Healthcare in America Post Election Analysis and Strategy in a Trump Administration Agenda Welcome: Carmela Castellano Garcia Overview and Facts: Burt Margolin & Angie Melton Threat Analysis: Andie Patterson Advocacy Plan: Andie Patterson Education: Ben Avey Closing: Carmela Castellano Garcia 2 1
WELCOME 3 Carmela Castellano Garcia President and CEO CaliforniaHealth+ Advocates 4 2
5 OVERVIEW AND FACTS 6 3
Burt Margolin President The Margolin Group Angie Buckingham Melton Vice President The Margolin Group 7 Facts (what we think we know) A Trump Administration represents the most serious threat to the health care safety net since Medicaid passage in 1965 All federal power in the hands of one party Far right nominee for HHS Secretary 8 4
But this is not a normal presidency... So it is impossible to confidently predict what will happen next. Will Trump delegate health to Pence/Price? Can the House and Senate work together? Will Trump stick to any of his campaign promises on health? 9 The Threat List Repeal of the ACA with an underfunded and ineffective replacement Attack the ACA s Medicaid expansion through a reduced federal match and a freeze on new states End Medicaid as an entitlement and convert to a Block Grant or Per Capita Cap 10 5
The Risk to PPS and Health Center Funding No current plan directly goes after PPS and Health Center Funding Long history of bi partisan support reflected in 2015 Primary Care Cliff victory But a major Medicaid overhaul could put PPS at risk. 11 Federal Budget Process Normal Year President s Budget February Budget Resolution April Discretionary Appropriations Hearings/Markups late spring/early summer Appropriations Bills on the Floor of House and Senate Summer Budget Reconciliation (if needed) Summer Appropriations Process complete by September 30 12 6
Likely 2017 Budget Process January 2017 FY 2017 Budget Resolution (Should have passed April 2016) January/February 2017 FY 2017 Budget Reconciliation February/March 2017 FY 2018 President s Budget April 2017 FY 2018 Budget Resolution April 2017 FY 2017 Continuing Resolution Expires, either new CR or Omnibus Appropriations for remainder of FY 2017 Spring/Summer 2017 Hearings/Markups/Floor Consideration FY 2018 Discretionary Appropriations Summer 2017 FY 2018 Budget Reconciliation By September 30, 2017 passage of FY 2018 Discretionary Appropriations 13 What is Budget Reconciliation? Budget Resolution (non binding) Framework for Mandatory and Discretionary Spending Can include reconciliation instructions to Committees to make mandatory budgetary changes Budget Reconciliation Produced by committees with jurisdiction over Mandatory programs Not passed every year Only needs 51 votes in Senate to pass Narrow focus on changes with budgetary impact Byrd Rule provisions ruled not germane by Senate Parliamentarian are struck from bill 14 7
115 th Congress Senate Dynamics 52 Republicans/48 Democrats Most legislation needs 60 votes to pass except: Congressional Review Act Budget Reconciliation Some Appointments 2018 election Democrats defending 25 seats, Republicans 8 5 Democratic Senators up for reelection from states where Trump won big: Manchin (WV), Donnelly (IN), Tester (MT), McKaskill (MO), Heitkamp (ND) 15 THREAT ANALYSIS 16 8
Andie Patterson Director of Government Affairs CaliforniaHealth+ Advocates 17 Big Picture ACA: Repeal/ Replace Republicans could repeal major portions of the ACA within the first 100 days in office Senate Democrats hold enough seats to prevent total repeal of the ACA Republicans could impact many provisions through the budget reconciliation process, and could affect any program with a federal fiscal impact Repeal without a replacement would cause significant harm to the safety net 18 9
Big Picture Medicaid Block Grants/ Per Capita Cap Block grants and caps appear to be the preferred method to operate Medicaid by new leadership Likely will take a while to construct / implement due to complicated nature of Medicaid Big challenge is determining how much each state gets Risk to Medi Cal that CA may not receive sufficient resources to maintain program as it is today Advocates remains optimistic that the FQHC program will be retained as a covered service requirement but strong advocacy will be necessary PPS rate/ or APM could be modernized in process though 19 Expansion and Marketplace Increased Federal Match for Medicaid Expansion Potentially back to 50/50 match State will have to decide if it wants to absorb the cost Could lead to more uninsured Individual Mandate Repealing is a top priority for Republicans Will need to develop alternative mechanism for stabilizing risk pool (in order to keep guaranteed issue) Likely to result in more uninsured Marketplace Subsidies Republican plans keep tax subsidies Subsidies no longer tied to buying on Exchanges Fate of Covered California unknown 20 10
330 Grants & Workforce FQHC/330 Grant Program Primary Care Fiscal Cliff (September 2017) NACHC leading campaign, CHCs have strong bipartisan support Losing 70% of base grant would have deleterious impact on CHC capacity to serve potentially larger uninsured population Workforce Funding National Health Service Corps, Teaching Health Centers, Area Health Education Centers Efforts geared towards maintenance Teaching Health Centers part of ACA, most at risk 21 Waivers FQHC Payment Reform in California Moving forward, CMS needs to approve SPA If block grants, value based payment more important than before APM could go statewide Section 2703, PCHH Likely to be zeroed out Unlikely state will absorb financial risk of entire program 1115 Waiver in California Potentially renegotiated or rescinded New programs ($7 billion funding) at greatest risk 22 11
340B, DACA, 1332 Waiver 340B unknown DACA Recipients Trump likely to overturn Obama s executive order Could result in more uninsured 1332 Waiver Trump administration not likely to approve 23 Reproductive Health Planned Parenthood Day one expectation that new administration will attempt to block Planned Parenthood from participating in Medicaid Severe ramifications for women s health Title X Likely attempt to dramatically alter program Less funding for Planned Parenthood and CHCs for reproductive health care FPACT If block grants, could be rolled in to a larger pot Would need to outwardly protect 24 12
Coverage and Plans Essential Health Benefits Likely to be repealed CA has standalone minimum requirements, but may be at risk if insurance is sold across state lines Providing Coverage via high deductible health plans and health savings accounts Enrollees could pay out of pocket for the full cost of health care until deductible is met HSAs provide tax advantages that mostly help the wealthy CHCs could see more patients on sliding fee scale Sale of Health Insurance Across State Lines Home state rules govern plan (not state they sell in) Could result in beneficiaries in plans with poor coverage Threat to local initiatives and county organized health systems 25 ADVOCACY PLAN 26 13
Andie Patterson Director of Government Affairs CaliforniaHealth+ Advocates 27 Advocacy Plan: 3 Phases Phase 1 Research, Learn, Communicate What we know Phase 2 Slow down Repeal/Replace ACA and Medicaid Block Grants Phase 3 Influence the ultimate plan in California 28 14
Research, Learn, Communicate Message Much unknown Desired actions by new administration include repeal and replace the ACA and Medicaid block grants Change, especially unknown change, offers opportunity 29 Research, Learn, Communicate Nov 9: CEO message acknowledging Trump administration and likely changes to health care Nov 17: CEO message with deeper allusions to suspected changes to health care and CPCA/Advocate s commitment to defend and advance clinics and health centers Nov 21: RAC message to members affirming commitment to defend and advance clinics and health centers Dec. 1: Advocacy Alert Value of health center letters 30 15
Research, Learn, Communicate Fact Sheets Fact Sheet Healthcare Policies to Understand November 23, 2016 Fact Sheet Immigrant Resources November 22, 2016 Talking Points General Talking Points November 14, 2016 Patient Talking Points November 23, 2016 DACA Recipient Talking Points (CCALAC) November 21, 2016 Communications and Messages CEO Message: Carmela Castellano Garcia November 17, 2016 Regional Association of California November 21, 2016 All resources can be found on the Advocates website: www.healthplusadvocates.org/healthcare_2017 31 Message Slow down Repeal/Replace, Medicaid Block Grants The Affordable Care Act has strengthened, enhanced, and begun to modernize the health care system in America Keep the building blocks of a program that has afforded new health care coverage to over 20 million Americans. Secure funding to community health centers that are the bedrock of Medicaid and the health home for almost 25 million people across the country. 32 16
Slow down Repeal/Replace, Medicaid Block Grants Research Block grants/per capita cap ACA impact on California ACA impact on FQHCs Impact of FQHCs in California Advocacy State/ Congressional letters from individual health centers Health centers conduct in district meetings Participate in HealthAccess Campaign to defend the ACA Work with NACHC to tell the health center story, build advocacy capacity in CA, and advocate to fix the fiscal cliff LTE/Op eds about the value of the ACA and health centers 33 Message Influence the Ultimate Plan Block grants and state flexibility must have a basic level of practical safeguards. FQHC covered services must remain a benefit. 34 17
Influence the Ultimate Plan Research FQHC implications in a block grant Necessary protections for patients, health centers, larger system Reimbursement mechanisms/ provisions critical to sustaining robust primary care Advocacy Build and partner with health care coalition in CA Develop framework for what elements Medi Cal must retain and elements that should be built Ensure adequate resources for clinics and health centers 35 Take Action Become a Health Care Advocate www.healthplusadvocates.org/become_an_advocate Utilize the resources we are building www.healthplusadvocates.org/healthcare_2017 Stay informed Weekly Update: Thursday Advocacy Alert: Thursday Government Affairs Update Call: Wednesday, 11 a.m. Dial in Number: 1 888 585 9008 / Conference Room: 616 822 842# 36 18
Take Action Current Advocacy Ask Letters to your representatives Congressional Republicans Congressional Democrats State Legislative Republicans State Legislative Democrats Health Center tours and visits NOW 37 EDUCATION 38 19
Ben Avey Assistant Director of External Affairs CaliforniaHealth+ Advocates 39 40 20
New Training Program CaliforniaHealth+ Advocates and Regional Associations of California Five part webinar training series, 60 minutes each. Dates TBD. No cost to health centers or individual consortia Learning Objectives How nonprofit organizations can legally advocate without jeopardizing their tax status or foundation funding; How to effectively and legally track and report advocacy activity; 501(c)(3) and 501(c)(4) organizations and how they can work together; and How to maximize advocacy in 2017 at the National and State level. 41 Resources Congressional Profiles State Legislative Profiles Fact Sheets & Templates www.healthplusadvocates.org Healthcare 2017 Upcoming Events Become an Advocate 42 21
Resources 43 NACHC ACES Campaign For America s Health Centers Website: www.saveourchcs.org Advocacy Center of Excellence (ACE) Program An Advocacy Center of Excellence, or ACE, is any Health Center that has achieved certain measures of advocacy success and demonstrated ongoing commitment to advocacy by making it an organizational priority. ACEs are not only actively engaged and involved with NACHC and federal policy issues, but also with their state s PCA and any key state level policy issues impacting Health Centers and their patients. There are three levels of ACE status Bronze, Silver, and Gold and the designation is valid for two years. There is a checklist of items a Health Center must complete before becoming an ACE. 44 22
NACHC Policy and Issue Forum March 29 April 1, 2017 Marriott Wardman Park Washington, DC The NACHC Annual Policy and Issues Forum (P & I) is the largest gathering of community health professionals. The P & I Forum is an opportunity for community health leaders to voice their perspectives to Members of Congress and offer constructive solutions to the issues at hand. Participants will also have the opportunity to hear from government officials, some of the nation s leading healthcare experts, and their peers. 45 May 3, 2017 California State Capitol Sacramento, CA Day at the Capitol CaliforniaHealth+ Advocates' 2017 Day At The Capitol is an annual event that welcomes physicians, clinicians, directors, and patients and health center advocates to Sacramento to engage with legislators and legislative staff about budget and legislative priorities impacting community clinics and health centers. 46 23
Carmela Castellano Garcia President and CEO CaliforniaHealth+ Advocates 47 48 24
QUESTIONS 49 Questions CaliforniaHealth+ Advocates (916) 503 9130 advocacy@healthplusadvocates.org www.healthplusadvocates.org Speakers Carmela@healthplusadvocates.org Andie@healthplusadvocates.org Ben@healthplusadvocates.org Bmargolin@margolingroup.com Amelton@margolingroup.com 50 25