Live from DC:
A Federal Policy Update
Amy Gotwals, Senior Director, Public
Policy & Advocacy
National Conference for Caregiving
Coalitions, Denver, CO
July 10, 2012
n4a’s 2012 Policy Priorities
• Reauthorization of the OAA
• Enhancing the Health of Older Adults
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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 OAA
TIMELINE
• 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 AAAs
And more…
Senator Kohl’s Bill
• Strengthening Services for America’s
Seniors Act (S. 1819), Sen. Herbert Kohl (DWI) & 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
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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 mil
FY 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
WA
ME
ND
MT
N
V
H
NY T
MA
RI
CT
NJ
PA
MN
OR
WI
SD
ID
WY
IA
NE
NV
UT
CA
CO
MI
IN
KS
MO
OK
TX
VA
KY
TN
MS
NM
MD DE
WV
IL
AR
AZ
OH
AL GA
NC
SC
Percent Change
-30% to -20%
LA
-20% to -10%
AK
HI
FL
-10% to -5%
-5% to -1%
1% to -1%
1% to 6%
Source: NASUAD’s analysis of data from U.S. Census Bureau,
Survey of State Government Tax Collections, 2007-2011 reports.
Above 6%
www.nasuad.org
What is Medicaid Managed LTSS?
MMLTC is Delivery Model States Use in Lieu of Fee-for-Service
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)
State
Medicaid
Agency
Capitated
Payment
Managed
Care
Contractor
Providers
Negotiated
Payments
(FFS, Per Diem,
etc.)
Source: AARP Public Policy Institute Issue Brief, Medicaid Managed Long-Term Care, 2005.
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/advocacy
www.twitter.com/n4aACTION
www.twitter.com/amygotwals