Congressional and Administration Health Care News


John C. Zang, DMGS Ohio contributed to this report. 

Election 2016

According to FiveThirtyEight modeling based on current polling, Clinton continues to maintain her lead over Trump and is projected to receive 48.7% of the popular vote with Donald Trump receiving 41.6% and Libertarian Gary Johnson, 8.4%. Recent polls have shown Clinton & Trump tying in South Carolina. There are increasing concerns that Donald Trump’s unpopularity will have a negative effect on Republicans Congressional chances, and a Democratically controlled Senate is a looming possibility, though the House is unlikely to change hands.

 Flood Risk Standard Would Be Stronger Under FEMA Proposal

Federally funded projects in flood-prone areas would be built two to three feet higher than the 100-year floodplain elevation, under a proposal issued by the Federal Emergency Management Agency. The Aug. 22 proposal (RIN:1660-AA85) would amend FEMA’s regulations to implement a January 2015 executive order, which established a strengthened federal flood risk management standard. The standard—which FEMA is proposing to adopt in its entirety—is meant to ensure that communities build back stronger after storms by taking future climate risks into account. It allows federal agencies to choose from one of three approaches. They can:

  • use data and methods informed by best-available, actionable climate science;
  • build two feet above the 100-year (1 percent-annual-chance) flood elevation for standard projects and three feet above for critical buildings such as hospitals and evacuation centers; or
  • build to the 500-year (0.2 percent-annual-chance) flood elevation.

The standard applies to federally funded projects that are new construction, a substantial improvement or that address substantial damage to a structure or facility. It’s based on a strengthened regional standard developed in the aftermath of Hurricane Sandy.

Medicare Driving Up Federal Health Spending

Medicare spending is projected to account for more than half of the increase in federal health spending in 2016, according to the latest projections from the Congressional Budget Office. Federal spending for the major health-care programs will jump $77 billion, or about 8 percent, the CBO said in its Aug. 23 budget outlook update. However, that number reflects a $22 billion shift in the timing of certain Medicare payments from 2017 into 2016. After adjusting for the shift, the CBO said it expects health-care spending will rise $55 billion in 2016. Medicare spending is expected to grow $30 billion, or 6 percent, this year, largely because of increased spending per person, particularly for prescription drugs. Spending for such drugs is projected to increase by roughly 15 percent, mainly because of people whose out-of-pocket costs for prescription drugs exceeded the catastrophic limit on out-of-pocket spending. Many lawmakers, and Democratic presidential nominee Hillary Clinton, have attacked drug companies for what they see as exorbitantly high prices, and have looked at ways to rein in price increases.

The CBO projected Medicare spending would continue to grow over the next decade because of a rapidly aging population. The number of people age 65 or older is more than double what it was 50 years ago. Over the next decade, as members of the baby boom generation age and as life expectancy continues to increase, that number is expected to rise more than one-third, the CBO said. “As a result, projected spending for people age 65 or older in three large programs—Social Security, Medicare, and Medicaid—increases from roughly one-third of all federal noninterest spending in 2016 to about 40 percent in 2026,” it said. However, the agency noted that growth in health-care spending was slower in the past several years than it has been historically.

10-Year Deficit Seen Down on Lower Interest Costs

The good news from the Congressional Budget Office summer update was almost a trillion dollars less in projected interest costs on the national debt. The bad news was a slow economy that means the debt in proportion to the economy will remain high. The nonpartisan CBO, in its update released Aug. 23, said it still expected the 2016 budget deficit to show the first annual increase since 2011, to $590 billion from $439.9 billion in 2015. The CBO initially made that forecast Aug. 5 in its monthly budget review (See previous story, 08/08/16).

Over the 2017-2026 budget window, the CBO revised its projected cumulative deficit downward by $712 billion from what it projected in January, a development that ordinarily would be met with some degree of applause from deficit hawks. But with a lower starting point for economic growth in the forecast, the debt as a percentage of gross domestic product—a measure many economists say gives the best picture of the U.S. debt burden—will remain close to previous projections, the CBO said.


Congress remains in recess through Labor Day, resuming September 6.

Health Care News

Despite Insurer Exits, HHS Analysis Finds Plans Still Affordable

A majority of consumers on the federal insurance exchanges would still be able to buy affordable plans even if premium rates on all ACA plans were to increase by double digits in 2017, according to an HHS analysis. The study, released Aug. 24, is an attempt by the agency to reassure consumers that the exchanges are still competitive and affordable, despite the high-profile exits of major insurers like Aetna and UnitedHealth. The decisions by the insurers to exit certain markets have raised questions about the overall stability of the Affordable Care Act’s insurance marketplace, as well as the possibility of dramatic premium increases by those plans that choose to stay.

According to the analysis, the combination of premium tax credits and the opportunity to shop around for coverage would protect consumers even if there were double-digit increases. Market fluctuations are expected to occur as insurers continue to adjust to new coverage requirements under the ACA, officials from the Department of Health and Human Services told reporters during an Aug. 24 call. In a hypothetical scenario in which all rates increase by 25 percent, nearly three-quarters of consumers (73 percent) would still be able to purchase coverage for less than $75 per month, according to the report. In addition, 78 percent of consumers could find coverage for $100 or less. Rates for 2017 won’t be made final until October.

HHS officials also noted on the call that current rates for the federal marketplace are well below initial Congressional Budget Office (CBO) projections, and that even if rates increase in 2017, there are a variety of “predictable upward pressures” that will dissipate in 2018 and beyond. For example, the end of the ACA’s temporary reinsurance program in 2016 puts upward pressure on 2017 rate increases that won’t exist for 2018 and beyond, the agency said.

CMS to Let Consumers in Six States Compare ACA Networks

The CMS will let consumers in six states compare the relative size of provider networks within ACA plans during the 2017 open enrollment period, according to recent agency guidance. Earlier this year, the Obama administration indicated that comparison tools about provider networks would be available in all states. According to the Aug. 19 guidance from the Centers for Medicare & Medicaid Services, only six states will participate in the pilot program, which will allow consumers choosing a plan on to compare the breadth of provider networks at the county level.

“The consumer experience is a priority for CMS, and the goal of the network breadth pilot is to help CMS understand how consumers make use of the network breadth information,” the agency said. Rolling out the network comparison tool on a smaller scale before national implementation matches what the agency has done with other initiatives, including the agency’s marketplace quality rating system.

According to the guidance, consumers will be able to compare networks for three provider types: adult primary care providers, pediatricians and hospitals. The CMS said it will consider expanding the pilot to additional states and/or provider types in future years. The analysis will compare a plan issuer’s contracted providers to the number of specific providers and facilities included across all qualified health plan (QHP) networks available in a county. The CMS will make a final determination to use a separate or composite rating for the three categories of providers based on the results of consumer testing, the agency said. The agency outlined its desire for network breadth transparency in the final 2017 Letter to Issuers in the Federally-facilitated Marketplaces, an addendum to its 2017 Notice of Benefit and Payment Parameters (NBPP) final rule (See previous story, 03/01/16) (See previous story, 03/01/16).

The CMS didn’t indicate which states it would use, but said it is considering “states that provide a sample of plans in geographic areas with a range of network availability.” The pilots will be implemented in QHPs on both federally and state-run ACA exchanges. According to the guidance, network breadth information will display to consumers shopping for individual policies in exchange markets only in the pilot states. The CMS will collect data on the 2017 consumer experience from the consumers in the states in which this information will be displayed and use it to inform the display in future years, the agency said in the guidance.

CMS Ordered to Improve Outreach on Maintenance Therapy Coverage

The CMS has less than two months to develop a better plan to educate providers and auditors that Medicare covers home health, skilled nursing and outpatient therapy services, even if a patient’s condition isn’t expected to improve (Jimmo v. Burwell, 2016 BL 267947, D. Vt., No. 5:11-cv-17, 8/17/16). The deadline was set by a federal trial court that said the Centers for Medicare & Medicaid Services should improve its efforts to educate regulated entities concerning when so-called maintenance therapies—services that maintain or prevent decline of a patient’s condition—are covered by Medicare. The decision by the U.S. District Court for the District of Vermont is important said Judith Stein, executive director of the Center for Medicare Advocacy (CMA), because it reaffirms that federal law requires Medicare managed care organizations to cover maintenance therapies. The CMA is a beneficiary advocacy organization.

In its Aug. 17 ruling, the court said that the CMS failed to follow through on certain corrective measures on covering maintenance services outlined in a January 2013 settlement. That settlement, the result of a class action lawsuit brought on behalf of lead plaintiff Glenda Jimmo, eliminated Medicare’s “improvement standard” for coverage and called on the CMS to better educate providers and auditors that Medicare covers maintenance services. Before the Jimmo settlement, Medicare would typically only cover home health, skilled nursing and outpatient therapy services if there was an expectation of patient improvement, which could result in beneficiaries receiving sizable bills if they were prescribed physical therapy or other types of maintenance treatments (See previous story, 10/21/15). In March, the CMA asked the court to determine if the CMS had properly implemented the required educational campaign. The Aug. 17 order rejected two of CMA’s challenges to the agency’s implementation of the settlement but found that the agency hasn’t done enough to educate providers and private claims auditors about the settlement and should come up with a new educational plan within 45 days.

Cancer ‘Moonshot’ Blue Ribbon Report Out in September

The cancer “moonshot” panel charged with developing the White House initiative’s scientific agenda will release its recommendations in early September. David Arons, a member of the Cancer Moonshot Blue Ribbon Panel, said the group will deliver the findings from the past four months during the National Cancer Advisory Board’s Sept. 7 meeting. Amy Williams, acting director of the National Cancer Institute’s Office of Advocacy Relations, said she expects the report will be released publicly a few days after the NCAB’s meeting.

The early September projection is the most specific announcement yet about when the recommendations from the advisory panel—which the NIH formed in late April—may be coming out. During a teleconference involving another committee of the NCI, part of the National Institutes of Health, Arons indicated what topics and types of recommendations are likely to be in the report. If adopted by the NIH, the panel’s recommendations would eventually inform the types of grants the NIH will fund to support the initiative led by Vice President Joe Biden to double the rate of progress on cancer treatments and prevention.

Arons, CEO of the National Brain Tumor Society, made his remarks during an Aug. 21 teleconference meeting for an NCI advisory committee called the Council of Research Advocates. As both chairman of the research advocates committee and a member of the blue ribbon panel, Arons updated the research advocates council on the cancer initiative. The blue ribbon panel’s report is likely to cover specific topics such as clinical trials, include policy recommendations and provide recommendations on cross-cutting topic areas such as pediatric cancers and health-care disparities.

Final Rule to Expand Oversight of EHR Safety Expected Soon

A final rule to expand federal regulators’ authority to oversee electronic health record safety issues is moving closer to public release. The proposed rule (RIN 0955-AA00) would give the Office of the National Coordinator for Health Information Technology the ability to directly review federally certified EHRs and other health information technologies. Currently, the agency relies on a few designated organizations in the private sector that ensure certified EHRs are working properly.

The ONC currently authorizes several certified bodies, known as ONC-authorized certification bodies (ONC-ACBs), to certify EHRs for use by providers and hospitals in the meaningful use program. These ONC-ACBs are also responsible for ensuring that federally certified EHRs continue to meet certification requirements after they’re certified. However, the ONC-ACBs have limited resources and authority to address problems that arise when EHRs are connected to other health IT tools, such as other EHRs and clinical decisions support software, the ONC said in the proposed rule. Changes in EHR performance can cause serious safety issues, the ONC said.

The Office of Management and Budget Aug. 16 started reviewing the final rule, which would give the ONC the ability to respond directly to complaints that certified EHRs aren’t working as advertised or could pose a threat to patient safety, particularly when used with other health IT tools, according to the website.

CMS Seeks Info on Steering Patients to Health Plans for Higher Pay

The CMS wants information on the improper steering of Medicare and Medicaid patients by health care providers to Affordable Care Act plans to get higher reimbursements.

The Aug. 18 request for information (CMS-6074-NC, RIN:0938-ZB31) and letters to all Medicare dialysis facilities “focus on situations where patients may be steered away from Medicare or Medicaid benefits, which can among other concerns result in beneficiaries experiencing a disruption in the continuity and coordination of their care as a result of changes to their network of providers,” as well as cost more to the individual insurance market, the agency said in a release. Information was requested on “instances of problematic steering of consumers to individual market plans,” it said.

The issue involves third-party organizations that pay premiums and cost sharing for qualified individual health plans in the ACA marketplaces. Health insurers have fought against allowing the payments, arguing that they can pose a conflict of interest for the providers who stand to receive coverage payments, while the provider groups argue that allowing them to make the premium and cost-sharing payments provides needed care for patients.

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