Leadership Conference: Taking Charge of Change November 29, 2018
Agenda 1 Election s Impact on National Politics and Policies Election s Impact on State Politics and Policies Preview of the 2019 Legislative Session New York Alliance s Priorities/Strategies for Engagement Taking Charge of Change
Happy Thanksgiving 2
James William Donovan, Future Politician/Lobbyist 3
4 Election s Impact on National Politics and Policies
Congressional Election at a Glance 5 HOUSE SENATE Democrats: 235 (+40) Republicans: 53 (+2) Republicans: 200 (-36) Democrats (including 2 Independents): 47 (-2) Source: RealClearPolitics as of November 14, 2018, available at: https://www.realclearpolitics.com/elections/live_results/2018/senate/
2018 Midterm Elections Significantly Impact Health Policy, Federally and Within States 6 A New House Means a Shift in Health Care Priorities Limited, bipartisan federal legislation that make some drug pricing changes and bolster popular ACA provisions are possible States Remain at the Forefront States will remain the drivers of new ideas; increased one-party control in state government will be significant for health policy, particularly Medicaid Courts and the Executive Branch Will Have a Say The Trump Administration and the courts will continue to put their stamp on health policy Four key areas will dominate health care debates federally and at the state level in coming years: Medicaid Individual Market Health Reform Drug Pricing
Key Takeaways 7 A divided Congress has no path forward for major proposals including Republican ACA repeal and replace, entitlement reform and Medicare for All Amidst 2019 budget pressures, Congress will need to find common ground on select issues Democrats will use majority to set the House agenda and intensely investigate Trump Administration actions this oversight could impact the White House s willingness to partner with House Democrats, even on mutual priorities
What I m thankful for 8 Right to Vote
Budget Caps a Platform for Bicameral Negotiation? 9 The Budget Control Act (BCA) will trigger automatic spending cuts in FY 2020 if Congress does not pass and the President does not sign legislation that reduces the federal deficit Congress will have three options: 1. Lift the budget caps; 2. Extend the budget caps; and/or 3. Find $126 billion in offsets (to fund FY 2020 alone) Offsets may be discretionary or mandatory Timing: Jan. Feb. March April May June July Aug. Sep. Oct. Nov. Dec. Congress will aim to reach agreement before starting FY 2020 appropriations FY 2020 begins Current BCA cap relief expires
Prospects for Health Care Legislation Possible but Slim 10 A Democratic House will overwhelm the Administration with oversight hearings and investigations; but, there may be select areas of agreement Oversight/ Investigations House-led and GAO investigations will focus on health care issues like: Medicaid coverage waiver approvals (e.g., work requirements, premiums, lock-outs) and rulemaking (e.g., public charge rule) Policy changes that undermine health coverage for people with preexisting conditions (e.g., AHPs, short-term plans, 1332 waiver guidance) Select Issues with Bipartisan Potential Democrats and Republicans may work together to pass legislation on select issues, including: Drug pricing Marketplace improvements, especially restoring federal reinsurance Price transparency (for providers, insurers, pharmaceutical manufacturers)
Key House Committees for Health Policy 11 Jurisdiction Likely New Chair Ways & Means Tax, Medicare Richard Neal (MA) Health Sub: Lloyd Doggett (TX) Energy & Commerce Education & Workforce Medicaid, Public Health, Private Insurance Employer Coverage Frank Pallone (NJ) Bobby Scott (VA) Reps. Pallone, Scott, and Neal recently introduced legislation to eliminate the caps on ACA tax credits, halt AHPs, and bolster ACA protections (like EHBs) Appropriations Discretionary Spending Nita Lowey (NY) Budget Allocations John Yarmuth (KY) Oversight & Government Reform Government Oversight Elijah Cummings (MD) Cummings will lead the way in investigations of the White House. During 115 th, he requested at least 64 subpoenas that the majority rejected.
Administration Maintains Control of Regulatory Authority 12 A Democratic House will put pressure on the executive branch, but will have limited means to stop administrative actions The executive branch has the authority to set policy through regulations and administrative authorities like state waivers Regulations are generally not subject to legislative roadblocks and are a crucial policymaking lever in a polarized political environment Under the Congressional Review Act, Congress can overturn an agency rule within 60 legislative days of release with a simple majority vote but it is subject to the President s veto
The Judiciary May Thwart Administrative and Legislative Actions 13 The courts will weigh in, even as the Trump Administration continues judicial appointments without challenge given Senate control Individual Market / ACA The court continues to work through lawsuits challenging major Marketplace initiatives, like cost-sharing reductions, risk corridor payments, and the federal risk adjustment methodology In Texas v. U.S., twenty Republican-led states are challenging the constitutionality of the ACA; similarly, states and advocacy groups are filing lawsuits in support of the ACA and against Administrative changes Medicaid Medicaid coverage waiver provisions, such as work requirements, are already facing legal challenges and the battle will continue Drug Pricing Lawsuits about state price transparency laws will continue and new lawsuits about federal Administrative action are likely
What I m thankful for 14 Checks and Balances
Governorships: Republicans Win 20, Democrats win 16 15 Washington Oregon Montana North Dakota North Dakota Minnesota Vermont Maine Nevada California Idaho Utah Arizona Wyoming Colorado New Mexico South Dakota Nebraska Kansas Oklahoma Wisconsin Michigan Iowa Indiana Ohio Illinois Missouri Kentucky Tennessee Arkansas West Virginia North Carolina North Carolina South Carolina New York Pennsylvania Connecticut New Jersey Delaware DC Maryland Virginia New Hampshire Massachusetts Rhode Island Georgia* Alaska Hawaii Texas Louisiana Mississippi Alabama Florida* Republican Governor (20) Democratic Governor (16) No Election in 2018 (14) Party Flip (8) Post-election Breakdown: Republicans 27-Democrats 23
36 States are Controlled by a Single Party 16 Before Midterm Elections After Midterm Elections 8 states 14 states Democratic Trifecta 25 states 22 states Republican Trifecta* 16 states 13 states Split Control *Does not include Nebraska, which has a unicameral/nonpartisan legislature
Voters in Three Red States Passed Medicaid Expansion Ballot Initiatives 17 Idaho Governorelect Brad Little (R) says he will respect the referendum Idaho Utah Montana Nebraska Montana s ballot initiative to permanently fund its Medicaid expansion via a tobacco tax failed; the legislature will be asked to fund the program past July 2019 Utah s referendum for a full ACA expansion triumphed over State partial expansion legislation that includes work requirements The Nebraska referendum (which has already withstood litigation in the State) does not include a specific funding source; Nebraska Governor Pete Ricketts (R) says he will respect the vote, but opposes funding the program with tax increases Expanded Medicaid Has Not Expanded Medicaid
Spotlight States Illustrate the Election s Impact on Health Care Policy 18 California: Poised to lead progressive reforms, but will face fiscal challengesny California Michigan, Wisconsin, and Kansas: New Democratic governors will alter states Medicaid initiatives Kansas Wisconsin Michigan Maine: Democratic trifecta means Medicaid expansion will move forward, other reforms possible New York Maine New York: Single payer, nurse staffing ratios, reproductive health on the table New Mexico New Mexico: Potential to be national leader with Medicaid Buy-In
Other States to Consider 19 Republican Trifectas Seeking to Redirect Some Subsidies Off-Marketplace Idaho: Interested in approving underwritten plans without a 1332 waiver; would test whether such plans substantially comply with ACA Iowa: Potential to refile 1332 waiver that shifts subsidies toward off- Marketplace coverage and tests limits of new federal 1332 guidance Split Control States Seeking Bipartisan Solutions Minnesota: Democratic governor will seek to expand MNCare with split legislature Pennsylvania: Democratic governor will aim to strengthen Marketplace with Republican legislature
California: Aspirational, but Tempered by Fiscal Prudence 20 AT A GLANCE 7.2% Uninsured Expanded Medicaid State-based Marketplace Governor: Senate: House: Gavin Newsom 28 D 12 R 57 D 23 R Dynamics: The legislature will propose a progressive healthcare agenda, requiring Newsom to weigh State budget constraints Newsom will look for incremental coverage gains over single payer proposals Newsom campaigned on: Moving the State s Medicaid whole person comprehensive care pilots focused on the coordination of health, behavioral health, and social services, into a long-term solution that addresses issues like homelessness Building on Covered California s active purchaser approach to drive delivery system reform Source: National Conference of State Legislatures, updated November 9, 2018, available at: http://www.ncsl.org/portals/1/documents/elections/legis_control_110918_26973.pdf
What I m thankful for 21 Federalism
22 Election s Impact on State Politics and Policies
Governor s Office 23 With Governor Cuomo returning to Albany for his third term as Governor, we expect that many of the key staff persons in charge of health and mental hygiene issues will remain the same. Paul Francis, Deputy Secretary to the Governor for Health and Human Services Shelly Weizman, Assistant Secretary to the Governor for Mental Hygiene Megan Baldwin, Assistant Secretary to the Governor for Health Axel Bernabe, Assistant Counsel to the Governor for Health
Attorney General 24 After Attorney General Eric Schneiderman was forced to resign, Barbara Underwood was appointed to complete his term. This fall, Letitia (Tish) James won the Democratic primary and the general election and will assume the position of Attorney General in January. Ms. James becomes the first woman in New York to be elected as Attorney General, the first African-American woman to be elected to statewide office and the first African-American person to serve as Attorney General. Key role in supervising not-for-profit organizations, overseeing Medicaid Fraud Control Unit, defending state agencies and enforcing consumer and healthcare laws.
New York State Senate 25 Democrats win their most substantial Senate Majority in a century January 2018 January 2019 31 Republicans 23 Democrats Senator Felder 8 IDC 39 Democrats 23 Republicans Senator Felder
Makeup of the new New York State Senate The Democratic Majority consists of two surviving members of the IDC and 15 new members, including six who defeated IDC members in primaries. Democrats Republicans 26 Returning Democrats Returning Republicans Former IDC Senator Felder New Members
New York State Assembly 27 Democrats continue to retain strong control of the Assembly with 107 members. A new Majority Leader will be named to replace Joe Morelle who won election to Congress, which could lead to some committee changes. While there may be some jockeying over committees, those of relevant interest will likely remain the same. Carl Heastie Speaker of the Assembly Assemblywoman Aileen Gunther Chair of the Committee on Mental Health Assemblyman Richard Gottfried Chair of the Committee on Health
What I m thankful for 28 Living in a State with a heart
29 Preview of the 2019 Legislative Session
Issue of interest: Medicaid and Managed Care Transition 30 While the legislature has generally taken a back seat to the Executive in administration of the Medicaid program, there are still significant negotiations over budget and policy. The budget generally involves significant negotiations over the Medicaid budget and various programmatic changes proposed by the Executive. This year, we suspect the following issues will be central to budget negotiations: Increased costs associated with pharmacy and long term care benefits The children s transition The OPWDD transition The Alliance will also need to engage the regulators on implementation of various changes to the Medicaid program, with special focus on the implementation of managed care in OPWDD system and the continued need for investment in managed care readiness. Should also pay close attention to the future of integrated care link between Medicare and Medicaid in post-fida era.
Issue of interest: Single payer 31 A single payer healthcare proposal has been endorsed by virtually all Democratic legislators, but its cost and other implications has made Governor Cuomo skeptical. New York Health Care Act (S.4840/A.4738) A tax supported insurance plan for all New Yorkers (called New York Health) funded by payroll taxes plus taxes on certain income. All Medicare and Medicaid coverage would be delivered through New York Health, pursuant to (unlikely) federal waivers and agreements DOH would pay all claims and there would be no role for health plans (although the bill does not prohibit not-for-profit plans from serving as care coordinators) The debate may lead to consideration of other coverage expansion proposals, such as: A state-only individual insurance mandate or other approaches to stabilizing the individual insurance market Expanding eligibility for coverage to uncovered groups, including immigrants Price transparency in healthcare Pharmaceutical cost containment The Rand Study found: The bill would result in large shifts in the types of payments people make for healthcare tax payments vs premiums/out-of-pocket payments The additional state tax revenue needed to fund the program in 2022 would be $139 billion, a 156% increase Highest-income households could pay substantially more while lower-income households could pay less
Issues of Interest: Workforce 32 The Governor s office has already indicated that workforce issues may be a significant part of its 2019 State of the State and program Addressing the need to retain a highly qualified workforce both upstate and down to meet the needs of the 21 st Century will be a key theme AI threat/opportunity and critical health and human services workforce needs will be at the top of the list The New York Alliance and the I/DD field can be the poster child for the need for a thoughtful workforce policy Continued advocacy for the direct care workforce will be necessary to preserve and enhance gains Focus on credentialing and professionalization of workforce
Issues of Interest: Telehealth 33 The SFY 18-19 Budget made several changes aimed at increasing coverage of telehealth services by Medicaid, including: Eliminating the restrictions on the originating site (i.e. the location of the patient) Requiring DOH, OMH, OASAS and OPWDD to issue a consolidated guidance document explaining the various rules for coverage across all agencies OPWDD issued Emergency Regulations last summer to comply with State telehealth policies: New regulation confirms that Medicaid payment will be made for clinical services to clients at their residences or other temporary location from an OPWDD certified clinic or satellite site Assessment, diagnosis, consultation, treatment, education, care management and/or selfmanagement (but not IPSIDD) services may be provided via telehealth
Issues of Interest: Reproductive Health/Maternal Mortality 34 Reproductive Health Proposal to codify Roe v. Wade and otherwise update State s laws governing abortion has stalled in the Republican Senate and is poised for quick passage next year Appointment of Justice Brett Kavanaugh and potential for re-examination of Roe makes issue particularly timely In addition, proposals that would strengthen existing ACA and State law mandates governing coverage of contraception are also likely to be considered Maternal mortality & depression As a result of New York s high maternal mortality rates, the Governor has convened a taskforce on maternal mortality, which will submit proposals for addressing maternal mortality in advance of the upcoming legislative session. OMH s Project TEACH program is designed to help health care providers to diagnose and treat maternal depression across the state. While these conditions are treatable, a pediatric primary care provider or family practice doctor may not have access to the consultation or training needed to help. OMH has also opened its first state-operated intensive outpatient clinic program, focused on maternal depression, to ensure women have access to crucial screenings.
Issues of Interest: Responses to the Opioid Epidemic 35 We should expect both the Legislature and the regulators to continue to advance new responses to the opioid epidemic, including: Increased funding that could be used for: Data collection to better identify and investigate high-volume opioid prescribers Training for providers who; treat substance use disorders, provide pain management and treatment First responders for access to Naloxone and resources to go after drug dealers who sell substances that result in death Potential for additional insurance mandates and reforms New models of treatment, including safe injection facility sites where people can use drugs in a controlled environment with staff who have access to and are trained in the use of Narcan
Issues of Interest: Marijuana 36 Democrats have identified legalization of adult use marijuana as a significant priority for the upcoming session. Adult use marijuana The Governor convened a task force looking at legalization of marijuana for adult use, which is apparently preparing a legislative proposal. The Governor has been holding listening sessions across the State. Both the Senate and Assembly have also been conducting hearings on legalization and Senate Democrats seem committed to it. Medical marijuana Since legalization of medical marijuana occurred in 2015, there have been a number of changes to aimed at expanding the program and this trend is likely to continue. Most recently, any condition for which an opioid could be prescribed as a qualifying condition for medical marijuana Proponents of the medical marijuana program have indicated that they will be seeking to protect the program from any disruption that might be caused by legalization of adult use marijuana.
37 New York Alliance s Priorities/Strategies for Engagement
Policy Priorities 38 The New York Alliance for Inclusion and Innovation Priorities for 2019 include: Managed Care Readiness and Transition, including: Continuation of MCCOP/Provider Technical Assistance Funding New investments in Technology Infrastructure Workforce, including: bfair2directcare/living Wage/Cost of Living Adjustment Other benefits/incentives, including tuition, housing, healthcare support, childcare, etc. Credentialing High Needs/Complex Populations Justice Center Housing Policy Issues, including Wrap-around supports/medication Administration Tax incentives/loans for housing development Unfunded Mandates
Strategies for Engagement 39 Significant changes in Legislature, including many new members, will require the Alliance to re-introduce itself and to aggressively engage policy makers on key issues. The Alliance should maintain its leadership role in advancing issues relating to the I/DD-related workforce, through engagement in the Bfair campaign The key mission of the Alliance in the immediate future will be to continue to be a key resource for managed care readiness for the I/DD community The Alliance should aggressively identify other issues and areas where it wishes to be a thought leader on key state priorities and consider advancing proactive approaches to these issues The Alliance should continue to participate in coalitions when that is most productive and continue to advocate in its own right on other issues
Strategies for Engagement 40 Significant changes in Legislature, including many new members, will require the Alliance to re-introduce itself and to aggressively engage policy makers on key issues. The Alliance should maintain its leadership role in advancing issues relating to the I/DD-related workforce, through engagement in the Bfair campaign The key mission of the Alliance in the immediate future will be to continue to be a key resource for managed care readiness for the I/DD community The Alliance should aggressively identify other issues and areas where it wishes to be a thought leader on key state priorities and consider advancing proactive approaches to these issues The Alliance should continue to participate in coalitions when that is most productive and continue to advocate in its own right on other issues
Strategies for Engagement 41 Encourage membership to develop stronger relationship with their elected officials Set up in person meetings with the local legislators in the district offices; Ensure that local legislators are invited to any appropriate events; Identify themselves as information resources on issues of concern to legislators Participate in budget and other policy advocacy lobbying days Identify potential champions in both houses and on both sides of the aisle to cultivate as leaders on our issues Maintain and strengthen relationships with legislative leadership, committee chairs, central legislative staff
42 Taking Charge of Change
Transitions can be scary 43
The inevitability of change 44 When you are finished changing, you're finished.
What I m thankful for 45 The mission and soul of the organization