Critical National

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Critical National State IssuesA Legislative
Storm Big Year for Advocacy

• Pennsylvania Community Providers Association
  October 9, 2009
• Suellen Galbraith
• ANCOR Director for Government Relations
• sgalbraith_at_ancor.org

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American Network of Community Options and
Resources

• Private providers of supports to individuals with
  disabilities of all ages
• 850 members supporting over 450,000 individuals
  with disabilities employing more than 500,000
  DSPs
• Celebrating 40 years in 2010
• Consortium for Citizens with Disabilities (CCD)
• Friday Morning Group of national aging and
  disability organizations

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Overarching Themes

• Distressed economy
• Unchartered territory for many lawmakers
• Medicaid LTSSfocus on functional level
  person-centered self-directed transforming
  service delivery systems
• Medicaid waste, fraud and abuse

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Gathering Storm Intersection of Swift Series of
Negative Consequences

• Impact of Recession
• Federal State Cuts
• Limited Donations
• Demographic Shifts
• Waiting Lists/Pent-up Demand for services
• Workforce crisis
• Transformation of Service Delivery Systems
• But, need to find the opportunitiesthe blue sky!

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Big QuestionWhen Will Economy Recovery

• The V version deeper the recession, faster
  the recovery and GDP
• The L version big GDP drop flat recovery
• The U version GDP drop slow recovery
• The W version GDP drop, affect of stimulus,
  drop as stimulus wears off, then recovery

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American Recovery and Reinvestment Act

• 787 Billion stimulus package for job creation,
  education, training employment services, state
  stabilization funds
• 87 Billion in temporary Federal increase in
  Medicaid FMAP to states October 1, 2008-December
  31, 2010
• FMAP6.2 base for all states prevents drop in
  any state FMAP additional FMAP for high
  unemployment states

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Health Care Reform

• Currently spend 2.2 trillion annually 16 of
  GDP
• 45 million uninsured
• Over 200 million lack any insurance for costs of
  long-term services
• 68 of Americans want health care reform this
  year
• But when drill down, most dont think reform will
  affect them as much as help the country.
• However, stars are aligned best opportunity for
  reform in 15 years.

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Barack Obama

• Require children to have health coverage
• Require large employers to offer or contribute a
  percentage of payroll to coverage provide tax
  credit to small employers that offer coverage
• Expand Medicaid and SCHIP
• Create a national health insurance exchange with
  private plans and a public plan with benefits
  similar to those in FEHBP
• Provide income-related subsidies for low-income
  families
• Regulations on insurers to prevent denials of
  coverage
• Core principles of expanded coverage by making
  health care affordable, provide choice, control
  rising costs, and build upon existing
  public-private.systems.
• Wants Congress to give him a bill by October 15th.

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Best Opportunity in 15 Years to Reform Health
Care..But Questions Remain ???

• Will there be a bipartisan approach?
• Will it expand Medicaid coverage?
• Will reform include long-term services
  supports?
• Will it not add one dime to deficit?

• Will it include a public plan?
• Will it include employer mandate? Penalties?
  Enforcement?
• Will it include individual mandate? Penalties?
  Enforcement?

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Getting to a Final BillCommittees and Floor
Debate
SENATE
COMMITTEES
Week of Sep. 21-25
FLOOR CONSIDERATION
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Lawmaking Often Compared to Watching
Sausage-Making

• Involvement of 5 committees jurisdictional
  issues
• Senate Finance plan is conceptual/plain English
  text while other committees in statutory language
• CBO scoring (Congress)
• OMB (White House)
• Senate merger of two bills (HELP Finance)Whos
  in the room?
• House Senate dynamics committee as well as
  chamber dynamics personalities

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Played Out Against Backdrop Ticking Clock and
Future 2010 2012 Elections

• Conference committeeWhos in the room?
• Rules of engagement for floor debates in each
  chamber
• Senate reconciliation process which allows only
  51 majority vote?
• Role of the President White House?????
• All with an eye to mid-term elections in 2010
  Presidential 2012 election

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Health Reform Isnt Complete without Including
LTSS

• Reform focused on health care coverage costs
  related to 45 million uninsured (and
  underinsured)
• However, there are 200 million Americans who lack
  insurance coverage for long-term supports
  services

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What We Know

• Demand for community supports continue to grow
• Increasing numbers of individuals are being
  supported in own homes and in community
  settings
• Waiting lists for services are expanding
• Continued reliance on costly institutional models
• Increasing numbers of states with serious revenue
  shortfalls

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Push to Get Long Term Services Supports into
Health Care

• CLASS Act
• Community First Choice Option
• Enhanced FMAP for HCBS waiver or state plan
  option
• Addressing long-term services supports
  workforcedirect support professionals

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Push to Include Long Term Services Supports

• Class Actnew social insurance with cash benefits
  program paid for through payroll deduction
  reduce pressure on Medicaid expenditures by
  nearly ½
• Community Choice Actmandatory Medicaid state
  personal attendant benefit
• Empowered at Home Actfix to DRA section 1915(j)
  HCBS state option
• Address LTSS Workforce Crisis
• HCBS enhanced FMAP

• Reduce institutional bias in Medicaid
• Reduce pressure for people to become impoverished
  to obtain LTSS through Medicaid
• Bend the trend in LTSS decouple institutional
  level of care with eligibility for HCBS waiver
• Address caps/waiting lists with increased FMAP to
  states who target funds for new HCBS enrollees
  from institutions
• Provide statutory automatic FMAP increase during
  recession
• End 2-year waiting period for SSDI beneficiaries
  to obtain Medicare

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Status of Long Term Services Supports

• CLASS Act (HELP House)
• Cantwells enhanced FMAP for HCBS Balancing
• Medicaid Section 1115 transparency
• Rockefeller Sense of Senate
• Direct Care Workers (HELP ??? Finance)
• Community First Choice (House)
• Direct Care Workforce Commission/Grants (HELP)
• Kohls personal care/aide workforce grants

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Year of Community Living

• President Obama Year of Community Living
  Proclamation June 22
• Funding to expand AoA CMS funded Aging and
  Disability Resource Centers
• Additional 1,000 HUD vouchers for transitioning
  from institutions, targeting states operating
  Money Follows Person Demos
• HHS Creation of Federal Coordinating Council
  (AoA, CMS, SAMHSA, ASPE Office of Civil Rights)
  led by Office on Disability
• HHS national listening sessions

• CMS June 22nd ANPRMchanging HCBS regulations
• States could opt to design waivers with multiple
  target populations needs based not based on
  diagnosis
• Person-centered plans
• Identify characteristics of home and community
• States set standards
• Provider owned, least or controlled settings
  would trigger standard as defined by state and
  approved by CMS

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Medicaid The Fight Over Future Direction

• State Priorities Federal Policy Reforms

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Federal Priorities

• 1. Rein in Federal spending on health care
• 2. Assure Medicaid program and fiscal integrity
• States pay full matching share with legitimate
  public funds
• Closer scrutiny of provider claiming
• Closer scrutiny of rate setting
• A more fundamentalist approach to Medicaid
  benefit and eligibility definitions

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Federal Priority - Program Integrity

• Congress has been a driver
• GAO audits of federal agency oversight
• Critical of CMS
• Administration response focus on federal/state
  fiscal relationship
• Increased scrutiny of state fiscal arrangements
  (100 new auditors reviewing state financing)
  state schemes and fraud and abuse theme

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CMS Universal Principles

• Across all CMS programs (HCBS waivers, State plan
  options, managed care waivers, demo waivers,
  Money Follows the Person, and system
  transformation grants)
• Person-centered systems
• Self-direction
• Facilitating transitions/diversions from
  institutions
• Measuring quality
• Assuring true home and community settings
• Efficiencies

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State Reaction

• Budget cutting, rather than health reform, is
  again the top priority in many states
• States once again freezing or cutting rates
• Expansion plans in jeopardy or delayed
• Utilization of Recovery Act increased Medicaid
  FMAP to meet growing eligibility service
  demandbut also filling in other state budget
  shortfalls.

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State Priorities

• 1. Cover the uninsured (build on Medicaid)
• 2. Assure Medicaid fiscal sustainability
• 3. Increase value for public dollars
• Quality
• Outcomes
• Efficiency
• 4. Increased Flexibililty

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So, Whats New

• Confronting change, crisis, and chaos

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Implications for Providers

• Focus on performance and accountability will
  continue
• Federal Office of Inspector General (OIG)
  priority list targets local use of Rehab, TCM
• If Congress remain unwilling to discuss
  financing, focus on waste and abuse likely to
  continue
• Continued focus on services to people with
  chronic or disabling conditions may create
  opportunities to improve Medicaids support of
  vulnerable populations
• When covering the uninsured becomes key federal
  issue, will needs of chronically ill/disabled be
  addressed?

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The Future

• Medicaid sustainability will drive reform and
  limitations on funding
• Service delivery will become more and more
  community/home-based, individualized and
  virtual
• Providers will need to transform their business
  models.diversification
• Long-term services and supports will be based on
  need not diagnosis

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Community-Based Service Providers will be
challenged more than ever before

• Limited funding and stiffer competition for those
  funds
• Stricter regulation and oversight
• Demand for individualized services

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What are the Signs

• Building on ADA Olmstead Decision
• Building on Bush New Freedom Initiative
• Cash Counseling
• Money Follows the Person
• DRA 1915(i) self-directed services Medicaid state
  option
• DRA 1915(j) HCBS state plan option
• CMS review of waivers to determine
  institution-like living arrangements
• CMS upcoming proposed HCBS waiver regulation
• Costs of institutional v. HCBS services
• Federal and State rebalancing efforts

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Hot Issues Right Now

• H1NI Virus
• CMS changes to HCBS waiver in two areas
  allowing consolidation of target populations
  definitions of home community.
• CMS Rebalancing project
• Self-direction
• CMS 7 deadly sin regulations either rescinded
  partially rescinded (case management) or
  postponed (provider tax)
• Medicaid Medicare fraud waste
• Economic picture for states in coming years
  next FMAP???
• Litigation

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Other Legislative Regulatory Issues

• HR 868 DSP Fairness and Security Act to address
  wage disparities
• CMS revision of ICF/MR Interpretive Guidelines
  and clarifying letters
• Legislation to eliminate DOL Wage and Hour 14(c)
  minimum wage certificates
• Section 811 Housing Reform
• SEVRA Housing Reform
• Employee Free Choice Act (card check)
• The Healthy Families Act (S.1152/H.R. 2160)
  requiring all employees accrue (up to 56 paid
  sick leave days) for every 30 hours worked
• OSHA Regs
• What wont be done this year

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Advocacy Quiz

• How many bills were introduced in the House and
  Senate (combined) January 2005 through December
  2007 (the 109th Congress)?
• 267
• 14,193
• 10,537
• 3,581
• What percentage of ALL bills introduced in the
  House and Senate DO NOT become laws?
• 95
• 62
• 25
• 10

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AdvocacyIts About Building Personal
Relationships

• All politics is local.
• Former House Speaker Tim ONeill (D-MA)
• Caveat All politics is tribal.
• Politicians learn to count first, before they
  vote.
• Former Senator Lowell Weicker, Jr. (R-CT)
• To a neighbor who didnt vote for Tim ONeill
  when he asked her why not?
• Because you never asked me to.
• Politics is too important to be left to
  politicians! --anonymous

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National State Trends

• What Do We Know Where Are We Going

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Its a Maze

• Federal Judges observe
• Byzantine Justice Powell
• a morass of complexity. Chief Justice Burger
• one of the most intricate laws ever crafted by
  Congress. Judge Friendly

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Big and Complex Subject

• The Big Picture a federal/state health plan
• The Maze eligibility and benefits
• The Problem cost, financing, control
• The Mystery rate setting
• The Fight Over Future Direction state priorities
  and federal policy reforms

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The Big Picture

• Publicly financed and administered health plan
  for low income Americans

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Projected Growth in Medicaid Enrollees 2007 - 2017
Medicaid Annual Growth by Category of Eligibility
Source Calculations by Health Management
Associates based on CMS historical data and
Congressional Budget Office Projections through
2017, March 2007 Medicaid Baseline.
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The Problem

• On-going Medicaid spending pressures expected to
  persist
• Increasing health care costs
• Increasing uninsured / declines in employer
  coverage
• Increasing aged and disabled
• Tension in federal / state financing for Medicaid
• Cost
• Financing
• Control

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The Future will look different from today

• Work on changes that dont call for immediate
  funding
• Overhaul regulations, adopt individual budgeting,
  develop consumer quality teams, etc.
• But as providers we are use to change, and we
  can help lead the change.

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Dispelling Those Myths

• Biggest myth is that special interest lobbyist
  have greatest influence over decision-makers.
• Finding out about legislation lawmakers is very
  difficult and should be left up to the
  professional lobbyist.
• They are the expert, not me.

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AdvocacyIts About Building Personal
Relationships

• All politics is local.
• Former House Speaker Tip ONeill (D-MA)
• Caveat All politics is tribal.
• Politicians learn to count first, before they
  vote.
• Former Senator Lowell Weicker, Jr. (R-CT)
• To a neighbor who didnt vote for Tip ONeill
  when he asked her why not?
• Because you never asked me to.
• Politics is too important to be left to
  politicians! --anonymous