Inside the Beltway - December 2019 - NAPNAP

Inside the Beltway – December 2019

Leveraging Individual Voices in the Electoral Process to Make a Difference

Contributed by: Health Policy Committee Member Linda Zekas, MSN, MJ, APRN, NNP-BC, CPNP-PC, CWON

As 2019 comes to a close, it seems the perfect time to discuss the responsibility that advanced practice providers (APPs) have to leverage their individual voices to effect positive change for both our profession and the patients we serve. One of the most impactful ways to accomplish this is to participate in local, state and federal elections. Elections can potentially impact rules and regulations (local), Medicaid and nurse practice acts (state), and the Affordable Care Act (federal). Electing a candidate who understands child health and/or nursing and best represents our interests can make a difference when it comes time for each of us to advocate for policy change concerning our patients and profession.

In order to cast your vote in an informed way, educate yourself on the electoral processes in your district and state. The most elemental step is making sure you are registered to vote in your state’s primary and general elections by the deadline. Use multiple sources to learn about individual candidate’s positions on health care related issues. It is important to not rely on social media or any single news source. You should evaluate a variety of reliable sources to find common truths. If you can, attend town hall events to ask candidates about child health positions/issues because you may have an opportunity to ask targeted questions not otherwise covered in a candidate’s position statement. An added benefit of these types of events is being able to educate the candidate (and other attendees) regarding child health issues. Ultimately, common sense should be the rule.

Don’t skip an election because you question your political efficacy (e.g. will my vote make a difference?). The best way to ensure that your vote will make a difference is to educate yourself and dive in! Remember, knowledge is power.

Professional organizations, including NAPNAP, are great resources regarding key professional issues. Use NAPNAP’s health policy agenda  to guide your research into candidates’ positions or visit our Advocacy Center to view key legislation for child health and practice issues. Local and state candidates are often easier to meet and get to know due to the benefits of geography, but don’t miss your chance to meet federal candidates when they are in your district. During election years, Congress has many recesses so senators and representatives can visit home districts. Try to cultivate a relationship with candidates early to understand their views and establish yourself as an expert in the field of child health.

While you may feel your individual vote impacts the local and state levels more, the upcoming 2020 presidential election also represents an opportunity to make your voice heard. As we’ve seen in recent elections at all levels of government, the ballot counts between leading candidates can be very close so every vote counts.

NAPNAP’s Advocacy for Immigrant Child Health

Contributed by: NAPNAP President Rajashree Koppolu, RN, MSN, CPNP, MSL

NAPNAP’s leaders continue to address health issues faced by immigrant children. As always, NAPNAP’s conversations are evidence-based and non-partisan, with the hope of gaining a better understanding of how we may be helpful in sharing the perspective of advanced practice pediatric nursing. We appreciate the importance of data collection to better inform the care needed. We advocate for the services of pediatric-trained providers who can provide screening and treatment services and be aware of pediatric mental health and developmental concerns. We emphasize the evidence of adverse childhood experiences and how assessment of early trauma is critical to supporting the health and well-being of children, specifically those separated from their families. In our meetings with government and organizational leaders, we discuss the importance of safe and sanitary conditions and the appropriate use of medications. We encourage clear and transferrable documentation be available to help support the healthcare of children in the community. We advocate for clear guidance and oversight to ensure that developmentally-appropriate and trauma-informed services are provided.

Leaders are seeking NAPNAP’s voice and experts for thoughts, ideas and perspectives. We will continue to keep members on the forefront of this issue and many others impacting child health.

Administration Wavers While Congress Advances E-Cigarette Limits

As Congress takes action to raise the age to legally purchase tobacco products as part of a year-end appropriations agreement (see related story), the Trump administration appears to be wavering on the President’s September promise to issue regulations prohibiting the sale of flavored e-cigarettes. Officials said Dec. 3 that Trump would soon be presented with “some options” on how to proceed with the planned regulations after being told that it could eliminate thousands of small-business jobs and anger voters. A Nov. 22 White House meeting involving e-cigarette advocates and anti-tobacco activists erupted in shouting and debate as the President appeared to backpedal from his previous pledge.

The issue also confronted Dr. Stephen Hahn, confirmed by the Senate Dec. 12 as the new commissioner of the Food and Drug Administration, who refused to commit to stronger e-cigarette regulations during his Nov. 20 confirmation hearing.

On Nov. 19, the House Energy and Commerce Committee voted mostly along party lines to advance the “Reversing the Youth Tobacco Epidemic Act of 2019” (H.R. 2339), a sweeping ban on flavored tobacco including vaping products, raising the purchasing age to 21 nationwide, and prohibiting online sales in an effort to curb teen tobacco use. Three Democrats broke with their party to vote against the bill, citing concerns about banning the sale of menthol products.

Courts Opinions Differ on Administration Immigration Policies

The U.S. Supreme Court’s conservative majority appeared willing to allow the Trump administration to shut down the Deferred Action for Childhood Arrivals or DACA program during Nov. 12 oral arguments on three cases challenging the administration’s actions. While the justices were sympathetic with the 700,000 “Dreamers” in the program and their families, schools and employers who relied on it in good faith, conservatives implied that they wouldn’t second-guess the administration’s reasoning and considered its explanations adequate. A ruling is expected by early next year, at the latest. Elimination of the program would put additional pressure on Congress to come up with a compromise on immigration reform, although reaching an agreement in the midst of an election year would be difficult.

A three-judge panel of the federal 4th Circuit Court of Appeals rule Dec. 9 lifted a lower court injunction blocking the enforcement of the Homeland Security Department’s regulations on determining if immigrant are considered a “public charge” based on their use of federal benefits, following a similar stay issued by the 9th Circuit Court of Appeals. However, the regulations still can’t take effect because of a separate nationwide injunction imposed by a New York federal district judge and under review by the 2nd Circuit Court of Appeals. If the New York appellate court also lifts the injunction, steps could be taken to implement the “public charge” policies while cases are appealed to the Supreme Court.

Separately, an Oregon federal district judge issued a nationwide order Nov. 26 blocking President Trump’s October proclamation to deny visas to immigrants unless they buy health insurance within 30 days of entering the country or otherwise show they can cover their medical costs, a policy that could a significant barrier to the ability of people to legally enter the country. The judge noted that requiring immigrants to buy unsubsidized insurance, preventing them from obtaining financial assistance to buy ACA marketplace coverage, was intended to prevent low-income people from entering the country, which he said clearly violated the law.

The 9th Circuit Court of Appeals has also set a schedule Dec. 6 for the filing of briefs in its review of a lower court ruling striking down the Trump administration’s regulations intended to replace the Flores Settlement Agreement and permitting longer-term detention of immigrant children in federal custody. Briefs must be filed by January 28, with arguments in the case expected shortly after that.

Final 2020 Spending Deal Boosts Nursing Program Funding

With federal agencies running out of money Dec. 20, congressional and administration leaders finally reached agreement on a plan to fund the government for the rest of the 2020 fiscal year, about two-and-a-half months behind schedule. After agreeing in principle Dec. 12, House and Senate appropriators released two “mini-bus” packages Dec. 16 to implement a nearly $1.4 trillion fiscal 2020 budget that included a 4 percent increase of $10.5 million in funding for nursing workforce program to a total of $259.97 million, including $5.5 million for statutory programs under Title VIII of the Public Health Service Act and an additional $5 million for a new nurse practitioner optional fellowship program in primary or behavioral health. The agreement also increased funding for the National Institute of Nursing Research by $6.12 million to a total of $169.11 million for fiscal 2020.

The final agreement, which President Trump indicated he would sign, a host of extensions of expiring Medicare and Medicaid policies including Medicaid funds for U.S. territories, a delay in scheduled cuts in Medicaid payments to disproportionate share hospitals, and funding for community health centers and the National Health Service Corps. The bill also provided $25 million to fund gun violence research at the Centers for Disease Control and Prevention and the National Institutes of Health and included provisions raising the legal age to purchase tobacco products including e-cigarettes to 21.

House, Senate Advance Plans to Lower Prescription Drug Costs

House Democrats wrestled with some intraparty disagreements before voting 230 to 192 Dec. 12 to pass a revised version of their “Lower Drug Costs Now Act of 2019” (H.R. 3) after agreeing to expand the federal government’s authority to directly negotiate drug prices, ultimately including at least 50 single source, brand-name drugs that account for the greatest spending, based on average prices for the drugs paid in other countries. The bill, which the White House threatened to veto, would also require drug makers to issue rebates for drugs whose price increases faster than inflation and reduce the annual out-of-pocket spending threshold and eliminate beneficiary cost-sharing in the Medicare prescription drug benefit.

Leaders of the Senate Finance Committee took a different approach in unveiling an updated version of their bipartisan “Prescription Drug Pricing Reduction Act” (S. 2543) Dec. 6 with new provisions to lower Medicare beneficiaries’ out-of-pocket payments. The revised bill would reduce seniors’ cost-sharing requirements, impose a discount on branded drugs, and require that pharmacy-negotiated discounts be shared directly with seniors. The new version of the Senate bill also included more than a dozen broader health care extenders, many of which were included in the final year-end spending agreement, including a delay in scheduled cuts in Medicaid payments to disproportionate share hospitals and Medicaid funding for Puerto Rico tied to strict anti-fraud provisions demanded by the White House.

Feds Propose Medicaid Funding Changes as States Consider Block Grants

The Centers for Medicare and Medicaid Services proposed regulations Nov. 12 that would increase scrutiny of provider taxes, intergovernmental transfers, supplemental payments and other financing mechanisms used by states to fund their Medicaid program. The goal of the new “fiscal accountability” rule is to help the agency cut back on unauthorized Medicaid spending, the agency said. It would require states to give the federal government provider-level information about Medicaid supplemental payments, which rose from 9.4 percent of all Medicaid payments in 2010 to 17.5 percent in 2017. Advocates for Medicaid enrollees worry that the rule would reduce state funding for Medicaid programs, limiting benefits and reducing payments to providers.

On Nov. 19, the agency released the annual update of its Payment Error Rate Measurement (PERM) program, reporting that improper Medicaid payments surged from about $36 billion in fiscal 2018 to about $57 billion in 2019, jumping from about 10 percent in fiscal 2018 to roughly 15 percent in 2019. Although advocates question the methodology used to identify errors, they fear the agency will use the data to bolster arguments for stronger enforcement and tighter restrictions on program eligibility.

Meanwhile, Tennessee officials submitted a request to CMS Nov. 20 seeking to receive federal Medicaid funding as a capped block grant in exchange for greater flexibility in setting enrollment and benefit policies – the first state seeking to apply the restrictions to individuals covered by the traditional Medicaid program. Although the state said it would use the added flexibility only to add coverage and wouldn’t seek to change children’s coverage, advocates fear that reduced federal funding will inevitably require the state to reduce eligibility and benefits. CMS has promised to soon issue guidance to state Medicaid directors on applying for block grant funding waivers.

On Dec. 12, CMS approved South Carolina’s Medicaid waiver request to impose work requirements on enrollees, making it the first time the Trump administration has approved work rules in a state that hasn’t expanded Medicaid coverage under the Affordable Care Act and where the majority of affected recipients would be low-income mothers.

Meanwhile, Michigan became the fifth state to be sued by advocates seeking to block enforcement of work requirements in its Medicaid program in a lawsuit filed Nov. 22. Indiana officials announced on Oct. 31 that they were suspending their state’s work requirements until a lawsuit challenging them was resolved. And Virginia formally asked the Trump administration Dec. 3 to delay finalizing their application for a waiver including work requirements and premiums after a Democratic majority in the state’s legislature was elected in November.

Affordable Care Act in Doubt Again After Appeals Court Ruling

The federal 5th Circuit Court of Appeals ruled Dec. 18 that the Affordable Care Act’s requirement that individuals must have health insurance coverage is unconstitutional but told a lower court to take another look at whether other parts of the 2010 health reform law remain valid, renewing uncertainty over the future of the law’s protections for people with pre-existing medical conditions and incentives for states to expand Medicaid coverage. California Attorney General Xavier Becerra said the 20 Democratic attorneys general who intervened to defend the law would try to take the ruling to the Supreme Court, but it’s unclear whether the high court would weigh in before to the 2020 election.  If the appellate judges’ ruling remanding the case remains, it could take years to resolve, casting even uncertainty over the law as the process begins anew at the district court level.

President Trump said the appeals court decision was “a win for all Americans and confirms what I’ve been saying all along: that the individual mandate, by far the worst element of Obamacare, is unconstitutional.” He added that the ruling doesn’t change the current system and that his administration continues to work to provide affordable care and protect those with preexisting conditions, claiming that Democrats seeking to expand coverage through “radical changes” are the ones who are trying to take away coverage, while Republicans are trying to protect it.

In Other News…

Compromise to Stop Surprise Billing Remains Elusive
Bipartisan leaders of House and Senate health committees announced a deal Dec. 8 intended to break a stalemate on efforts to eliminate surprise medical bills, but chances for a year-end agreement faded three days later when the leaders of the House Ways and Means Committee unveiled their own bipartisan alternative.  Senate Health, Education, Labor and Pensions Committee Chairman Lamar Alexander (R-TN) joined House Energy and Commerce Committee Chairman Frank Pallone (D-NJ) in offering the earlier plan that would set a benchmark payment rate for out-of-network bills at the median in-network rate for a geographic area and allow health care providers or insurers to move to an independent dispute resolution process for payments over $750.  But Ways and Means Committee Chairman Richard Neal (D-MA) and ranking member Kevin Brady (R-TX) went in a different direction Dec. 11, proposing to allow insurers and providers to try to work out billing disputes on their own and imposing an outside mediation process if there’s no resolution, with no federal benchmark payment rate for resolving disputes.

The earlier Senate and House agreement also includes several provisions on e-cigarette policies including improving age verification, imposing labeling and advertising restrictions, and preventing online sales of e-cigarettes to children, as well as providing $20 billion for community health centers over five years and raising the nationwide tobacco purchasing age to 21 – some of which were folded into the year-end appropriations proposals.

Congress Moves Toward Reauthorizing Nursing Workforce Funds
Both chambers of Congress took steps in October to advance legislation reauthorizing federal funding for nursing workforce programs, but efforts to pass the legislation before the end of the year have slowed as negotiators work to resolve differences between the House and Senate versions of the bill. The Senate Health, Education, Labor and Pensions Committee unanimously approved the “Title VIII Nursing Workforce Reauthorization Act of 2019” (S. 1399) on Oct. 31, just three days after the full House of Representatives approved a similar bill (H.R. 728) by voice vote on Oct. 28. It’s unclear when the full Senate might vote on its bill.

The Congressional Budget Office released an analysis of S. 1399 on Nov. 27, estimating that the bill would cost nearly $1.04 billion over five years (2020 to 2024) – $67 million more than the House version of the bill, which the CBO said in October would cost $970 million over five years. The office notes that the difference in the cost estimates reflects the Senate bill’s different authorized amounts and requirements that the Government Accountability Office and HHS conduct evaluations of the programs.

CMS Addresses Documentation Issues in Fee Schedule Regulation
The Centers for Medicare and Medicaid Services released final regulations Nov. 1 that authorizes advanced practice registered nurses (APRNs) to review and verify – rather than re-document – information included in medical records by physicians, residents, nurses, students or other members of the medical team for all services paid for under the Medicare Part B fee schedule. Addressing concerns that NAPNAP and other nursing organizations have raised for more than a year, the agency amended regulations for teaching physicians, physicians, PAs and APRNs in the final 2020 Medicare fee schedule rule to add the new flexibility for medical record documentation for all services furnished by physicians, PAs and APRNs in all settings. The new policy corrects an apparently unintended imbalance created when the agency issued guidance aimed at reducing documentation burdens but excluded APRNs and physician assistants. CMS also modified its original proposal to include nurse anesthetists, who had been left out of the APRN category, and to explicitly list the types of students for whom the rule applies, including NP, CNS, CNM and CRNA students as APRN students.

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