Home Health & Hospice Week

Legislation’s road to enactment riddled with potholes.

Ding dong, the employer mandate is dead — or at least on its way to becoming so. So indicates the draft legislation released by House Republican leadership to repeal and replace Obamacare — aka, the Affordable Care Act. The new American Health Care Act contains sweeping changes ranging from insurance requirement eliminations to tax credit and subsidy changes to drastic Medicaid reform. The bill also keeps some of the most popular parts of the ACA — the ban on denying insurance coverage to people with pre-existing conditions and on lifetime coverage caps, and the provision allowing people to remain on their parents’ insurance until age 26.

Home care providers and their representatives are cautiously assessing the 123-page bill’s potential impact on them. The proposed legislation is “a combination of positives, negatives, and speculative impacts,” says William Dombi, VP for law for the National Association for Home Care & Hospice.

Positives

The most immediate benefit in the bill for home health and hospice agencies with 50 or more employees is likely the elimination of the so-called employer mandate. Under that provision, the ACA required that all businesses with 50 or more full-time equivalent employees provide health insurance to at least 95 percent of their full-time employees and dependents up to age 26, or pay a fee.

The employer mandate requirement, which was effective in January 2016, “has raised home care costs, particularly for companies providing Medicaid and private pay personal care,” Dombi says in a statement. “The problems created by that mandate have been compounded by the fact that no state Medicaid program has raised payment rates to cover this added cost.”

While it’s not a change, preservation of another part of the ACA will be helpful to hospices, points out Judi Lund Person with the National Hospice & Palliative Care Organization. “One section of the Affordable Care Act that providers have implemented throughout the country allows children with Medicaid or CHIP coverage who are hospice-eligible to receive hospice and other treatments and services concurrently,” Lund Person tells Eli. “NHPCO is pleased that the proposed legislation preserves a part of the ACA that allows Medicaid and CHIP programs to cover palliative care for children with advanced and life-limiting illness. This important policy offers much needed support and comfort to families at a difficult time and is the type of common-sense policy that we can all agree on.”

Negatives

The new bill “repeals the 6 percentage point bonus in the federal match rate for community-based attendant services and supports, and would return to prior law without the 6 percent bonus,” says a House Energy & Commerce Committee summary of the bill. The bonus was available under the ACA’s Community First Choice benefit, Dombi notes.

Since it became available, eight states have adopted the program — California, Connecticut, Maryland, Montana, New York, Oregon, Texas, and Washington, he says. “At least an additional five states have submitted applications or are actively considering” the benefit, including Alaska, Arkansas, Colorado, Minnesota, and Wisconsin, Dombi adds. “This program was designed to encourage states to rebalance spending on long-term services and supports away from institutional care and towards home care.”

Cutting this funding could decrease access to home care services and drive up the costs of Medicaid.

For example: Connecticut is “a state that has made tremendous progress on rebalancing from nursing homes to home and community based services,” says Deborah Hoyt of the Connecticut Association for Healthcare at Home. New analysis of the state’s most recent data from 2015 shows “home and community based-providers saved the Connecticut Medicaid budget $108 million as a result of rebalancing and home-based care provision to Medicaid clients, compared to what it would have cost in institutions,” Hoyt tells Eli. And “in total, over the past 10 years, our provider sector has saved Connecticut Medicaid over $1 billion.”

These types of savings are “very impactful … as Connecticut is facing multi-billion annual projected state budget deficits in the next two fiscal years,” Hoyt notes.

Unknowns

A huge change in the bill, the proposed shift of Medicaid to a per capita caps program, is an element that could swing either way for home care, Dombi observes. “This would limit the amount of federal Medicaid payments to the states while increasing the state’s flexibility in structuring its Medicaid program benefits,” he explains. “That flexibility may favor or disfavor home care.”

In other words, states that feel home care will lower their institutional costs may throw more resources home care’s way. Hopefully savings like the ones shown in Connecticut will sway lawmakers to increase utilization of the program. But “there isn’t any clarity” on that point, Hoyt concedes.

On the other hand, states that are looking to trim costs may find the non-acute home care benefit an easy mark, observers worry.

Even if states continue to support home care, “the payment cap will restrict the opportunity for home care benefit expansions,” Dombi points out. “As such, the home care impact can vary widely between and among the states.”

Marcia Tetterton with the Virginia Association for Home Care and Hospice suspects “states like Virginia that have lean Medicaid programs may not fare well under block grants.”

Note: Read the bill text at https://energycommerce.house.gov/sites/republicans.energycommerce.house.gov/files/documents/AmericanHealthCareAct.pdf. Read an eight-page summary of the bill at https://energycommerce.house.gov/sites/republicans.energycommerce.house.gov/files/documents/Section-by-Section Summary_Final_pdf.