance measures;
  • Establish a new strategy for oversight, monitoring, quality assurance, and quality improvement for HCBS programs;
  • Strengthen person‑centered service planning and incident management systems in HCBS; and
  • Require states to establish grievance systems in fee-for-service HCBS programs.

“The Biden-Harris Administration has made clear where we stand: We believe all Americans deserve the peace of mind that having health care coverage brings,” Department of Health and Human Services Secretary Xavier Becerra said in a statement. “We are proposing important actions to remove barriers to care, engage consumers, and improve access to services for all children and families enrolled in these critical programs.”

Providers expressed a lukewarm reaction to the rule. While they were pleased that the Biden administration is addressing access challenges and rate transparency with HCBS, they did not appreciate that the rule does not confront actual payment rates. NAHC said in response to the proposal that “however, we are concerned that CMS is not proactively addressing the chronically woeful state payment rates for home and community-based services and instead is creating a new bureaucratic analysis that may or may not ever impact the wages of workers. We are further concerned that CMS has decided to forego ensuring adequate state payments in favor of applying an arbitrary requirement to pass through a proportion of the rates to direct care workers. This policy cannot be effective without consideration of the actual payment rates or the substantial administrative requirements that federal and state regulations place on providers.”

President Biden Issues Executive Order to Make Home Care More Affordable

On Tuesday, President Biden signed an Executive Order (EO) that includes 50 directives to Cabinet-level agencies with the goal to improve transparency and access for home care services, including for veterans, while boosting industry standards and expanding areas of federal coverage. Some of the provisions included in the EO include:

  • Directs HHS to consider issuing several regulations and guidance documents to improve the quality of home care jobs, including by leveraging Medicaid funding to ensure there are enough home care workers to provide care to seniors and people with disabilities enrolled in Medicaid, as well as build on the minimum staffing standards for nursing homes and condition a portion of Medicare payments on how well a nursing home retains workers.
  • Identify which of their grant programs can support long-term care for individuals working on federal projects, and consider requiring applicants seeking federal job-creating funds to expand access to care for their workers.
  • Directs the Department of Veterans Affairs (VA) to improve access to home-based care for veterans who require support with activities of daily living, like bathing and getting dressed, by giving them more decision-making power over who delivers that care and when.

In addition, the EO notes that the Department of Labor will publish a sample employment agreement so domestic child-care and long-term care workers and their employers can ensure both parties better understand their rights and responsibilities. The purpose of this is to grow awareness of employee’s options when it comes to unionizing. This is a report that we will be closely watching for when it is released. If you have any questions, please don’t hesitate to reach out.

Possible Bagel?

For those that didn’t religiously watch the West Wing, a bagel is another term for a recession. Forecasters at the Federal Reserve in April, warn of a possible recession later this year, further stowing doubt in the U.S. economy. Even though inflation eased this last month, only up 5% compared to last year, which is the lowest rate in the last 2 years, some recent data spooked forecasters to raise the probability of a bagel. Data that was released in April showed that retail spending is down, grocery sales were flat (even though prices went down), and service inflation (price of services like restaurant meals and haircuts) increased to over 7%, an absurdly high number. This is what led the federal reserve to increase interest rates once again in the beginning of May. This data along with reports that banks have started to cut back lending due to high interest rates and the recent collapses of SVB, Signature and just this last week One Republic bank, led some forecasters to raise the probability of a mild bagel later this year….. I hate when they do that, say something will happen “later this year”, it’s already May, almost halfway through the year? Does that mean it could happen in October or November? Then just say that!

Anyway, not everyone is predicting a mild bagel, some predict the economy to just “slow down” but not to fall into a bagel. But that still means that everyday people will continue to suffer. For the economy to “slow-down” that would mean that unemployment would rise, wage growth would drop, and the housing market would get worse than it is. In plain English, the Fed is trying to FUCK over average American’s and continue to make regular life harder and harder. I already accepted that I won’t be able to buy a house right now, but the Fed has made it clear that their actual goal is to making owning property impossible for millions of Americans. Bagel or no Bagel, it is getting really rough out here in America. And a bunch of fat-cat, ivy league people are trying to convince me that they are on my side during all this. History has shown that that is never the case. In the end, the more powerful and rich will continue to become richer and more powerful. All I can say is please put your money in some high yield savings accounts and hope for the best.

Pentagon Leak

We have finally hit the time that Si-Fi movies were predicting in the 80s when top-secret government documents were being leaked through video games. Like something out of The Americans, 21-year-old Jack Teixeira, American airman in the 102nd Intelligence Wing of the Massachusetts Air National Guard, leaked top secret Pentagon documents in a group chat on the platform Discord. The leaked highly classified documents included details about the war in Ukraine, intercepted communications about U.S. allies such as Israel, South Korea and Egypt, and details of American penetration of Russian military plans, among other topics. Teixeira charges include unauthorized retention and transmission of national defense information and unauthorized removal and retention of classified documents or material. The bulk of documents that were leaked are thought to have originate from the CIA’s Operations Center and the Pentagon’s Joint Chiefs of Staff. The documents appear to have been printed and folded twice. In some images there are items clearly visible in the background, including a hunting magazine, a knife and a tube of Gorilla-brand glue.

What I find most interesting about this story is that he used Discord. Now I have only been in this job for a little over a year but from everyone I have met, I can imagine that over 95% of you have no idea what discord is, and those that do is because they have kids that are at least teenagers. For those that don’t know discord is a rapidly growing communication platform where gamers can join parties to talk to other gamers. Think of it as like having one platform for all your group chats. That chat rooms vary, they could be filled with close friends, or just with people that share similar interests. While Discord is rapidly growing, its user rate is far behind bigger communication platforms like Twitter and Facebook. While 150 million active users may seem like a lot, that is only a quarter of Twitter’s active users (450 million) and a fraction of Facebooks 2.96 billion users.

So, it begs the question why he would choose this platform to release the documents. If he wanted to blow the lid on the U.S.’s foreign activities he would have used a bigger platform to reach more people. Using Discord is equivalent to leaking a story to the Cape Cod times rather than the Boston Globe. Not a lot is known about his true reasoning for why he leaked the documents. What is known is that he was suspicious of law enforcement and the U.S. intelligence community and was prone to ranting about “government overreach,” one of the group members told the Post. It is reported that roughly half of the chat group members lived abroad and that those who appeared most interested in the classified material were primarily from the “Eastern Bloc and those post-Soviet countries.” I think he was just trying to show off to his friends in some sort of manner and didn’t care about the consequences. He forgot that real life isn’t like Call of Duty and that when you are caught, you can’t just start the level all over again.

Look Ahead

Debt Ceiling

Currently, all focus is on the debt ceiling negotiations. Congress is running out of time to increase the debt ceiling to avoid federal defaults. Treasury Secretary, Janet Yellen, recently announced that the U.S. could default on its debt as early as June 1 and must move quickly to avert disaster. A debt default could trigger an economic downturn, which would prompt a spike in unemployment.

House Republicans lead by Speaker Kevin McCarthy recently passed “The Breaking the Gridlock Act”, that would increase the debt ceiling but would also scale back a wide swath of annual government spending to last year’s levels, a cut of about 8%, and cap its growth by 1% each year after that. The package also includes provisions that would require certain adult Medicaid recipients to work, perform community service, or participate in an employment program for at least 80 hours per month or earn a certain minimum monthly income. It would apply to those ages 19 to 55, but not those who are pregnant, parents of dependent children, those who are physically or mentally unfit for employment or enrolled in education or in substance abuse programs, among other exceptions.

This is where a line has been drawn in the sand. Democrats strongly disagree with every aspect of the Republican bill, Democrats do not want to pass a debt ceiling bill that would require a cut in spending nor cap growth in any capacity, nor do they want to implement work requirements. With Democrats in control of the Senate by a super slim margin, they do not have any plan to pass the Republicans proposal as is. Publicly Democrats have railed against Republicans for their proposal, accusing Republicans of holding the country hostage to demand federal cuts that will hurt the poor. But behind close doors their are reports that senior Democrats and the White House are actively working with a group of Republicans on a last minute deal to either suspend or lift the debt ceiling. Little is known of what Democrats are willing to leave on the table from the Republican package. I do expect that a deal will be reached in some capacity by the end of the month that will increase the debt ceiling. Both political parties love the spectacle that these situations create, but at the end of the day the few actual adults on both sides will work out a deal to avoid a potential disaster.

2024 Presidential Election Race

There is a massive storm brewing that is expected to hit all of America, that storm is the 2024 presidential race. The race is getting closer and closer with each passing day, President Biden announced that he plans to run for office again, if elected he would 86 when his second term ends; making him the oldest president ever.

Reports are also speculating that Florida Governor DeSantis will soon announce a presidential exploratory committee and may even announce his candidacy in Mid-May. Cloudy skies are starting to form and before we know it, we will all once again experience the nausea that comes from the race for president.

Trump Arrest

Now many legal experts have said that the charges are not that strong, and that amongst the multiple cases he could be facing, this one is the weakest. This case will not go through the thick of the legal system, where expensive lawyers make their money filing motion after motion to delay and change the scope of the case. I do not imagine a final ruling on a case anytime soon. The arrests will not stop him from running from president. Political analysts are split on whether or not the arrest will hurt him politically. Trump has shown time after time that analyst know nothing and that anything can be true and false at the same time when it comes to Trump.

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.