Category: White House

FY 2022 budget proposal sets the stage for Biden administration

  

The Biden administration released its proposed FY 2022 budget, which helps bring some clarity to the continued priorities of the administration. The budget reflects the administrations promise to rebuild a strong public health and community-based care system that can respond to the health challenges faced in diverse areas across the United States. Many priorities of the administration align with ANA’s advocacy focus to support nurses in areas such as workforce, behavioral health, maternal health, rural health, preparedness and safety including personal protective equipment (PPE), and research.

Below are a few highlights from the proposed budget that align with the work of ANA:

  • $15.4 billion for the Centers for Disease Control and Prevention, which reflects the largest budget authority increase in nearly two decades. The funding would go to support core public health capacity improvements, modernize data collection, training for public health experts, and prepare for, and respond to emerging global threats.
  • $12.6 billion for the Health Resources and Service Administration, which is $497 million above FY 2021 enacted.
  • $52 billion for the National Institutes of Health (NIH), an increase of $9 billion above FY 2021 enacted. $6.5 billion of the $9 billion increase is to support the establishment of the Advanced Research Projects Agency for Health, that is intended to speed transformational innovation in health research for diseases like cancer, diabetes, and Alzheimer’s. The remaining $2.5 billion will continue the research and translation into clinical practice for some of the most urgent challenges including the opioid crisis, climate change, and gun violence. ANA continues to monitor communications and opportunities to engage with the National Institute of Nursing Research under NIH.
  • An increase of $3.7 billion above FY 2021 enacted, for a total of $9.7 billion for the Substance Abuse and Mental Health Services Administration with a charge to respond to the opioid and substance use epidemic by expanding programs and targeting prevention and treatment; and increasing access to mental health services to protect the health of children and communities.
  • $14.2 billion for the Department of Labor (DOL), including $665 million for the Occupational Safety and Health Administration (OSHA), $73 million above FY 2021 enacted, for increased enforcement and whistleblower protection programs. The DOL budget requests $285 million for apprenticeship programs, specifically $100 million increase for the Registered Apprentice Program. There is no additional information on the DOL industry-recognized apprenticeship programs (IRAPs), which have supported nurse training initiatives.

The Biden administration has been vocal about priorities that will transform the health care system. However, the administration’s budget is slightly more than a wish list. Ultimately it is up to Congress to fund the agencies. ANA urges the Administration and Congress to focus on rebuilding and transforming the health care system to improve on the challenges brought forth during the pandemic. Nurses have been the agents of transformative change in facilities, systems, and communities to support improved patient outcomes and advancing equity. Building on these successes, ANA will work with the agencies and administration to build on the budget priorities to continue to put nurses at the forefront of change.  

ANA is also working on the Hill for legislation that will address infrastructure and access for telehealth services, PPE for the current and future public health emergencies, and workplace safety programs for nurses. ANA’s advocacy includes a multi-pronged approach to deliver what nurses need in all settings. It is clear through the first budget of this administration that health care is a top priority to improve as we transition to a post-pandemic environment.

What Does Trump’s New Executive Order Mean for Nurses?

  

President Trump signed a new executive order (EO) on October 3 relating to new policies the administration intends to implement in the Medicare program. The EO on Protecting and Improving Medicare for Our Nation’s Seniors builds upon a previous EO from October 2017, Promoting Healthcare Choice and Competition Across the United States, and the subsequent report, Reforming America’s Healthcare System Through Choice and Competition. The EO is intended to reform the Medicare program overall. The policy proposals address Medicare Advantage plans which are granted more flexibility under law in determining coverage and payment, as well as the traditional fee-for-service program.

Section 5 of the EO affects advanced practice registered nurses (APRN) and physician assistants (PA) in significant ways that the administration hopes will allow patients to spend more time with their providers. This section directs the Secretary of Health and Human Services (Secretary), within one year, to propose reforms to the Medicare program that would:

  • Eliminate excessive supervision requirements that prevent APRNs and PAs from delivering appropriate diagnosis and quality care;
  • Provide equal pay for equal work, with Medicare reimbursing APRNS and PAs at the same level as physicians for the same procedures;
  • Remove certain unspecified conditions of participation (CoP) requirements; and
  • Enable APRNs and PAs to practice to the full extent of their education and clinical training.

EO’s are typically broad and don’t get into the finer details of what is being proposed or the actions that will be taken. While we can make logical assumptions with some instructions in the EO, there are others that are less clear and we will work with the administration to clarify these issues as proposals are developed.

The subsections of the EO that would eliminate the unspecified supervision requirements, conditions of participation requirements, and licensure requirements in Medicare that limit clinicians from practicing at the top of their profession, would be done through the federal regulatory process. This involves the Secretary writing a “proposed rule” (i.e. regulation) and allowing for a 60-day public comment period. After which, the Secretary will publish a “final rule” and the new regulations will move into the implementation process. ANA will be engaging with the Secretary throughout the process to get the best regulatory results for nurses.

The third subsection dealing with pay disparities between physicians and other clinicians only instructs the Secretary to conduct a comprehensive review of regulatory policies.  Currently, the Medicare statute stipulates that nurse practitioners and clinical nurse specialists are paid at 85 percent of the physician fee amounts that are set annually by CMS for fee-for-service. Based on previous actions and communications with the Secretary, we expect he will do what he can to eliminate pay disparities in certain parts of Medicare through regulation and also advise Congress to eliminate the pay disparities through legislation.   Any legislation would need to be introduced and go through the normal legislative process.

One wild card in this proposal is the elimination of unspecified CoP requirements. CoP are federal regulations that certain health care facilities must comply with in order to be reimbursed by Medicare and Medicaid. While we would like to see some CoPs go, like the one that requires a certified registered nurse anesthetist to be supervised by a physician, there are others that positively benefit nurses and patients alike.

ANA is pleased that the Administration recognizes the value of APRN services to health care consumers and the Medicare program. We look forward to working with the Administration and Congress on on the development and implementation of these policies through the regulatory and legislative processes.

Congress Aims to Keep Campaign Promises on Health Care as Courts Continue to Review Administration Policies

  

By: Gregory Craig and Matthew Fitting

Following a midterm election cycle in which voters consistently listed health care as their top issue priority, members of the 116th Congress have wasted no time in proposing, introducing, and debating several measures that would significantly impact the way Americans receive and pay for health coverage.

Health Care Legislation in the U.S. House of Representatives

Most recently, Rep. Frank Pallone, Jr. (D-NJ), the Chairman of the House Energy and Commerce Committee, on March 26, 2019 introduced H.R. 1884 – the “Protecting Pre-Existing Conditions and Making Health Care More Affordable Act of 2019”. This legislation would strengthen many of the consumer protections and pre-existing conditions provisions of the Affordable Care Act (ACA), promote individual health insurance enrollment on the ACA Marketplace, and roll back regulatory actions that the administration has implemented since January 2017. Some of the specific provisions would:

  • Expand income-based eligibility for premium tax credits used to purchase individual health insurance coverage and increase tax credits for all income brackets, allowing more individuals to purchase subsidized health insurance coverage;
  • Fix the so-called “family glitch” to make it easier for low- and middle-income individuals to purchase subsidized family coverage;
  • Rescind the administration’s final rule expanding the availability of Association Health Plans (AHPs) that can circumvent many of the ACA’s consumer protections, specifically those involving Essential Health Benefits (read ANA’s comment letter on AHPs here);
  • Rescind the administration’s final rule expanding the availability of short-term, limited duration insurance plans, which are not required to comply with any of the ACA’s consumer protections (read ANA’s comment letter on short-term, limited duration insurance here);
  • Require the Department of Health and Human Services to conduct marketing and outreach for open enrollment with $100 million in annual appropriations (read ANA’s plan year 2018 open enrollment report here);
  • Establish a state-based reinsurance program that would allow states to set up their own reinsurance programs, or to use the funds to provide premium subsidies or cost-sharing support, with a federal reinsurance program as a backstop.

ANA has publicly supported many of the provisions in H.R. 1884 and has consistently promoted a bipartisan proposal – similar to the reinsurance proposal included in H.R. 1884 above – that Sens. Lamar Alexander (R-TN) and Patty Murray (D-WA) introduced in the previous Congress that would have established a similar program and restored cost-sharing payment reductions that help low-income individuals afford co-insurance and deductible costs (the Administration canceled these payments in October 2017).

The proposal that has arguably grabbed the most headlines, however, is “Medicare for All,” a general campaign slogan that was recently introduced as legislation by Rep. Pramila Jayapal (D-WA) with a Senate bill soon to follow to be introduced by Sen. Bernie Sanders (I-VT). The bill would implement an expanded government-run Medicare program and do away with much of the private insurance system currently in place (well over half of Americans currently receive health insurance through their employer or in the Marketplace).

While the legislation is consistent with ANA’s support for universal access to health coverage, there are several provisions that could negatively impact the nation’s four million registered nurses, as well as the patients for whom they provide care. Some of these include:

  • A fee-for-service program that could significantly reduce payment rates and have a trickle-down effect on Advanced Practice Registered Nurses (APRNs), who are currently reimbursed at 85% the rate that Medicare reimburses physicians for the same work;
  • A Medicare Trust Fund that could lead to uncertainty around payments and impact access to care should beneficiary access to services exceed the fiscal year budget;
  • The establishment of regional offices charged with recommending changes in provider reimbursement and establishing quality assurance mechanisms for their regions, which could lead to a patchwork of coverage and tempt providers to practice where reimbursement rates are higher.

Federal Courts Reviewing ACA Provisions

The Department of Justice on March 25 unexpectedly sent a letter to the Fifth Circuit Court of Appeals to state that the Administration fully supports the December 2018 U.S. District Court decision in Texas v. Azar that would invalidate the entire Affordable Care Act (the U.S. District Court decision was stayed pending appeal; the Administration had previously only supported striking down parts of the ACA, including pre-existing conditions provisions). This case will likely make its way to the U.S. Supreme Court for a final decision, though that decision would probably not come until 2020 or later. Invalidating the entire ACA with no plan to replace it would be extremely disruptive to the U.S. health care system and would result in enormous insurance coverage and financial losses.

On March 27, the Federal District Court for the District of Columbia threw out Medicaid work requirements in both Kentucky and Arkansas. This is the second time that Kentucky’s Medicaid work requirements have been blocked in federal court. Arkansas’ work requirements were implemented in June 2018 and have resulted in 18,000 individuals losing coverage. The same federal court on March 28 issued a ruling that rejects the administration’s final rule that expands the availability of Association Health Plans. ANA has consistently opposed expanding the availability of these plans, as they represent an end-around of the ACA’s essential health benefits requirements for insurance coverage.

ANA’s Commitment to Universal Access to Quality Health Care

ANA is committed to a pragmatic approach to ensuring universal access to quality, affordable, and accessible health care for all Americans, particularly vulnerable populations and those with pre-existing conditions. As ANA stated in a recent press release: “Universal access to a standard package of essential health care services for all citizens and residents is of paramount importance to the American Nurses Association. Nurses have a critical voice in this debate, and ANA is committed to advancing policy initiatives that provide and expand access to affordable coverage and quality care for all.”

This is the latest chapter in the decades-old health care debate – we expect that many proposals will be offered before the 2020 election. ANA will continue to be involved and actively advocate for nurses and the patients for whom they provided care.