Category: Rural Health

What Medicaid Reforms in H.R. 1 Mean for Nurses

  

As Americans were celebrating our nation’s birthday with BBQ and fireworks, President Donald Trump signed the One Big Beautiful Bill (OBBBA; H.R. 1) into law. This new law:

  • permanently extended the 2017 tax cuts,
  • adopted additional tax reforms, and
  • provided funding for other Trump Administration priorities.

One tax reform includes tax deductions on overtime pay for nurses, first responders, and others. To partially offset the law’s $3.3 trillion price tag, OBBBA includes almost $1 trillion in cuts to Medicaid spending and will make health insurance coverage inaccessible to 10 million individuals by 2034, according to estimates from the Congressional Budget Office.

Here is an overview of Medicaid and other health reforms that will impact the nursing workforce and the patients whom they serve.

Medicaid Finance Reforms

OBBBA makes several reforms that lower federal and state government spending on Medicaid and have a trickledown effect on healthcare facilities and the nursing workforce in these settings. For example, one provision restricts states’ use of provider taxes to finance their share of Medicaid spending with exceptions for nursing homes and intermediate care facilities. Another section in the bill related to state-directed payments changes how much states can direct Medicaid managed care plans to pay providers. Finally, OBBBA eliminates the temporary 5% increase to the traditional federal medical assistance percentage (FMAP) that the federal government provided to new expansion states under the American Rescue Plan.

Finally, OBBBA eliminates the temporary 5% increase to the traditional federal medical assistance percentage (FMAP) that the federal government provided to new expansion states under the American Rescue Plan.

Restrictions on Medicaid financing will force states to limit eligibility, coverage, and payments to meet statutory budget constraints.

Consequently, healthcare facilities that are heavily reliant on Medicaid funding will be forced to either cut critical services or close their doors altogether. This could:

  • jeopardize nursing jobs,
  • aggravate nursing workforce challenges, and
  • reduce reimbursement for advance practice registered nurses (APRNs).

Patients will ultimately see less access to care, particularly in rural and medically underserved communities.

Changes to Medicaid Eligibility and Access Policies

H.R. 1 also makes several policy changes that restrict Medicaid eligibility and access. Starting in 2027, the law requires adults between the ages of 19 and 64 to work or participate in a qualifying activity for at least 80 hours a month. Thanks to ANA’s advocacy, the law provides an exemption for adults who are enrolled in nursing school or other academic settings.

OBBBA will require states to conduct eligibility checks every six months beginning next year and restrict their ability to provide retroactive coverage starting in 2027. The law also delays implementation of the Eligibility and Enrollment Rule, a pair of Biden-era rules that aim to reduce barriers to enrollment in Medicaid and other programs, until 2035. One bright spot for patients in the law is its expansion of home and community-based services to individuals who do not need an institutional level of care beginning in July 2028.

Most of these policy changes will make it difficult for Medicaid beneficiaries to retain coverage and disincentivize other patients from enrolling in the program. Patients who no longer have access to Medicaid coverage will delay care and experience worse patient outcomes when they finally do receive care. Healthcare providers will also experience an increase in uncompensated care. While it is heartening to see H.R. 1 expand home and community-based services to patients who do not need an institutional level of care, the jury is out on whether these patients will have adequate access to nurses and other healthcare personnel.

Rural Health Transformation Program

H.R. 1 is projected to result in a $155 billion reduction in Medicaid spending in rural communities over the next decade, resulting in hospital closures and reduced access to care for rural patients. To blunt the impact on Rural America, the law establishes a Rural Health Transformation Program that will support efforts to address challenges facing rural health systems. Initiatives that aim to strengthen the rural health workforce, improve access to rural providers, and/or promote technology-driven solutions like robotics and artificial intelligence are perfect candidates for support from this program. OBBBA authorizes $50 billion in funding to the program with $25 billion equitably distributed among the states and $25 billion given out at the discretion of the CMS Administrator. More information from CMS is expected in September.

While well-intentioned, the reality is that this program does not fully offset the cuts that rural facilities will face because of the law. Additionally, the language in the section creating this program is written in a manner that makes non-rural facilities eligible for funding.

Delayed Implementation of Nursing Home Staffing Rule

Last year, the Centers for Medicare and Medicaid Services (CMS) finalized the Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting Final Rule (CMS 3442-F). This rule:

  • sets minimum staffing standards,
  • requires a registered nurse (RN) to be onsite 24 hours a day, 7 days a week in long-term care facilities that participate in the Medicare and Medicaid programs, and
  • requires facilities to engage nurses in identifying staffing needs through facility assessments.

To help defray the cost of OBBBA, the law delays HHS from implementing the final rule through September 30, 2034. However, the facility assessment and Medicaid transparency provisions in the rule were excluded from the final text because they were subject to the Byrd Rule in the Senate. The Byrd Rule requires that provisions included in budget reconciliation measures focus on fiscal matters. This delay in implementation of the staffing rule only exacerbates staffing challenges in long-term care facilities that lead to nurse burnout and attrition from the profession. This moratorium also delays patient care and results in worse patient outcomes for nursing home residents.

Temporary Payment Increase for Healthcare Providers

Since Calendar Year (CY) 2000, the reimbursement rate that healthcare providers receive has been declining due to statutory budget neutrality requirements. This gradual reduction is especially challenging for APRNs who receive 15% lower reimbursement than physicians in Medicare for doing the same work. In CY 2025, CMS finalized a 2.8% cut to the conversion factor after a temporary increase in payments for CY 2024 expired.

H.R. 1 temporarily increases the conversion rate by 2.5% for 2026. While this increase does not resolve reimbursement challenges facing APRNs, it is a step in the right direction to ensuring that patients have access to APRN care.

Future Opportunities to Shape Medicaid Policy

The fight to save Medicaid is far from over. Through the Partnership for Medicaid, ANA recently endorsed a pair of bills to roll back provisions in H.R. 1:

  • Senator Josh Hawley’s (R-MO) Protect Medicaid and Rural Hospitals Act (S.2279) would repeal the law’s restrictions on provider taxes and state directed payments. It would also double the duration and funding for the Rural Health Transformation Program.
  • Senate Minority Leader Chuck Schumer (D-NY) and Senate Finance Committee Chair Ron Wyden (D-OR) introduced the Protecting Health Care and Lowering Costs Act (S.2556) to repeal the entire health section of H.R. 1. The measure also permanently extends the ACA premium tax credits that are set to expire at the end of this year and result in an additional 5 million individuals losing healthcare coverage.

ANA will also have ample opportunity to weigh in on implementation of H.R. 1 by the federal government and the states. It is also quite possible that the Administration issues regulations that adopt Medicaid reforms that did not make it into OBBBA. Similarly, House Speaker Mike Johnson and other Republican lawmakers have mentioned the possibility of additional budget reconciliation measures. While it’s not clear what these bills would cover, it’s quite possible that they may address policies that didn’t make it into H.R. 1. ANA and its allies in the nursing and broader healthcare community stand ready to play defense yet again if the need arises.

Check out our report on H.R. 1 for more information about what is in the bill that is relevant to nurses. Let us know how the reforms will impact your practice and patients, share your story today.

Large health care investments cap off eventful 2020 as we look ahead into 2021

  

What a historic year it has been on so many levels. Leaving behind the first year of a new decade that saw struggles which we could not have foreseen in January 2020, and going into a holiday season that looks vastly different from years passed and a future that is still unclear – it’s easy to focus on the negative. However, despite the trials and tribulations of this year, it is important and inspiring to recognize all of the ground-breaking work that ANA and nurses have done in the policy, government affairs and advocacy spaces, as we look towards what is on the horizon in 2021.

At the time of publication, Congress is in the process of passing a year-end package that will avert a government shutdown, include money for vaccines and COVID-19 aid to frontline workers, boost the economy, and include language to protect patients from surprise billing for health care. ANA has been working with our allies in Congress, and advocating to get these items addressed. Please be on the lookout for further details on the year-end package by visiting ANA’s new advocacy page. In the meantime, let’s acknowledge the progress made throughout 2020, which was necessitated by the COVID-19 public health emergency (PHE).

Earlier this year, the U.S. Congress and the President signed into law the Coronavirus Aid, Relief, and Economic Security (CARES) Act. Included in the law is language that reauthorizes Title VIII Nursing Workforce Development Programs and authorizes Nurse Practitioners (NPs) and Clinical Nurse Specialists (CNSs) to order home health care for their patients. These are longtime ANA federal legislative priorities, and we applaud Congress and the administration on their passage in the early stages of the pandemic. Advanced Practice Registered Nurses (APRNs) like NPs and CNSs are key to COVID-19 care and maintaining access to non-COVID-19 care throughout the crisis.

By summer, ANA was becoming a regular voice for nurses as Congress sought additional solutions to PHE challenges in the healthcare system. ANA President Ernest Grant testified at a hearing before the Senate Finance Committee, “Part 2: Protecting the Reliability of the U.S. Medical Supply Chain During the COVID-19 Pandemic.” Dr. Grant was there to answer the many questions Senators had about the impact of COVID-19. Questions ranged from what more the federal government could do to strengthen the supply chain, to the needs of nurses on the ground.

ANA also responded on behalf of nurses to proposals outlined in a white paper released by the Senate Health, Education, Labor, and Pension (HELP) Committee. The Committee requested input on what the U.S. had learned from the past 20 years of public health preparedness and response, and how we can better prepare for future pandemics. ANA’s response focused on how to rebuild and maintain state and federal stockpiles, improving public health capabilities, and increasing medical supply surge capacity and distribution. 

ANA has been consistently present with effective advocacy on personal protective equipment (PPE), which has been in short supply all year. As a result, the enterprise was tapped as leadership of a broad-based the coalition that will be a united voice to Congress and the administration on PPE and supply chain issues, to improve public health.

As we pivot to start working with the incoming administration, ANA has hit the ground running, providing substantive recommendations to transition leaders, and applauding the appointment of a registered nurse to President-elect Biden’s COVID-19 Task Force. We have communicated the many ways in which ANA and nurses can be a resource to the transition and the upcoming administration. We continue to solidify relationships to ensure that ANA will maintain a strong voice in the White House and key agencies in the months ahead.

Like the rest of the Policy and Government Affairs team, the ANA Political Action Committee (ANA-PAC) experienced a very successful year in 2020 despite the multitude of challenges it faced at the start of the pandemic. For starters, the PAC continued its winning streak with a 95 percent win rate in the 2020 general election for the nearly 100 candidates the PAC supported based on their pro-nursing agendas. Members of ANA drove their support unlike in years passed to the tune of over 5,600 contributors to the PAC which was an increase of 34 percent over 2019 and counting! And it doesn’t stop there: the financial strength of the PAC continues to improve as receipts are up 3 percent over last year and this number only continues to grow as we head toward the year end. Policy and GOVA will be spending the early part of 2021 strategizing our support for our existing nursing champions and starting new outreach efforts to those new freshman members of Congress. Stay tuned for updates in the next ANA-PAC quarterly newsletter.

ANA advocacy on federal regulatory policy has also strengthened nurses and demonstrated the power of nurses’ voices. With the COVID-19 PHE extended until March 2021, Medicare payment flexibilities gained in 2020 will continue. A number of these provisions expand access to APRNs for non-COVID-19 care as well as COVID-19 care, which has been a boon to patients and their providers throughout the pandemic, especially in rural areas.

The readiness of the Centers for Medicare and Medicaid Services (CMS) to remove regulatory barriers to practice has come as a result of direct advocacy over the years by ANA and partner organizations. The voices of frontline nurse providers were also heard, as CMS gathered first-hand accounts and created space to share this information on regular conference calls with nurses about the impacts of COVID-19 on their practice.

The pandemic has demonstrated the value of APRNs across the health care system, and CMS’ actions tell us that Medicare leaders are hearing us. The future is indeed bright, as CMS continues to review unnecessary barriers and craft regulatory relief. ANA policy leaders are right there, urging specific changes, and making a powerful case for making permanent changes to expand access to APRNs. We saw some success in the physician payment rule for 2021, which removed federal restrictions on APRN supervision of diagnostic tests.

CMS was not the only agency hearing nurses’ voices as important decisions were made. Early and often, ANA repeatedly called for steps to improve protections for frontline providers, including a return as soon as possible to pre-pandemic standards for PPE.

We made our case to the Occupational Safety and Health Administration, the Office of Minority Health at HHS, the Department of Veterans Affairs, Federal Emergency Management Agency, Government Accountability Office, and the White House Economic Advisors. ANA has become the “go to” organization for agency staff when they hear about events happening on the ground to work together to improve conditions for nurses. 

The pandemic made ANA’s presence even more valuable with the American Medical Association’s (AMA) RUC and CPT committees, which are the driving force for health care reimbursement. ANA CPT advisors were at the table when the CPT codes for both the Pfizer and Moderna vaccines were developed. In a separate process, ANA advisors were consulted to account for increased practice expenses incurred during the pandemic. Throughout, ANA engaged feedback and comment from the nursing community. All of these accomplishments could not be done without the loud impassioned voice of our ANA members and RNAction advocates. This united voice sent nearly 460,000 letters to Congress, responded to public comments and engaged in several surveys where the results were presented to Congressional offices across Capitol Hill. All of the input from nurses, our nation’s most trusted profession for 18 straight years, directly impacted legislation and policy throughout the year. We have you to thank for that – your efforts on the frontlines, your expertise and your advocacy do not go unnoticed. With over 200,000 RNAction advocates, we are poised to improve the profession of nursing and conditions for your patients again in 2021.

Nurses Key to COVID-19 Response, Addressing Maternal Health in Rural Communities

  

Today, November 19, we celebrate National Rural Health Day and acknowledge the nurses that are critical to ensuring access to health care services in rural communities across the nation. This year we focus on rural health and the role you play as clinicians in rural communities, in the midst of the ongoing COVID-19 pandemic, at a time where the number of cases and hospitalizations are steadily increasing. As we begin the holiday season, the Centers for Disease Control and Infection (CDC) continues to issue guidance and recommendations for mitigation efforts necessary to curb the spread of the virus.

ANA continues to recognize and advocate on behalf of all nurses on the frontlines of the pandemic response, as well as providing resources and support. The association knows the role of the nurse is especially critical in our rural communities that struggle with continued or exacerbated spread of the virus. This is particularly concerning as the CDC has detailed how people living in rural areas are at higher risk of contracting and/or facing complications from COVID-19. Because of this increased risk, the CDC has provided several resources and information for rural communities to respond to the COVID-19 pandemic.

In addition to releasing rural-focused data and resources, CDC also recently released data detailing how pregnant women face an increased risk of severe illness if they contract the virus, as well. The agency is working with state and external partners to collect information on COVID-19 cases in pregnant women and it continues to monitor the impact. The increased risk of COVID-19 to pregnant women is troubling given the underlying issue of existing high rates of maternal mortality in the United States, with rates more likely to be greater in rural areas.

Just earlier this year, we saw the Centers for Medicare & Medicaid Services (CMS) issue a Request for Information (RFI) seeking comment from stakeholders on how to improve access to care and outcomes for women and infants in rural communities. Submissions to the RFI, part of CMS’ larger goal of improving health through the Rethinking Rural Health Initiative, will inform the agency as it develops new and refines existing programs targeting rural families. ANA used this opportunity to share with CMS how nurses in rural communities are an integral part in addressing maternal health and ensuring women have access to needed health care services before, during, and after their pregnancy.

ANA recognizes existing barriers to improving maternal health in rural areas, such as gaps in access to providers or loss of coverage. To mitigate these barriers and challenges, nurses must be engaged to expand provider capacity. This includes utilizing Certified Nurse Midwives (CNMs) for pregnancy care, Nurse Practitioners (NPs) trained in women’s health, and Registered Nurses (RNs) to providing care coordination and connecting women to needed services—all leading to better outcomes for women and infants. Across the country, nurses are leading maternity and infant care models that ensure access to care, provide quality care, and ensure better outcomes.

Innovative models and initiatives must be encouraged in strategies to address maternal health in rural areas. It is imperative that strategies strengthen and uplift the contributions of nurses in all communities. Nurses are an integral part in the health care delivery system—especially in rural communities that face barriers to accessing needed care. Innovative payment models should be developed and implemented that recognize the critical value of RNs, NPs, and CNMs and adequately compensate for services these clinicians provide. To address gaps in access to providers, states must be incentivized to allow NPs and CNMs to practice at the full extent of their education and training.

We expect to see renewed attention on discussing and addressing maternal mortality and morbidity at the federal level. For example, the Medicaid and CHIP Payment and Access Commission continues to discuss this issue at public meetings and the June 2020 Report to Congress includes a chapter examining why mortality and morbidity rates continue to rise. As policymakers seek approaches to address rural maternal health challenges and barriers, the critical role of the nurse cannot be overstated. Leveraging the education and expertise of CNMs, NPs, and RNs to expand provider capacity and lead innovative care delivery models will only result in better maternal and infant health.

ANA continues to closely monitor this issue and take advantage of opportunities to highlight the importance of the nurse in addressing maternal health and other health care challenges in rural communities. In addition to the resources linked above, the following are available to better understand current challenges in addressing rural maternal health:

• Maternal Health Care in Rural Communities
• Maternal and Obstetric Care Challenges in Rural America
• Rural Disparities, Racial Disparities, and Maternal Health Crisis Call Out for Solutions
• Left Out: Barriers to Health Equity for Rural and Underserved Communities

We want to hear from you! Share your story of #RNAction in rural health by sending a message to rnaction@ana.org.