Shaping policy, sharing solutions, strengthening communities

Shaping policy, sharing solutions, strengthening communities

What s Happening on the Federal Front? A National Perspective Presenter: Katherine Berland, Director of Public Policy American Network of Community Options and Resources Ohio Centers for Intellectual Disabilities Summit August 24, 2017

ANCOR is A national nonprofit trade association advocating and supporting Over 1,300 private providers of services and supports to Over 800,000 people with disabilities and their families And employing a workforce of over 600,000 direct support professionals (DSPs) and other staff Membership benefits include robust government relations representation at federal level and access to exclusive ANCOR content, as well as exclusive discounts on technology and I/DD products through the ANCOR marketplace.

Inside the Beltway: What s Going on in DC? 4

Inside the Beltway: What s Going on in DC? The 115 th Congress Takes Hold: House of Representatives Speaker of the House Paul Ryan (R-WI) Minority Leader Nancy Pelosi (D-CA) 194 (+7) 241 (-5) 5

Inside the Beltway: What s Going on in DC? The 115 th Congress Takes Hold: Senate Majority Leader Mitch McConnell (R-KY) Minority Leader Chuck Schumer (D-NY) 46 (+2) 52 (-2) (2 independents) 6

Outside the Beltway: What s Going on in the States? 7

Inside the Beltway: What s Going on in DC? Appointment: Secretary of Labor Alexander Acosta Dean of Florida International University College of Law Former U.S. Attorney for the Southern District of Florida Appointed to NLRB, DOJ by President George W. Bush Sided against unions in several cases Pledges to streamline DOL per President Trump s budget plan Sworn in on April 28, 2017 8

Inside the Beltway: What s Going on in DC? Appointments: Health and Human Services Tom Price Secretary, HHS Served as U.S. Representative for GA s 6 th District Former Chair of House Budget Committee Sworn in on February 10, 2017 Seema Verma Administrator, CMS Founder/CEO of SVC Inc., health policy consulting Instrumental in crafting Healthy Indiana Plan, other state Medicaid plans Sworn in on March 14, 2017 Brian Neale Director, CMCS Former healthcare policy director for Mike Pence Worked with Pence, Verma on Healthy Indiana Plan 9

Inside the Beltway: What s Going on in DC? The Federal Budget Process Agencies submit budgets for review President proposes FY2018 budget (5/23/17) Congress reviews POTUS budget, proposes FY2018 budget (7/18/17) House and Senate approps committees markup and vote on budgets Conference committee to finalize budget; Congress approves omnibus President signs into law Reconciliation instructions? 10

Inside the Beltway: What s Going on in DC? The Federal Budget Process Upcoming Budget Fights: Debt Ceiling Tax Reform Health Care Reform? 11

Inside the Beltway: What s Going on in DC? Affordable Care Act on Day 1 On January 20, President Trump issued his first Executive Order, directing government agencies to scale back as many aspects of the ACA as possible. This permits agencies to delay, waive, or refuse to enforce provisions of the ACA prior to repeal by Congress. 12

Affordable Care Act Repeal and Replace: What the heck is happening?

January 4: January 20: March 6: March 13: March 24: April 25: May 4: June 22: June 26: July 11: July 19: July 20: July 25: July 26: July 27: ACA Repeal & Replace A Timeline (2017) Senate resolution to repeal the ACA through budget reconciliation President Trump signs Executive Orders on ACA enforcement House introduces American Health Care Act (AHCA) CBO releases AHCA score AHCA withdrawn from House floor MacArthur amendment introduced House passes AHCA Draft text released in Senate (BCRA) CBO releases BCRA score August recess delayed CBO releases ORRA score CBO released revised BCRA score Senate moves to proceed, introduces BCRA with Cruz amendments Senate vote-o-rama begins All versions fail to gain needed votes

American Health Care Act (AHCA) Deep Medicaid cuts ($834B) Per capita caps Fixed growth rate stays at CPI-M+1 Eliminates Medicaid expansion Removes EHB protections Eliminates CFCO 23 million people lose coverage Status passed the House 5/4/17 ACA Repeal & Replace Better Care Reconciliation Act (BCRA) Deep Medicaid cuts ($756B) Per capita caps Growth rate starts at CPI-M+1, then drops to CPI-U Eliminates Medicaid expansion Removes EHB protections Replaces CFCO with 4 year waiver for certain states 22 million people lose coverage Status : Failed (43-57) Obamacare Repeal Reconciliation Act (ORRA) No per capita caps Repeals ACA Eliminates Medicaid expansion Removes EHB protections Eliminates CFCO 32 million people would lose coverage Status: Failed (45-55) Health Care Freedom Act (HCFA) (aka skinny repeal ) Repeal individual & employer mandates, tax on medical device companies Allows states to opt out of some ACA regulations., so long as people are covered at same levels 16 million people would lose coverage Status: Failed (49-51)

Medicaid Reform Block Grants and Per Capita Caps Current System Block Grants Per Capita Caps Open-ended entitlement, federal match of state funds (50 73%). Federal contribution State spending Medicaid program must cover certain populations and meet certain requirements to qualify for funding. Set dollar amount allocated to states based on as-of-yet undetermined criteria. Regardless of the level of state spending, states receive a fixed pot of money. Any shortages are the responsibility of the state. Lower state spending Higher state spending Fixed level of federal funding Fixed dollar amount allocated per person eligible for Medicaid. Fewer enrollees More enrollees Less federal funding More federal funding Most capitated proposals do not tie payment increases to actual cost increases.

Medicaid Reform Block Grants and Per Capita Caps Source: Avalere Health

ACA Repeal & Replace What s next? Cost-Sharing Subsidies: President Trump has said he may discontinue the payments, but as of August 2017 they are continuing Problem Solvers Caucus: About 40 centrist House members formed a bipartisan working group and recommended changes to the ACA (e.g. changing definition of large employer, 40 hour workweek, continuing cost-sharing subsidies) HELP Committee: Plans to hold bipartisan hearings in September focusing on stabilizing individual market

ACA Repeal & Replace What s next? Senate HELP Committee 19

ACA Repeal & Replace What did we do? ANCOR led grassroots advocacy efforts by: Organizing the first major Hill rally on Medicaid, featuring Senators and hundreds of advocates on Capitol Hill Leading Hill days and developing an advocacy toolkit to assist with conducting in-district visits Responsible for 6,774 advocates delivering 21,901 messages to Congress

ACA Repeal & Replace What s the plan? Expect that Medicaid will continue to be on the table during future health care reform and tax reform conversations. ANCOR s Save Our Services (SOS) campaign will keep up grassroots advocacy.

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CMS Home and Community Based Settings Rule Price/Verma Letter A letter sent on March 14 to Governors: Characterizes current Medicaid program as outdated, rigid and full of burdensome federal rules Asserts HHS commitment to streamlined approval of 1115 demonstrations that innovate around training, employment, and independence Suggests state-led reforms that could made including cost-sharing, HSA-like programs, and premium payments Suggests extension of HCBS implementation deadline (later extended by three years) Suggests states may get more flexibility in making heightened scrutiny determinations 23

CMS Home and Community Based Settings Rule Guidance issued on May 9: Extends compliance deadline for HCBS rule by three years, to March 17, 2022 Does not extend planning period, saying: [S]tates should continue progress in assessing existing operations and identifying milestones for compliance that result in final Statewide Transition Plan approval by March 17, 2019. Does not change requirement that new settings must come into the HCBS program already in compliance CMS has not indicated that the rule will be rescinded Priority on avoiding unintended consequences Current Status: 35 Initial Approvals (incl. OH), 4 Final Approvals 24

DOL Overtime Exemption Rule Finalized: May 23, 2016. Purpose: To update the white collar exemptions threshold which had not been updated since 2004 Key Provisions: $47,476/year ($913/wk) salary threshold for white collar exemptions (40 th percentile of lowest-wage Census region salary data) $134,004/year salary threshold for highly compensated employees (90 th percentile of national salary data) Update every 3 years, beginning January 1, 2020 No changes to the duties test Time-limited non-enforcement policy for certain Medicaid IDD providers 25

DOL Overtime Exemption Rule Legal challenge: On September 20, 2016 twenty-one states, chambers of commerce, and other industry groups filed suit challenging the rule. District Court: On November 22, 2016, a federal judge issued a preliminary injunction against the rule, effectively suspending it nationwide. DOL asked that the injunction be suspended pending appeal, but was denied. Future of the Rule: In a brief filed with the court on June 30, the Trump administration indicated that it intends to revise the rule and will not defend the current threshold. On July 26, DOL issued an RFI seeking public comments on the rule in preparation for new rulemaking. 26

DOL Overtime Exemption Rule Request for Information: On July 26, DOL issued an RFI seeking public comments on the rule in preparation for new rulemaking. Comments are due September 25, 2017. DOL has asked for input on several areas, including: Inflation rate Multiple salary levels based on employer size/location Use of the long/short duties test Relationship between salaries and duties Employer action based on 2016 rule Moving to duties-only criteria 27

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ENACTED: 21 st Century Cures Comprehensive Funding Package for Medical Research (enacted December 13, 2016) Research and drug development $1B in state grants to fight opioid epidemic Expedited FDA drug approval process Informed consent waivers $4.8B to NIH for medicine and biomedical research ($1.5B for brain disease, $1.8B for cancer moonshot ) Behavioral health Strengthens mental health parity regulation Requires insurance companies to cover mental health treatments to same extent as medical treatments Grants for community mental health resources (suicide prevention, de-escalation training for LEOs) Electronic Visit Verification (EVV) Imposes penalty in the form of FMAP reduction for states that do not implement EVV by certain dates Personal Care Services:.25% in 2019 1% after 2023 Home Health Services:.25% in 2023 1% after 2027 29

ENACTED: 21 st Century Cures What is Electronic Visit Verification? EVV documents the type of service performed, the individual receiving the service, the date of the service, the location of service delivery, the individual providing the service, the time the service begins and ends. States must engage with stakeholders to ensure their EVV system is minimally burdensome, takes into account existing best practices, meets HIPAA requirements, includes public input. States that have already enacted or are in the process of implementing EVV systems will not be penalized so long as there is a good faith effort to comply with the EVV requirements. Unavoidable system delays will also be taken into consideration when assessing penalties. For more information, check out ANCOR s 21 st Century Cures/EVV webinar series! 30

INTRODUCED: The Save Local Business Act Introduced by Representative Bradley Byrne (R-AL) on July 27 Would amend National Labor Relations Act (NLRA) and the Fair Labor Standards Act (FLSA) to: Clarify that significant control over essential working conditions must be exerted by business to be considered a joint employer Directly responds to NLRB decision in Browning- Ferris case which held that indirect control was sufficient to establish joint employer status 31

HHS OIG Reports The Office of the Inspector General (OIG) (within the Department of Health and Human Services) has issued reports on abuse and neglect of individuals with IDD in communitybased group homes in three states: Connecticut, Massachusetts, and Maine Investigations focused on whether potential abuse, neglect, or rights violations are reported appropriately, and whether critical incidents are reviewed and analyzed with reporting to law enforcement as appropriate. OIG intends to continue investigations in all regions of the U.S. 32

PENDING: DD Improvement Act Currently being developed by Sen. Chris Murphy (D-CT) ANCOR continues to work with office to provide input In response to OIG reports showing incidents of death/abuse of individuals with IDD Would create uniform definition of critical incident that must be reported Would create federal law for who is a mandatory reporter of critical incidents Would create mandatory online training curriculum on abuse and neglect 33

On Our Radar 34

ANCOR Report: Addressing the Disability Workforce Crisis of the 21st Century Recommendations: Continue work at the state level to ensure sufficiency of rates Need additional visibility for workers and the value they add Provide tools and training for supervisors Utilize technology Think creatively about how to expand workforce Urge BLS to create new classification for DSPs 35

Workforce Recommendation: New BLS SOC for DSPs The Goal: To get the Bureau of Labor Statistics within Department of Labor to create a new Standard Occupational Classification for Direct Support Professionals. Why We Need It: BLS collects data that is relied on by policymakers nationwide. DSP data is not captured in its own category, and other SOCs (e.g. home health aides, nursing assistants) do not give us a full and accurate picture. What We re Doing: Formal request to BLS, testimony at state and federal levels to urge DOL to create SOC, outreach to Congressional offices, reaching out to Governors to enlist their help 2017 Direct Support Professional Resolution: Will include language advocating the creation of a SOC 36

Life Safety Code ANCOR has become more involved in LSC issues at the federal level in recent years: Led a workgroup and submitted comments in advance of June 2016 final CMS rule Participated in working group with national organizations focused on ensuring balance between safety and independence Provides technical assistance to members regarding application of federal laws and regulations to state and local jurisdictions 37

Questions?

Upcoming Events 2017 ANCOR Leadership Summit September 18-19, 2017 The Dupont Circle Hotel Washington DC 2018 ANCOR Annual Conference April 15-17, 2018 Sheraton New Orleans New Orleans, LA

Contact Information Katherine Berland, Esq. Director of Public Policy kberland@ancor.org (703) 535-7850, ext. 104