The Year in Review: The COVID-19 Pandemic and Implications for Pediatric Advanced Practice
Contributed by: Health Policy Committee Member Linda Zekas, MSN, MJ, APRN, NNP-BC, CPNP-PC, CWON
Our world has become more complicated since the onset of the COVID-19 pandemic in early 2020. Some changes have been good (e.g., discovering new and innovative ways in which to provide health care) and some have been less positive (e.g., stress on our health care system). Because of its impact on most aspects of our economy and society, COVID-19 has triggered key federal legislation affecting health care, including health care for pediatric populations.
The Families First Coronavirus Response Act (FFCRA) was the first piece of COVID-19 related health care legislation passed on March 18, 2020. Medicare, Medicaid and all group insurance policies were mandated to cover COVID-19 testing with no cost-sharing. Additionally, these plans were prohibited from imposing prior authorization requirements during the federal emergency period.
Subsequently, the Coronavirus Aid, Relief, and Economic Security (CARES) Act was signed into law on March 27, 2020. The CARES Act expanded the mandate that COVID-19 related tests that had not yet received FDA emergency use authorization would be covered by insurers. A critical provision of the legislation was that it provided for expanded coverage and grants to promote the broader use of telehealth. In the case of medically complex children, the new telehealth provisions have proved to be key to providing necessary care. Other provisions include covering COVID-19 testing and services to those uninsured by Medicaid despite eligibility and without cost-sharing. Although still in development at the time of passage, the legislation coverage of COVID-19 vaccines without cost-sharing.
Important to pediatric health care, the Health and Economic Recovery Omnibus Emergency Solutions (HEROES) Act, passed on May 15, 2020, provides critical funding for SNAP and WIC nutritional assistance programs, Public Health Services Emergency Fund, substance abuse and mental health services, Centers for Medicare and Medicaid Services and social services targeted at families and children, as well as other programs.
As we look forward to 2021, federal appropriations will be necessary to support the various programs that were added or expanded in COVID-19 related legislation. This is particularly true for ongoing testing, vaccine review and monitoring by federal agencies, nation-wide safe and secure distribution of vaccines and research for special populations, including children, adolescents and young adults. From a population health perspective, funding will be needed to support individuals and families who have lost their jobs and health insurance because of the COVID-19 pandemic. Results of our recent election will also change the balance of power within the executive and legislative branches of national, state and local governments with down-stream effects yet unknown.
Biden Administration, Congress Begin Post-Election Transitions
Amid election challenges that delayed the process, President-elect Joseph Biden ramped up the transition to his administration in November, appointing a coronavirus task force and agency review teams and nominating members of his Cabinet. On Dec. 6 Biden tapped California Attorney General Xavier Becerra, who has led the legal defense of the Affordable Care Act, to be his Secretary of Health and Human Services. In nearly 25 years on Capitol Hill, Becerra helped draft the 2010 health reform law as chair of the House Democratic Caucus before being named in 2017 Vice President-elect Kamala Harris as California’s attorney general.
Biden filled out key health care posts in his administration by appointing former U.S. Surgeon General Vivek Murthy to reassume that role and naming Massachusetts General Hospital chief of infectious diseases Rochelle Walensky to direct the Centers for Disease Control and Prevention. The President-elect appointed a transition coronavirus task force Nov. 9 and expanded it Nov. 28 to include nurse Jane Hopkins, RNMH, a mental health specialist who has served on Washington State’s COVID task force and Safe Start Advisory Board.
Congress also took first steps to organize for its 117th session, reelecting the top House and Senate leadership in both parties. Rep. Rosa DeLauro (D-CT) was chosen to succeed retiring Rep Nita Lowey (D-NY) as chair of the House Appropriations Committee. DeLauro will retain her chairmanship of the Labor-HHS-Education Appropriations Subcommittee in the new Congress, as well.
Congress Nears Year-End Spending Deal
More than two months after the 2021 fiscal year began, congressional leaders are close to a final agreement on a $1.4 billion omnibus bill to fund the federal government, including nursing workforce and research programs, through next September. As of Dec. 15, House and Senate appropriators were expected to unveil the deal in time to set up a House vote as early as Dec. 16 and a Senate vote before the stopgap measure funding government programs runs out at midnight Dec. 18. Negotiation cleared the final stumbling block to a deal by agreeing to keep $12.5 billion in veterans’ health funding under the statutory cap on federal spending, rather than designating the funds as “emergency” spending outside of the limits.
The agreement appears likely to include increases in funding for nursing workforce and research programs, although as of Dec. 15 the final amounts aren’t known. The House approved a Labor-HHS-Education bill that increased funding for Title VIII nursing programs by $10 million to a total of $269.97 million, while Senate appropriators proposed an increase of more than $6 million. The Senate also offered to increase funding for the National Institute of Nursing Research by $5.61 million, while the House approved a $1.45 million increase with additional pandemic emergency funding.
Talking Advanced Practice Nursing in States
Mark your calendar for our Child Health Policy Learning Collaborative meeting on Jan. 6. Tay Kopanos, DNP, NP, AANP VP State Government Affairs, will be our special guest sharing insights on state level nurse practitioner issues for 2021.
You can view past Child Health Policy Learning Collaborative meetings on-demand.
Lame Duck Congress Presses to Agree on Coronavirus Aid
With the nation facing another surge in coronavirus cases and leaders in both parties saying Congress can’t adjourn for the holidays without a deal, lawmakers appeared to be close to agreement on a package of nearly $1 trillion in coronavirus relief and stimulus. A bipartisan group of senators on Dec. 14 released the details of a two-part proposal to provide $748 billion to extend federal unemployment benefits, support small businesses, and deliver emergency fund for education, transportation, and health care provider relief. A separate, more controversial bill would allocate $160 billion in additional funding for state and local governments linked with short-term liability protections for employers – two issues on which Republicans and Democrats have been unable to agree.
As of Dec. 15, it’s not clear that the whole package can win congressional approval. While the aid to businesses, schools, and the unemployed appeared to have broad support, Democrats continued to push for more assistance for states and localities – the proposal did not include increased federal matching funding for state Medicaid programs. Legislators also wanted to know the details of how added funding for vaccine distribution and administration would be allocated, and committees in both chambers were pushing to include provisions to outlaw “surprise” medical bills.
First COVID-19 Vaccinations Begin
The first coronavirus vaccination in the U.S. was administered Dec. 14 as public health officials reassured the public of the vaccine’s safety and effectiveness. Sandra Lindsay, an ICU nurse at Long Island Jewish Medical Center in Queens, received the first of two doses of a vaccine developed by Pfizer and BioNTech as her injection was carried live on several news channels. The rollout of the Pfizer vaccine followed its rapid approval by the Food and Drug Administration’s Vaccines and Related Biological Products Advisory Committee and the FDA’s Dec. 11 issuance of an emergency use authorization for the drug. The CDC Advisory Committee on Immunization Practices unanimously endorsed the use of Pfizer’s vaccine Dec. 12 for Americans 16 years and older, and CDC Director Robert Redfield signed off on the recommendations a day later.
The FDA advisory committee is scheduled to meet again Dec. 17 to consider drug maker Moderna’s application for emergency use authorization of its vaccine, and vaccines developed by Johnson & Johnson and Astra Zeneca could seek federal approval by the end of February. If approved, the government could have four vaccines available to meet its goal of immunizing 100 million people by the end of March.
Supreme Court Hears ACA Case, Agrees to Review Work Requirements
In a potentially critical Nov. 10 hearing on the fate of the 2010 health care reform law, Supreme Court justices appeared unlikely to strike down the Affordable Care Act over the elimination of a penalty for individuals not having health coverage. The challenge in California v. Texas, the third major challenge to the law heard by the court, centers on the 2017 decision by Congress to eliminate the law’s penalty for not having health insurance – without repealing the coverage requirement itself. During two hours of oral arguments, at least two of the court’s six-justice conservative majority appeared to have reservations about overturning the law. Chief Justice John Roberts and Trump appointee Justice Brett Kavanaugh questioned whether the elimination of the individual coverage mandate penalty made the rest of the law invalid, and Kavanaugh seemed to favor leaving the rest of the law intact if the mandate is struck.
On Dec. 4, the court agreed to consider the Trump administration’s request to reinstate work requirements for some Medicaid enrollees, even as President-elect Biden plans to reverse the policies. The justices will hear appeals of lower court rulings that overturned the Trump administration’s approval of waivers from Arkansas and New Hampshire requiring some low-income adults to work, volunteer or attend school as a condition of receiving coverage. Every lower court that considered work requirement cases have blocked the controversial policy, including a federal appeals panel earlier this year. Nearly 20 states have received or sought permission for similar work rules, but virtually none of those policies have been active as the legal battle played out.
In Other News…
CMS Boosts NP Medicare Payment, Test Supervision
The Centers for Medicare and Medicaid Services on Dec. 1 released the final rule for the 2021 Medicare Part B fee schedule, increasing payment for evaluation and management services that will give nurse practitioners an average 7 percent increase in reimbursement. The regulations also finalized policies authorizing NPs, clinical nurse specialists, and certified nurse-midwives to supervise Medicare diagnostic testing, affirming evaluation and management documentation and payment guidelines, and expanding Medicare coverage of telehealth services that the agency implemented during the coronavirus public health emergency.
While primary care and outpatient services generally received payment increases, specialists and providers of hospital-based services asked Congress to intervene to prevent cuts in their payment due to statutory budget neutrality requirements – nurse anesthetists are looking at an average 10 percent cut – in the midst of pandemic economic pressure. Nearly 330 members of the Senate and House have endorsed legislation to stop the cuts from taking effect on New Year’s Day, either by waiving budget neutrality for a year or freezing payments at current levels for two years, but Congress may not act before it adjourns.
Federal Judge Orders DACA Program to Be Reinstated
A New York federal district judge on Dec. 4 ordered the Trump administration to fully restore the Obama-era “Deferred Action for Childhood Arrivals” program designed to shield young, undocumented immigrants from deportation, dealing what could be a final blow to President Trump’s long-fought effort to end the program. Judge Nicholas Garaufis directed the administration to allow newly eligible immigrants to file new applications for protection under the program, reversing a memorandum issued in the summer by acting Homeland Security Sec. Chad Wolf that limited the program to people who were already enrolled. As many as 300,000 new applicants could now be eligible, according to the lawyers who pushed for the reinstatement.
EPA Rejects Stronger Air Pollution Standards
The Environmental Protection Agency on Dec. 7 declined to set tougher standards on soot and other deadly air pollutants, saying existing regulations remain sufficient even though nurses, public health experts and environmental justice advocates had called for stricter limits. The agency issued final rules retaining the current thresholds for fine particle pollution for another five years, deciding that levels set in 2012 are adequately protective of human health despite mounting evidence linking air pollution with illness and death.
EPA scientists had recommended lowering the annual particulate matter standard in a draft report last year, citing estimates that reducing the limit to 9 micrograms per cubic meter of air could save between 9,050 and 34,600 lives a year. The current national standards limit annual concentrations of soot and other chemicals to 12 micrograms per cubic meter, allowing emissions on specific days to be as high as 35 per cubic meter. Public health experts argued that these fine particles can enter the lungs and bloodstream of children and adults, causing inflammation that can lead to asthma, heart attacks and other illnesses.
