10/9/2017

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The View From DC

Barbara Gay

LeadingAge, Washington, DCOctober 13, 2017

Where Does Congress Stand?

• Fewer than 40 legislative days left in the calendar year

• Fiscal year 2018 began October 1

• 2018 budget still not passed (as of Oct 6)• 2018 budget still not passed (as of Oct 6)

• Emergency appropriations passed at beginning of September good through December 8

Post- and Pre-Election

• Policy/legislative agenda U turn

• Fear of primary challenges, especially in the House

• All eyes now on 2018 mid term elections• All eyes now on 2018 mid-term elections

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Affordable Care Act RepealLeadingAge Concerns

• Medicaid is the default payer for long-term services and supports

• Every state would lose money under the legislation especially after 2026

• With tightening funding, would optional coverageWith tightening funding, would optional coverage like medically-needy, home- and community-based services survive?

• Per capita caps would not adjust if a state’s elder population aged from young-old to oldest-old.

• Medicaid expansion has been important to coverage of direct care workers and some senior housing residents

Medicaid Advocacy

What Happened?

• House passed H.R. 1628, American Health Care Act, May 4

• Senate leadership developed substantially similar billS t f il d t th t d i il• Senate failed to pass that measure and similar ones July 28

• Sens. Graham and Lindsey revived the effort in September

• Still not enough votes to pass• Budget reconciliation process sunset 9/30/17

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Now What?

• Good question

• Alexander-Murray bipartisan effort to fix ACA could revive

• Other health care issues child health• Other health care issues – child health, Medicare extenders

• Shrinking legislative year, other priorities

• Medicaid cuts still a potential pay-for

Medicare Issues

• Observation days – H.R. 1421/S. 568• Count all time spent in a hospital toward the three day

stay requirement• Reps. Ciciline and Langevin, Sens. Reed and

Whitehouse are cosponsors

• Therapy caps• Exceptions process expires December 31, 2017• Current discussion – extend process and make less

burdensome• Caps in 2017 - $1,980 for outpatient physical and

speech therapy; $1,980 for occupational therapy

• Path to consideration not yet clear – maybe a Christmas tree ornament

Home Health

• S. 445 – Home Health Planning Improvement Act, introduced by Sens. Collins and Cardin

• Allows physician assistants, clinical nurse specialists, nurse practitioners and certified

id i t M di f hmidwives to approve Medicare coverage of home health care

• S. 309 - Community-Based Independence for Seniors Act

• Demo coverage of non-medical supportive services

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Adult Day Services

• H.R. 3098, Adult Day Services Act, introduced June 28

• Allows Medicare coverage of skilled nursing, rehabilitation and social services provided in a

tifi d d lt d i tcertified adult day services center• Services would have to be ordered by a

physician• Allows beneficiary choice of settings in which

to receive Medicare-covered services• LeadingAge strongly supports

CHRONIC Care Act

• S. 870, Creating High-Quality Results and Outcomes Necessary to Improve Chronic Care

• Sens. Hatch, Wyden, Isakson, Warner• Extends Independence at Home demonstrationExtends Independence at Home demonstration• Continued access to Medicare Advantage SNPs• Expansion of telehealth and other technological

applications• Encourage care coordination within ACOs• GAO study on medication synchronization

2018 Budget and Spending

• No federal budget plan adopted for fiscal 2018• Budget Control Act of 2011 caps – keep or

waive? (2% Medicare sequestration continues)• House 2018 resolution, H.Con.Res. 71, passed , , p

October 5• $203 billion/10 year mandatory spending cuts

• Senate resolution reconciliation instructions:• Tax cut - $1.5 trillion/ten year revenue loss• Medicare cut $479 billion, Medicaid cut $1 trillion

over ten years• Repeal ACA

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Senior Housing Rally

Senior Housing

• House passed HR 3354 September 14• Senate Appropriations Committee approved a

2018 HUD spending bill• Both fully fund Section 202 rental assistance y

renewals.• House bill under-funds renewal of all Section 8

contracts• Both bills give Section 202s with project rental

assistance contracts access to Rental Assistance Demonstration – RAD for PRAC

Tax Reform?

• Next big issue (?)

• Fulfill campaign promises

• Ultimate goal of cuts in mandatory spending programsprograms

• Tension point – “simplification” vs. popular tax benefits

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Possible Direction

• 3 individual tax brackets • Corporate tax rate 25%• Eliminate AMT, marriage penalty, estate tax• More tax benefits for capital gains, dividends,

interestinterest• Larger standard deduction (but maybe no personal

exemptions)• Preserve mortgage interest and charitable

contribution deductions. • Deduction for state and local taxes?• Timeframe – maybe for the holidays (2017 tax

year)

LeadingAge Position

• Retain tax-exempt status for charitable organizations

• Retain income tax deduction for charitable contributions

• Charitable giving one of the three legs of the stool that supports our members’ work

• Philanthropy bridges the gap between public programs and individual/family resources

• Also watching out for medical expense deduction

LeadingAge Agenda onRegulatory Reform

• Nursing home requirements of participation• Final rule issued too quickly, without adequate guidance for

compliance and underestimating time and resources needed• Should be delayed for at least a year

• Nursing home oversight system as a whole needs overhauloverhaul

• Five Star should change from grading on a curve to evaluation according to fixed, nationwide benchmarks

• Repeal automatic loss of CNA training• Repeal doubling of civil monetary penalties• Revise and simplify payroll-based journaling (PBJ)• Suspend Medicaid location rule that restricts coverage

on campus-based settings

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Nursing Home Requirements of Participation (RoPs)

• Complete overhaul of nursing home regulatory system

• Phase I effective 11/28/2016

• Phase II effective 11/28/2017• Phase II effective 11/28/2017

• New requirements include:• Antibiotic stewardship• Facility-wide assessment• Behavioral health

ROPs Advocacy

• Meeting with CMS Administrator Verma April 3

• Responded to CMS request for comments on regulatory burden

• Drafted congressional sign on letter asking for• Drafted congressional sign-on letter asking for delay

• Now working with the Health Care Association on their letter

Emergency Preparedness

• Deadline for compliance Nov. 15, 2017

• Applies to all health care providers

• Applies to natural and man-made disasters

• Goals:• Safeguard human resources• Maintain business continuity, access to care• Protect physical resources

• Each provider must develop a comprehensive plan, test it and train staff

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Medicare Red Tape Relief Project

• Initiated by Rep. Pat Tiberi (Ohio), chair of House Ways and Means Health Subcommittee

• Goal: reduce regulatory burdens on health care providers

• Stakeholder input through August 25• LeadingAge commented on requirements of

participation, five star, home health, multiplicity of quality measures, restrictions against Medicaid coverage for assisted living residents

• Next step – subcommittee to host roundtables around the country

Assisted LivingImpact of Higher Minimum Wage?

• RTI International and CEAL study

• ¾ of all jobs fall into minimum wage category

• $15 minimum wage would increase wages for 86% of these workers86% of these workers

• Increase would be smaller in states where wages already exceed median

• Rhode Island minimum wage $9/hour

• Provider costs would rise 13%

LeadingAge: A New Vision forLong-Term Services and Supports• Researched fairer and more rational system• Promote consumer choice and flexible options• Encourage interventions to delay LTSS need• Recommendations:• Recommendations:

• Universal approach more affordable for all• Catastrophic, back-end coverage • “Managed cash” benefit structure

• Work in progress, unanswered questions:• Amount of benefit, how to calculate waiting period,

integration with Medicare/Medicaid

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QUESTIONS?

Barbara Gay, Vice President for Public Policy Communications, LeadingAge

bgay@leadingage.org