Inside the Beltway – February 2021

Tackling Key Pediatric-focused Child Health Policy Issues: First 100 Days

Contributed by: Health Policy Committee Member Sarah Green, DNP, CPNP-AC

The first 100 days in office has been deemed an essential time for presidents to outline their policy priorities and a standard by which a president’s early success is measured. For President Biden, this symbolic standard still holds true. In a year ravaged by a pandemic, health, economic, racial and equity crises, as well as political unrest and division, there are numerous essential and competing priorities. This is most certainly a challenging burden placed on a president. For NAPNAP’s audience, I will address two issues with child health policy implications which President Biden and his administration seek to address during the first 100 days in office.

COVID-19 Relief

Given the sheer impact and toll that the COVID-19 pandemic have taken on the health and economic stability of the nation, it is no surprise that President Biden has expressed that addressing the pandemic is of upmost importance during his first 100 days in office. The President has proposed a 1.9 trillion-dollar stimulus bill dedicated to COVID-19 relief. This stimulus package focuses on a broad range of issues including vaccine production and support for distribution and administration, testing and tracing, to economic relief for American families, extension of unemployment benefits, economic relief for small businesses, states, localities, tribes, and schools throughout the country. It is clear that each of these issues have both direct and indirect impact on American families and child health. Examples of the impact on child health range from: ensuring that students have a safe and healthy school environment and receive essential services provided by school, helping families struggling with the economic impact of COVID through financial support including continuation of a federal eviction moratorium and direct payments to many Americans, and supporting vaccination efforts including children being able to receive COVID-19 vaccination in the not so distant future for their protection and for the greater community.

As of Friday, February 5th, the House and Senate approved a budget resolution that allows for President Biden’s COVID-19 relief plan to be transitioned from a framework to legislation that can be voted on through a process known as budget reconciliation. In the U.S. Senate, rules state that the majority of legislation requires 60 votes in order to be passed into law, however, when utilizing the reconciliation process, under the Congressional Budget Act of 1974, a simple majority and not the traditional 60 votes are needed to pass legislation directly related to the spending or taxes in order to help maintain alignment of the U.S. national budget. In this process both the House and Senate are required to pass the budget resolution and instruct committees within both chambers of Congress to develop the legislation that will subsequently become part of the reconciliation package. This “fast tracked” process prevents use of a Senate filibuster, a situation where the Senate could prevent voting on a bill. The budget reconciliation process can be utilized in either a bipartisan fashion when there is a divided government, or when the same party has control in both the legislative branch and the White House in order to reach the simple majority needed to pass the legislation. In addition to rules that only allow use of the budget reconciliation process for reconciling laws related to spending and taxes, it can only be used once in a fiscal year, and cannot be deemed to raise the federal deficit for greater than 10 years. If deemed by the Congressional Budget Office that the deficit would be impacted over greater than 10 years, provisions of the bill would not be eligible for consideration by this process and would be dropped from the legislation. Currently, there remain many details to be worked out in this COVID-19 relief bill that will require close monitoring in the coming weeks to determine the final components, amount of funding dedicated to priorities within the bill, and issues that will require additional work outside of this COVID-19 relief package.

Immigration Reform

President Biden and his administration have expressed a commitment to addressing comprehensive immigration reform and the plight of undocumented individuals and families living and those seeking to live in the U.S. The physical and mental health impacts of immigration concerns on children and their families cannot be overstated including the trauma experienced by children separated from their families at the border, issues related to deportation, and the residency status of undocumented individuals who arrived in the U.S. as children.

The Biden administration has taken initial steps through executive orders to alter U.S. immigration policy. An executive order is a “signed, written, and published directive” issued by the President of the United States pertaining to operations of the federal government. Unlike laws passed by Congress, executive orders are not legislation and do not require Congressional approval, nor can they be overturned by Congress. Only a sitting President can overturn an executive order by issuing an order that would counter the prior order. Although Congress cannot overturn an executive order, legislation can be passed in Congress that could make it difficult or prevent implementation of an order, including removal of funding needed to carry out the order.

On President Biden’s first day in office he signed an executive order directing the Secretary of Homeland Security to act to “preserve and fortify” the Deferred Action on Childhood Arrivals (DACA) program, a program that has provided a pathway to citizenship for undocumented immigrants who were brought to the U.S. as children and allows for immediate eligibility for green cards. Other Biden administration immigration-focused executive orders focus on creating a task force to address reuniting families who have been separated at the U.S.-Mexico border and restoration or a program founded under the Obama administration allowing minors to legally unite with parents who live in the U.S., seeking to prevent utilizing alternative methods sought to bring children into the U.S. though smugglers. The administration has also expressed plans for transforming the migration dynamics across the U.S.-Mexico border to one that addresses “root causes” of individuals who seek to emigrate from Central America, seeking to help facilitate safe alternatives for vulnerable refugees closer to home, and raising the cap on the number of refugees allowed entry into the U.S. on an annual basis. There remains a great deal of work to address comprehensive immigration reform. Advocacy efforts including those of pediatric-focused NPs are essential to ensuring that the immediate and long-term physical and mental health of immigrant children and families are integrated within the framework of immigration reform.


Removing Unnecessary Barriers

As NPs in some states prepare for barrier reduction bills in their legislatures this term, NAPNAP has published a statement calling for the removal of unnecessary barriers to patient access to care. We applaud the dedication so many of you have invested in practice advocacy during the last decade – or more. We encourage members in reduced or restricted practice states to get involved with their chapters and state-based NP or APRN coalitions to educate elected leaders on the benefits of allowing NPs and their fellow APRNs to practice to the full extent of their advanced education, national board certification and licensure. Chapters and advocacy-minded members are encouraged to download and use the statement in their advocacy efforts.


House Prepares to Vote on COVID-19 Rescue Plan

After a series of marathon committee markups during the week of Feb. 8, the House is preparing to vote on President Biden’s $1.9 trillion coronavirus relief and stimulus plan using a budget reconciliation procedure that will protect the bill from Republican filibusters in the Senate and allow leaders to pass the massive proposal with only Democratic votes. Leaders plan to have the full House vote on the plan the week of Feb. 22, with the goal of having a final bill on the President’s desk before the March 14 expiration of enhanced federal unemployment benefits.

House committees proposed more than $590 billion in economic aid for families including $1,400 direct payments and increased monthly child tax credits, as well as $350 billion in funding for state and local governments. The House also included the President’s proposal to increase the federal minimum wage to $15 an hour, although that proposal may not pass Senate rules for a budget reconciliation bill.


Biden Pushes to Speed Virus Response

After a flurry of executive orders in his first days in office, President Biden’s administration has continued to roll out initiatives to accelerate coronavirus vaccinations and increase the availability of tests and protective gear, at the same time urging Americans to double down on basic public health measures like wearing masks. The White House said Feb. 5 that the administration will use the Defense Production Act to make at least 61 million at-home or point-of-care coronavirus tests available by summer and the Defense Department will deploy more than 1,000 active military personnel to support state vaccination sites. While new infections, hospitalizations and deaths began to decline after a massive post-holiday surge, the administration stressed the importance of simple steps like masking as new virus variants – more transmissible and potentially more virulent and less susceptible to vaccines – continue spread throughout the country.

Drug maker Johnson & Johnson submitted its single-shot coronavirus vaccine to U.S. regulators Feb. 4 for emergency use authorization after the vaccine was shown to be robustly effective against illness in a global trial and especially at preventing severe disease and death. If approved by the Food and Drug Administration, the vaccine would be the third authorized shot in the U.S. and a much-needed addition to the tools public health officials have to build immunity as virus variants spread. FDA officials announced that outside experts would discuss the vaccine at a Feb. 26.


Biden Moves to Address Environmental Health Concerns

After moving to rejoin the Paris Climate Agreement and signaling in his early appointment that his administration would focus on climate change and environmental protection, President Biden issued orders Jan. 27 to greenhouse gas emissions and establish a National Climate Task Force to plan and implement policies reducing climate pollution, protecting public health, and addressing environmental justice including investing in low-income and minority communities.

The Department of Health and Human Services will also create a new office of Climate Change and Health Equity; establish an Interagency Working Group to Decrease Risk of Climate Change to Children, the Elderly, People with Disabilities, and the Vulnerable; and establish a biennial Health Care System Readiness Advisory Council. Biden also imposed a moratorium on new federal oil and gas leasing, pausing auctions on federal land and water as the new administration reviews the program.

Separately, the President signed a memorandum on “restoring trust in government through scientific integrity and evidence-based policymaking” with appropriate privacy protections, charging the Office of Science and Technology Policy with ensuring that all agencies establish and enforce scientific integrity policies.


Orsega Appointed Acting Surgeon General

President Biden named Rear Admiral Susan Orsega, MSN, FNP-BC, FAANP, FAAN, to be acting U.S. Surgeon General Jan. 25. The Senate has yet to consider Biden’s appointment of former Surgeon General Vivek Murthy to return to that post in the new administration.

Orsega has served as the Director of Commissioned Corps Headquarters (CCHQ) in the Office of the Surgeon General since March 2019, directing personnel, operations, deployment and policy for 6,100 members of the U.S. Public Health Service Commissioned Corps and the development of the Reserve Corps. She is responsible for CCHQ’s operations in the deployment of officers during the coronavirus public health emergency.


In Other News…

Senate Resumes Review of Biden Administration Nominees
With the completion of the second impeachment trial of former President Donald Trump, the Senate is preparing to resume consideration of President Biden’s nominations to fill key Cabinet and administration positions. Senators have confirmed seven of the 23 Cabinet-level appointees including secretaries of Defense, State, Treasury, Homeland Security and Veterans’ Affairs.  But in addition to slowing work on the COVID-19 reconciliation bill, the impeachment trial held up confirmation hearings for HHS Secretary nominee Xavier Becerra, U.S. Surgeon General nominee Dr. Vivek Murthy, and President Biden’s yet-to-be-made appointments for the administrator of the Centers for Medicare and Medicaid Services and commissioner of the Food and Drug Administration.

Administration Moves to End Medicaid Work Requirements
The Biden administration on Feb. 12 started to rescind the controversial Trump-era policy allowing states to require low-income residents to work, volunteer or take part in other so-called “community engagement” activities in order to enroll in Medicaid coverage. The Centers for Medicare and Medicaid Services withdrew a 2018 letter from former administrator Seema Verma to state Medicaid officials that invited them to apply for waivers including work requirements, and the agency also reversed its approval of Georgia’s partial Medicaid expansion, which is now considered “pending.” CMS will also send a letter to 10 states with waivers for Medicaid work rules, informing them that the agency will soon repeal their waivers, telling Arkansas officials that it had “preliminarily determined that allowing work and other community engagement requirements to take effect in Arkansas would not promote the objectives of the Medicaid program.”

However, it could take time to undo the waivers. Just before leaving office, Verma asked states to sign contracts that would make it more challenging for CMS to end states’ work requirements or other waiver policies – although experts have questioned whether those contracts are legally enforceable. Of the 13 states CMS approved for a work requirement, Arkansas was the only state to implement its experiment completely. But a federal court struck down the demonstration after seven months because the work rules were inconsistent with the Medicaid law. The Supreme Court is set to hear a final appeal March 29, but the Biden administration’s latest moves could make the case moot.

Opioid Prescribing Waiver Blocked by Biden Administration
A Department of Health and Human Services guidance issued Jan. 14 waiving certification requirements for physicians to prescribe the drug buprenorphine medication assisted treatment (MAT) was frozen by the Biden administration Jan. 25 based on concerns that the agency lacked the authority to waive requirements mandated by Congress. The guidelines would allow any physician licensed by the Drug Enforcement Agency to prescribe buprenorphine to up to 30 patients without having to go through the standard process to become authorized, which requires clinicians to undergo eight hours of training – but it did not include advanced practice registered nurses or physician assistants. NAPNAP and other APRN groups urged the Biden administration to include APRNs as the agency evaluates changes to the guidelines or other policies to improve access to MAT services.

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