Live from DC:A Federal Policy Update

Amy Gotwals, Senior Director, Public Policy & Advocacy

National Conference for Caregiving Coalitions, Denver, COJuly 10, 2012

n4a’s 2012 Policy Priorities

• Reauthorization of the OAA• Enhancing the Health of Older Adults

– Care Transitions/Care Coordination– Medicaid Managed Care– ADRCs– Prevention and Wellness

• Fiscal Year 2013 Appropriations• Livable Communities for all Ages• Senior Mobility Options

Challenges

• Real Fiscal Woes• Entitlement Reform Mixed with Deficit

Reduction• Policy Agenda Meets Political

Opportunity• Potential to have long-term effects on

federal policy and spending

What do we need to do?

• Step up our advocacy to protect key programs

• Work in coalition on bigger messages

• Push ourselves in advocacy (speak up at town halls over recesses)

BUDGET & FUNDING

FY 2013 Budget Process

• No joint budget resolution• Likely CR through election• Holiday Package =

– Expiration of Bush Tax Cuts– SGR Fix (Again)– January 2, 2013 Sequestration

AoA FY 2013 President’s Budget

• Moves SHIPs, Title V• Virtually all line items level funded• Zeros out Program Innovations in Title IV• Smaller elder justice ask from FY ’12• Only cut restored is Alzheimer’s grants,

partially

Status of FY 2013 Appropriations

Senate Labor/HHS bill was marked up in mid June

But House starting from different spending level, may go this week

Discretionary Levels• Senate -- $1.047

trillion*• House -- $1.028 trillion• Current Year = $1.043

* Set by Budget Control Act, Summer 2011

Senate OAA Funding

• National Family Caregiver Support Program, III E of OAA: Level Funded at $153.6 million

• Respite Gets Win: $4.99 mil recommended (vs. $2.49 now)

• Alzheimer’s Demos in OAA: Level funded ~$4 million, was $11.4 mil in FY 11, President asked $9.4 mil

Sequester!

• Budget Control Act: If Congress fails to act by the end of the calendar year, $1.2 trillion in automatic, across-the-board cuts would take effect through a sequestration process

• Cuts expected to be 8.4% for programs like OAA• Exempted programs: Social Security, Medicaid and

several low-income entitlement programs. (Medicare benefits could not be cut either, but provider payments could be reduced by up to 2 percent.)

• Takes effect on January 2, 2013

HEALTH CARE

Affordable Care Act

• Supreme Court Upholds mandate, but denies Administration ability to strip Medicaid $ from states unwilling to expand Medicaid coverage to 133% FPL.

• States can “just say no.”

Affordable Care Act

• But if they do say no, here is what happens:– People btwn state’s Medicaid eligibility

%age FPL and 100% FPL are stranded without coverage

– Between 100-133% FPL would receive subsidies to buy private insurance on state exchanges

Affordable Care Act

• Example: Arkansas• 0-17% FPL = Medicaid coverage, as is• 17-100% FPL = Zero coverage or help• 100-133% FPL = Subsidies for policies

bought on the state’s (or fed) exchange

• But if they take ACA offer, 0-133% FPL eligible for Medicaid coverage

Affordable Care Act

• Rebalancing LTSS (BIPPA, Community First Choice)

• Care Transitions – 30 contracts out• ADRCs – ACL putting $ out• Medicare Wellness Visit, No Co-Pays for

Preventive Services• Prevention and Public Health Fund

What’s Not in ACA Implementation Plans?

• CLASS Act– Obama Admin opted not to implement this

national, voluntary long-term care insurance program

– House efforts to repeal it– Advocates want to keep the conversation going. If

not CLASS, then what?

OAA REAUTHORIZATION

Reauthorization of OAATIMELINE

•AoA Listening Sessions, Winter 2010•Groups survey members, write recommendations, release by spring 2011•Senate HELP Subcomm holds listening sessions, summer 2011•Act “expires” Sept. 30, 2011•Fall 2011: AoA shares tech asst for Hill

NAC Recommendations

• Caregiver assessment allowable under NFCSP

• More $ for NFCSP!• Clarify/expand definition of qualified

caregiver (so older adults caring for adult children with disabilities are covered, as well as being inclusive of variety of family and care structures)

AoA Suggestions

• Add parent caregiver of adult children with disabilities to NFCSP• Consolidate nutrition programs• Expand the # of programs allowed to cost-share (would still

need waiver from AoA to test cost-sharing for nutrition and case management)

• Incentive payments to enhance Aging Network capacity• LTCOP updates• Establish minimum Title III funds for State Legal Asst Devel

Program; states pick which if any AAAs to fund• Transform Title IV

What are the issues under discussion?

• Cost-sharing• Coordination (e.g., ADRCs, community health

centers)

• Smaller programs shifting to be state-run (e.g., legal services, III D)

• Elder justice: APS, LTCOP

What are the issues under discussion?

• Investment in workforce, specifially home care, direct care workers

• Caregiver assessments• Financial exploitation• Home care ombudsmen programs

and home care consumer bill of rights

S. 2037• Consolidates $ for C1 and C2 but sets floors: 40/35/25• Recommends increases of 50% in funding for nutrition,

supportive services, SCSEP and HPDP• Encourages collaboration with Federally Qualified Health Centers• Add “economic security” to objectives, redefine “greatest economic

need” to 200% FPL• Redefines “greatest social need” to include LGBT individuals

and older adults with HIV/AIDs or Alzheimer’s• Senior Center Modernization encouraged• Legal services: establishes new definition “integrated legal assistance

delivery system”; boosts state’s role over current local role for AAAsAnd more…

Senator Kohl’s Bill

• Strengthening Services for America’s Seniors Act (S. 1819), Sen. Herbert Kohl (D-WI) & Sen. Barbara Mikulski (D-MD)– Voluntary caregiver assessment; states apply

for funding from AoA; data reporting – LTCOP: expands resource center,

strengthens program, encourages resident and family councils

– Advisory Council on legal assistance services

(NAC and n4a approved!)

OAA Reauthorization Timeline

• Senate Democratic Bills• July Mark-Up in Senate HELP Comm?• House still busy with other bills• Forecast is very unclear• We will need strong advocacy to make

Congress pay attention, get it right and keep it moving!

LIFESPAN RESPITE

H.R. 3266

• October 2011, Reps. Jim Langevin (D-RI) and Cathy McMorris Rodgers (R-WA) introduced the Lifespan Respite Care Reauthorization Act of 2011 in the US House of Representatives.

H.R. 3266

• Competitive grants to states in collab with state respite coalition

• Must work with ADRCs• Authorization levels:

FY 13 $5 mil FY 14 $10 mil FY 15 $15 milFY 16 $17.5

ALZHEIMER’S PLAN (NAPA)

CMS Regs on HCBS

• CMS rulemaking on Medicaid LTSS provisions, incl. definition of HCBS

• They also asked for feedback on proposed caregiver assessment

• NAC, NFCA and FCA

MEDICAID MANAGED LTSS

So how did we get here?

• Factors behind the rush to Medicaid Managed Care for Duals, LTSS:

– States’ economic situations– Evolving care models; move to better integrate

care (e.g., care transitions)– Affordable Care Act rebalancing, integration,

etc. provisions

Percent Change in State Tax Revenue 2007 to 2011

www.nasuad.org

AK

ME

MD NV

UT

WY

AZ NM

TX

ND

SD

NE

KS

OK

AR

LA

MN WI

IA

MI

IL MO

IN OH

KY TN

MS AL GA SC

FL

NC

VAWV

PA

NY

VT

NH

CO

Percent Change -30% to -20%

-20% to -10%

-10% to -5%

-5% to -1%

1% to -1%

1% to 6%

Above 6%

CA

OR

WA

ID

MT

HI

DE

NJCT

RIMA

Source: NASUAD’s analysis of data from U.S. Census Bureau, Survey of State Government Tax Collections, 2007-2011 reports.

What is Medicaid Managed LTSS?

Capitated MMLTC• State Medicaid Agency and contractors enter into agreement under

which contractor accepts risk of providing defined Medicaid LTC services

• Alternative types of MMLTC capitation packages:– Medicaid-covered LTC services only – All Medicaid-covered acute and LTC services– All Medicare and Medicaid-covered services

(additional plan contract with CMS required for Medicare portion)

ManagedManagedCareCareContractorContractor

ManagedManagedCareCareContractorContractorCapitated

Payment

StateStateMedicaidMedicaidAgencyAgency

StateStateMedicaidMedicaidAgencyAgency

ProvidersProvidersProvidersProviders

NegotiatedPayments(FFS, Per Diem, etc.)

Source: AARP Public Policy Institute Issue Brief, Medicaid Managed Long-Term Care, 2005.

MMLTC is Delivery Model States Use in Lieu of Fee-for-Service

It’s about the money!

• Ideally, states would save dollars by…– Coordinating care?– Coordinating care while shifting some of the costs

of dual eligibles to Medicare?– Capitated rates to control costs of care?...but it’s also about reducing risk (from escalating

costs) and predicting future expenditures! Value from paying one entity a fixed, capitated rate vs. paying multiple entities various fees per service.

Grassroots Activities• Reach out to newer MoCs to educate

them about your agencies and the work you do

• Stay in regular contact with Members and staff

• Invite your local congressional offices to do site visits, attend events

• Come to DC in April. Aging Policy Briefing, April 22-23, 2013.

Contact Info.

Amy E. Gotwals, agotwals@n4a.org

www.n4a.org/advocacywww.twitter.com/n4aACTION www.twitter.com/amygotwals