Congress reopens the government and reauthorizes CHIP while HHS creates a Conscience and Religious Freedom Division


Earlier today the Senate announced a deal for a three week continuing resolution to reopen the government. While this is an important step, ANA continues to advocate for a long-term, bipartisan solution to provide Americans with a greater sense of stability. In particular, we encourage both chambers to find an equitable compromise for the Deferred Action for Childhood Arrivals (DACA) program.

Included in this deal was a six year reauthorization of the Children’s Health Insurance Program (CHIP). It’s been more than 100 days since this vital, bipartisan program, which provides health coverage to 9 million children and pregnant women, was fully funded, and many Americans across the country worried that their family’s health care could run out. Nurses were critical in securing this win and we can’t thank you enough for reaching out to your representatives in Congress demanding a long term solution.

The shutdown and CHIP reauthorization are not the only important issues developing in Washington. Last Thursday, the Department of Health and Human Services announced it was establishing a Conscience and Religious Freedom Division under the Office for Civil Rights. This new division is charged with enforcing current laws that protect nurses and other health professionals who refuse to provide care to which they have moral or legal objections.

While health care professionals are obligated to follow laws and the federal government has the obligation to enforce these laws, both parties have the important responsibility to ensure that all patients receive the care and treatment to which they are entitled. All health care professionals’ first priority should be the quality and equal access of care their patients need. That is one of the reason that several organizations, including the National Women’s Law Center, the American College of Obstetricians and Gynecologists and the Human Rights Campaign, have expressed concerns that this new division could cause increased discrimination among certain groups of patients.

There are also legitimate concerns that this new entity could hinder or even deny some patients the care or treatment options open to them. Far too often vulnerable populations experience discrimination when it comes to their health care. Patients rely on nurses to provide honest and professional medical advice and treatment during the course of care regardless of their own beliefs. It is vital that all patients, regardless of their beliefs, sexual orientation, gender or health care needs know they are receiving the most accurate and timely care.

This issue is extremely important to the nursing profession. In response to this announcement Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN, president of the American Nurses Association (ANA), issued the following statement:

“The American Nurses Association Code of Ethics for Nurses with Interpretive Statements states that a nurse has a duty to care. It also states a nurse is justified in refusing to participate in a particular decision or action that is morally objectionable, so long as it is a conscience-based objection and not one based on personal preference, prejudice, bias, convenience, or arbitrariness. Nurses are obliged to provide for patient safety, to avoid patient abandonment, and to withdraw only when assured that nursing care is available to the patient. Nurses who decide not to participate on the grounds of conscientious objection must communicate this decision in a timely and appropriate manner, in advance and in time for alternate arrangements to be made for patient care. Nurses should not be discriminated against by employers for exercising a conscience based refusal.

However, we must take care to balance health care professionals’ rights to exercise their conscience with patients’ rights to access a full range of health care services. Discrimination in health care settings remains a grave and widespread problem for many vulnerable populations and contributes to a wide range of health disparities. All patients deserve universal access to high quality care and we must guard against erosion of any civil rights protections in health care that would lead to denied or delayed care.”

Discrimination, prejudice and bias have no place in the American health care system and no patient should have to worry they aren’t getting the timely or medically necessary treatment they need. Nurses will continue to advocate for their patients to prevent discrimination and ensure that all Americans receive the high quality care they are entitled to. As the Department of Health and Human Services moves forward with this undertaking we will continue to monitor not only the implementation of the Conscience and Religious Freedom Division but the activities coming out of it to ensure that patients and health care professionals are protected.

Trump, Congress can’t close deal as shutdown looms


 As the federal government appears headed toward its first shutdown since 2013, congressional leadership and Trump administration figures have engaged in an increasingly public back and forth over which side should be held most responsible for the high-stakes stalemate. Major sticking points remain around immigration, specifically Deferred Action for Childhood Arrivals (DACA), as well as the Children’s Health Insurance Program, which has now gone more than three months since its long-term funding expired (and after Congress kicked the can down the road before the holidays late last year).

While the House of Representatives was able to pass a short-term funding bill by a slim margin, Senate Democrats refuse to support any legislation that does not include long-term CHIP funding and a solution on DACA, which the President unilaterally decided to end last year, a move ANA condemned at the time.

While the House spending bill included a long-term funding solution for CHIP, it did not address DACA, and the President rejected a bipartisan immigration deal earlier this week. With 49 Democrats currently serving in the Senate, and any funding bill needing to enjoy filibuster-proof support of 60 votes, Democratic buy-in is necessary to keep the government open.

Additionally, while inclusion of long-term CHIP funding in the House bill is heartening to see, House Republican leaders have had ample opportunity to address CHIP long before this week. Moreover, due in part to the repeal of the individual mandate as part of last year’s tax reform legislation, the Congressional Budget Office (CBO) earlier this month revised its estimate of CHIP’s cost to the federal government and showed that it now stands at $800 million, down from $8.2 billion.

The President, largely via his Twitter feed, has repeatedly attempted to pin responsibility over a potential shutdown on congressional Democrats. Polling released Friday indicates he’s enjoying little success: 48% said they would blame the President and Republicans (who control every branch of government), with just 28% placing the blame on Democrats.

On Friday afternoon, Senate minority leader Chuck Schumer (D-NY) visited the White House to meet with President Trump, a meeting at which Speaker of the House Paul Ryan (R-WI) and Senate majority leader Mitch McConnell (R-KY) were not present. Following the meeting, Schumer indicated that progress was being made but that no agreement had yet been reached; nor was it clear what deal the President could reach with Schumer that would be acceptable to more conservative House Republicans, particularly those in the Freedom Caucus.

Regardless of the outcome, this episode is just the latest reminder for congressional leadership and the administration that a bipartisan, long-term budget is sorely needed, and that any such budget should include input from experts, including America’s nurses. Families who are affected by DACA or reliant on CHIP deserve better than what Washington has so far failed to deliver.

Trump Administration Continues to Undermine Healthcare for Low-Income Americans


The Trump Administration has picked up in 2018 where it left off in 2017 by dealing two more blows to the American health care system. The Department of Labor (DOL) on January 5th published a proposed rule which would expand the ability of groups of employers to create Association Health Plans (AHPs), while today the Centers for Medicare & Medicaid Services (CMS) sent a letter to state Medicaid directors indicating support for states to implement work requirements for “able-bodied” adult Medicaid beneficiaries. These moves threaten to restrict access to critical and comprehensive healthcare services for low-income Americans, even as the healthcare coverage of 9 million American children hangs in the balance as Congress continues to drag its feet on a long-term re-authorization of the Children’s Health Insurance Program (visit ANA’s CHIP action page here).

Association Health Plans

As I wrote in a blog post in October, AHPs currently exist and are used primarily by small businesses to purchase group health coverage, but are regulated under the provisions of the Affordable Care Act (ACA) in the same way as coverage purchased on the individual health insurance market. DOL’s proposed rule seeks to make it easier for employers to create AHPs by:  1) allowing AHPs to exist for the sole purpose of offering healthcare coverage and 2) broadening the definition of “commonality of interest” to allow for larger AHPs. This would in effect treat AHPs as large group health insurance plans and allow coverage under AHPs to be sold across state lines under certain circumstances.

Expanding the use of AHPs in this way exempts them from important provisions covered under the ACA. As a reminder, the ACA includes provisions on insurance plans sold on the individual market which:

  • Require plans to cover 10 Essential Health Benefits including reproductive and maternal health services and preventive services;
  • Forbid insurers from charging more to individuals due to pre-existing conditions;
  • Limit the amount insurance companies can charge to older individuals based on age.

While DOL notes that a non-discrimination provision within the proposed rule would prevent denying coverage on the basis of pre-existing conditions, AHPs could still select for younger, healthier individuals in other ways and could still charge higher premiums for older individuals, potentially leaving these individuals (who are statistically likely to be sicker) without a coverage option.

Furthermore, these insurance plans are ripe for instances of fraud, abuse, and insolvency. The Government Accountability Office (GAO) in 1992 issued a report which slammed similar small business insurance arrangements and noted that they left hundreds of thousands of enrollees with millions of dollars in unpaid claims, while widely failing to meet state insurance laws and regulations. The GAO report found that some plans tried to duck state insurance regulations entirely. This type of Wild West approach to insurance coverage does not offer the comprehensive level of coverage at a low price that the Trump administration claims. Based on the provisions of this proposed rule, we also expect several lawsuits to challenge this based on the legality under current federal law and on the insurance across state lines aspect.

Work Requirements for Able-Bodied Adult Medicaid Beneficiaries

CMS sent a letter on January 11th to state Medicaid directors announcing its support for states to implement waivers introducing work requirements for non-elderly, non-pregnant adult beneficiaries who are eligible for Medicaid on a basis other than disability. CMS bases its support for work requirements on what it describes as the health benefits of community engagement, including work and work promotion.

This latest attempt by the Trump Administration to restrict Medicaid eligibility is, however, nothing more than a straw man argument. Medicaid expansion ipso facto provides healthcare coverage to working, low-income Americans. According to a December 2017 Kaiser Family Foundation issue brief, roughly 6 in 10 of the 22 million non-disabled adults receiving Medicaid benefits are employed either full- or part-time, while 8 in10 of these adults live in a working family. Most of these individuals work either for small firms or in low-paying industries which do not offer healthcare coverage and thus rely on Medicaid for such.

Further, among those adults who are not working, most report a major barrier to employment such as illness, disability, or care-giving duties. According to the same Kaiser issue brief, Medicaid expansion has not negatively impacted labor market participation; in fact, some research demonstrates that Medicaid coverage supports work.

As such, Medicaid work requirements would likely have little to no positive impact on employment and could even negatively impact both access to healthcare and employment prospects for these Medicaid beneficiaries. From an empirical standpoint, the basis for imposing work requirements on Medicaid beneficiaries seems to stem less from a desire to assist low-income Americans to access critical healthcare services while simultaneously supporting employment, but rather from a preconceived notion as to the characteristics of the individuals who benefit from Medicaid.

The American Nurses Association opposes any action – legislative or executive – which threatens the ability of Americans to access and receive high quality healthcare. This is particularly true when it comes to the most vulnerable Americans. If 2017 showed us anything, it is that this administration is more concerned with scoring political points and reversing gains made in healthcare than it is about actually ensuring high quality healthcare coverage for all Americans; this seems to be the modus operandi in 2018 as well.

We urge the Administration and Congress to work toward finalizing a long-term Children’s Health Insurance Program (CHIP) re-authorization, toward a market stabilization package including cost-sharing reduction payment funding, and toward strengthening the existing healthcare system – which has resulted in coverage for tens of millions more Americans since 2014 – and put an end to these attempts to sabotage Americans’ healthcare for political gain. ANA is committed to working with Congress and the Administration on legislation and regulations which align with our four core principles of health system transformation. These moves, however, represent a major step backward from achieving those principles.