By Marissa Evans, CQ Roll Call

July 16, 2015 -- Independent Alaska Gov. Bill Walker said last week that he'll use a fiscal maneuver to extend health care coverage to nearly 42,000 low-income residents by Sept. 1 without his Republican-controlled legislature's approval.

"This is the final option for me," Walker said at a news conference announcing the plan. "I've tried everything else. One thing you have to learn about me is I don't give up, and I won't give up."

Walker said he'll accept the federal government's extra funding for states that are expanding Medicaid plus money from the Alaska Mental Health Trust Fund Authority to bring his plan to fruition. Expanding Medicaid, the state's health insurance program for low-income individuals, would bring in $146 million in new federal money for the state's 2016 fiscal year and more than $1 billion by the 2021 fiscal year.

The governor said he'll send the funding plan to the state's Legislative Budget and Audit Committee, which reviews requests to accept non-general funding when the legislature is out of session. The committee has 45 days to recommend whether the state should take the money, but its recommendation is not binding. The waiting period also gives the legislature time to reconvene for a special session if its leaders wish.

This is the eighth time an Alaska governor has used this maneuver, Walker said.

"We're going to help those that need our help," Walker said. "It's good for them, it's good for Alaska and it's good for our economy. We're not going to step away from this opportunity to help fellow Alaskans."

The announcement comes on the heels of a contentious budget battle between Walker and Alaska Republicans. The governor tried to include the Medicaid expansion funding in his 2016 budget, but the legislature stripped it out. Walker's expansion proposals were not taken to the floor for a vote during the latest session or the last two special sessions.

Alaska Republicans tried to put a line item in the 2016 budget that would prevent Walker from using funds to expand the program. However, according to a May memorandum by Alaska's Legislative Affairs Agency, this tactic was unconstitutional.

Under the 2010 federal health care law, states can accept federal funds to expand Medicaid eligibility to people with incomes at or below 138 percent of the federal poverty level. The federal government pays 100 percent of the cost until next year, when the U.S. subsidy begins to decline, falling to 90 percent by 2020.

Twenty-eight states and the District of Columbia are participating in the expansion already. States that did not expand their Medicaid programs under the health care law receive an average reimbursement of just 57 percent of their cost. Montana voted to expand Medicaid this past legislative session, but the plan is still pending approval from the Centers for Medicare and Medicaid Services.

Republican-led legislatures around the country have been adamant about not expanding Medicaid, citing doubts that the federal government will keep its financial promise to cover the cost and that extending coverage will further stretch state budgets.

Matt Salo, executive director for the National Association of Medicaid Directors, said Walker's unilateral action had to be a tough decision because "it's the nuclear option." A move like this could further polarize the governor's office and the legislature.

"It's not unique to Alaska that it's going to take multiple efforts to get it through," Salo said in an interview. "Medicaid expansion can happen anywhere, but the question ultimately isn't 'Do we provide better health insurance options to low-income people,' it's 'How do we best do it,' and that's what a lot of these conversations are," Salo said. "There are modifications or improvements that may be a better fit for our states."

Walker isn't the first governor to attempt to bypass the legislature to expand Medicaid, though efforts by Missouri Gov. Jay Nixon and Democratic Virginia Gov. Terry McAuliffe failed.

Montana House Republicans this year voted down Gov. Steve Bullock's Medicaid expansion plan in March but soon came up with their own proposal requiring beneficiaries to contribute to premiums and encouraging their participation in job training. Bullock signed off on the plan in April.

Meanwhile, Utah Republican Gov. Gary R. Herbert has appointed a commission working toward a July 31 deadline to negotiate the meshing of his Healthy Utah expansion plan with the House's Utah Cares plan, an alternative Medicaid expansion plan.

By Rebecca Adams, CQ Roll Call

July 15, 2015 -- Anecdotal reports of narrow networks in health law exchange plans are borne out by a new analysis showing that marketplace insurance covered fewer hospitals, cancer and cardiology specialists, mental health providers, and primary care physicians than commercial plans offered in the same geographic area.

The analysis of offerings for the 2015 plan year by the Avalere consulting firm found that networks in exchange plans had 42 percent fewer oncology and cardiology specialists and 32 percent fewer mental health and primary care providers than the average commercial plan in the area. The exchange plans covered 24 percent fewer hospitals than commercial plans on average. The commercial plan average was based on networks in both group plans and other individual plans outside of the marketplace.

The marketplaces created by the health care law are supposed to have adequate networks, but consumers have complained that the networks are sparse compared to other insurance plans.

Consumers who get care from out-of-network providers face higher costs—and the spending does not count toward out-of-pocket limits in the health law.

Avalere CEO Dan Mendelson noted in a statement that insurers sometimes seek to keep premiums low by being selective about which providers they will cover.

About 36 percent of the people who are eligible for exchange coverage had enrolled as of March 31, according to a separate analysis by the nonpartisan Kaiser Family Foundation that used data that the Centers for Medicare and Medicaid Services released in June.

Avalere examined the largest region in the five states with the greatest health exchange enrollment—Florida, California, Texas, Georgia, and North Carolina.

By Kerry Young, CQ Roll Call

July 16, 2015 -- Congress sent to President Barack Obama a two-year extension of a pilot program that tests whether house calls can save Medicare money by helping preserve the health of very frail elderly people, including those suffering from dementia or those needing help feeding themselves.

Last week, the House cleared by voice vote a bill (S 971) that changes the Medicare Independence at Home demonstration program from a three-year project into a five-year one. Although it was created as part of the Affordable Care Act, there was little controversy about its extension. The Senate Finance Committee moved the bill by unanimous consent before the Senate approved it by voice vote in April. The House Ways and Means Committee then approved it by voice vote in June.

The Centers for Medicare and Medicaid Services (CMS) provides no initial direct investment for the groups participating in the Independence at Home project, said Terri Hobbs, the executive director of Housecall Providers Inc., which was one of the biggest initial winners in the program. Instead, the participating organizations volunteer to be judged on their performance with an intention of later securing incentive payments.

"It was a little tough to not have any influx of support at the beginning," said Hobbs, whose Portland, Oregon-based group has been in operation since the mid-1990s.

Housecall Providers was awarded a payment of $1.23 million from CMS, when it was judged to have met quality measures set by the agency while also saving money. Only about half of the participants, or nine of 17 groups, qualified for the initial set of incentives payments. These ranged from $2.9 million awarded to the Visiting Physicians Association unit in Flint, Michigan, to $275,427 for Durham, North Carolina-based Doctors Making Housecalls, CMS said in a statement last month. The Independence at Home program, which kicked off in 2012, was estimated to save $25 million in its first year.

To qualify for care through the program, a person needs to have at least two chronic conditions, such as dementia and congestive heart failure, and also need a caregiver's help with at least two tasks of daily living, such as eating, walking or bathing. These patients also should have had at least one hospitalization and received rehabilitation services or another form of post-acute care within a year of their enrollment.

CMS said that all of the organizations participating in the program were found to have improved quality of care by at least three of six measurements. On average, results for the more than 8,400 elderly people in the program showed that there were fewer hospital readmissions within a month of an initial stay. CMS also observed a reduction in the use of hospital outpatient and emergency department services for conditions such as diabetes, high blood pressure, asthma, pneumonia, or urinary tract infection.

Among the organizations that didn't qualify for bonus payments was Boston Medical Center, which narrowly missed its financial target. CMS had set a benchmark of $4,781 per person in the Boston Medical Center program, which was judged to have had costs of $4,741. (Housecall Providers, in comparison, had a target of $3,568 and was judged to have costs of $2,434). Boston Medical Center intends to continue with the program, said Melissa Monahan, a spokeswoman.

"We know from our experience that the vast majority of older adults want to remain at home and we will continue to work hard to investigate outcomes to support this model of care for our patients," she said.

Beyond gathering data on the care of these patients, the Independence at Home program may change attitudes broadly about how medical care is delivered, said Bruce Leff, the director of the geriatric health services research program at Johns Hopkins School of Medicine.

There was a shift in the last century away from providing care at home, said Leff, who served on a technical expert panel that advised CMS on the development of quality indicators used in the Independence at Home program. In the past, most care was handled in the community. Leff, who is 54, said he remembers getting house calls from doctors while growing up in the Bronx, he said.

"That all went away," he said.

People began to value more highly the care that could be delivered in hospitals equipped with high-tech equipment, even in cases where the technologies may not provide much health benefit, he said. The money from insurers, including Medicare, incentivized this trend as well.

"There's a tremendous inherent bias toward facility-based care and interventions," said Leff, who also is co-director of the elder house call program at Hopkins.

By Rebecca Adams, CQ Roll Call

July 15, 2015 -- Former Centers for Medicare and Medicaid Services (CMS) Administrator Marilyn Tavenner will succeed Karen Ignagni as president and CEO at America's Health Insurance Plans (AHIP).

"There is no better individual than Marilyn to lead our industry through the increasingly complex health care transformation that is underway," said AHIP Board Chairman Mark Ganz in a statement after the board unanimously elected Tavenner. "As the unifying voice for our industry, AHIP and its members are uniquely positioned to address the pressing health care challenges facing consumers, and Marilyn is a recognized leader who brings the experience, tenacity, and dedication to achieve our advocacy goals and to move the health system forward in a way that is patient-centered."

Tavenner said she is "honored to join this association and to lead this industry that is deeply committed to improving care delivery and affordability for individuals and families."

The announcement comes weeks after the nation's largest health insurer, UnitedHealth Group, announced it would quit AHIP as of June 30. United is one of the founding members of the Better Medicare Alliance, a group that was created in December to advocate for higher payments to private Medicare Advantage plans. Former Democratic congresswoman Allyson Y. Schwartz was recently named president and CEO. The other major funders of the alliance are Humana and Aetna Inc.

Ignagni, who had been a top lobbyist for the industry for 22 years, left AHIP earlier this summer to take the helm at EmblemHealth in New York. AHIP Interim CEO Dan Durham led the trade association after Ignagni's departure.

Before leading CMS, Tavenner was Secretary of Health and Human Services for the state of Virginia. She held a number of executive roles with the Hospital Corporation of America, where she was president of HCA's Central Atlantic Division as well as group president of Outpatient Services. She will take the helm of the insurers' group on Aug. 24.

By Paul M. Krawzak, CQ Roll Call

July 15, 2015 -- House Budget Chairman Tom Price confirmed last week the Budget Committee will not act on reconciliation legislation until after the August recess. He added that House Republicans are still debating what to include.

"What we were told in Budget was leadership did not anticipate doing anything on reconciliation at the Budget committee level until after the break," the Georgia Republican said after speaking at the American Action Network, a right leaning non-profit advocacy organization.

The three authorizing committees in the House and two in the Senate charged with writing reconciliation legislation are not expected to report their proposals to the Budget committees until September at the earliest, missing the July 24 deadline in the fiscal 2016 budget resolution (S Con Res 11).

Reconciliation is an expedited process allowing legislation to be passed in the Senate with a simple majority, bypassing the usual 60-vote requirement for a bill to be considered. But its use is constrained by sometimes complicated rules that are interpreted by the Senate parliamentarian, including a prohibition against "extraneous" matter such as provisions that would not result in a change in revenue or spending.

Price noted that missing the deadline does not prevent moving reconciliation legislation. The deadline "is an internal deadline and it's not hard and fast," he said. "It doesn't preclude anything."

He said House GOP leaders "clearly think that it's better from a policy standpoint to push this off."

"We'll do reconciliation," Price said. "The question is what should the package include." Some House Republicans would prefer to use reconciliation for something other than repeal of the health care law (PL 111-148, PL 111-152), since it is almost certain that President Barack Obama would veto a repeal and Republicans would be unable to override the veto in the narrowly divided Senate.

The focus of reconciliation is still a partial repeal of the health care law, according to lawmakers. But other approaches are being advocated including changes to welfare programs.

Senate Majority Leader Mitch McConnell, R-Ky., said last week that Senate Republicans are considering using budget reconciliation "for repealing as much of Obamacare as is reconcilable" but he gave no timeline for action.

Price said much of the pressure to use reconciliation for health care law repeal is coming from the Senate. The original House budget resolution envisioned a broader reconciliation effort touching on non-health-care related programs as well, but the House narrowed its reach in conference negotiations with the Senate.

"I think that one of the big drivers for using reconciliation for Obamacare or the ACA has tended to be the desire in the Senate to have Senate Republicans be able to have an opportunity to be on record in how they stand on the ACA or Obamacare," he said, referring to the title of the law, the Affordable Care Act. "This is a dynamic process and so times change. The situation changes even not just from month to month but from day to day."

Price said Budget Committee Republicans are kicking off an effort to build a coalition among members of the public to overhaul federal programs such as Social Security, Medicare and Medicaid, which he said will run out of money at projected growth rates. "Our goal is to restore the trust for all generations by motivating our colleagues and the American people to get involved, to engage our fellow citizens in a discussion and to build a consensus, a consensus toward positive solutions."

By Rebecca Adams, CQ Roll Call

July 13, 2015 -- The long-term care industry voiced concern about the cost of complying with a 403-page rule that proposed the first comprehensive updated requirements for facilities in 24 years. The proposal was published in the Federal Register early last week.

During the first year, the industry is expected to pay more than $729 million to meet the new requirements and about $638 million per year after that. The average cost would be $46,491 in the first year for each of the 15,691 long-term care facilities affected by the rule and $40,685 per facility in later years, according to the Centers for Medicare and Medicaid Services (CMS).

"We would oppose such a large unfunded mandate, especially given the overall narrow margins of 1 percent to 3 percent that MedPAC calculates for skilled nursing care centers," said American Health Care Association Senior Vice President of Quality and Regulatory Affairs David Gifford, referring to Medicare Payment Advisory Commission calculations.

Gifford said that the industry could support some of the changes in the rule because many nursing home and other long-term care facilities have already incorporated similar changes. But the costs are a major concern.

"We are still working through it to see what we support and what we do not support. CMS estimates the cost to comply is significant," said Gifford.  "We will need to examine to see what parts of the rule increase operators' costs and if there are alternate, more efficient ways to comply."

Consumer advocates want more requirements in the massive rule, which notes that the way that skilled nursing homes and other facilities operate has changed significantly since the rules were last updated in September 1991.

The National Consumer Voice for Quality Long-Term Care and the American Association for Justice, which represents trial lawyers, met with Office of Management and Budget officials on June 19 to ask that the rule include specific ratios of staff per patients so that there would be enough staff members to take care of the residents, many of whom are frail. The groups asked for requirements that nursing homes or other facilities provide for at least 4.1 hours of direct nursing care per resident and have at least one registered nurse on duty at all times. The coalition said that certified nursing assistants should have at least 120 hours of initial training.

But the rule does not include those requirements.

"We note that some commenters requested changes that conflicted directly with statute," the rule states, regarding concerns about staffing levels.  "Moreover, some of the comments we received were outside the scope of our review...However, we have shared all of the stakeholder's comments with appropriate CMS staff for their review."

The differing perspectives of the groups are likely to be incorporated in comments to pressure CMS to change the proposal. CMS officials are accepting comments for 60 days. The agency said it had already received input from about two dozen groups that knew CMS was working on a rule.

The regulation would affect a wide range of issues, including hospital admissions, efforts to reduce the use of antipsychotic medications, initiatives to prevent infections, the expansion of residents' choices in mealtimes and living conditions, new credentialing requirements that physicians be licensed to practice medicine in the state, visitation rights and new standards on mental health care.

The rule would require patients to receive an in-person evaluation by a qualified medical professional before being transferred to a hospital and that a patient's physician be notified before the resident is sent to a different facility.

White House Conference

The proposal was released on the same day that the White House held a national conference on aging where officials announced a series of other initiatives related to the aging of the population. Those include:

• Updates to the Department of Health and Human Services' national plan to address Alzheimer's disease to reflect actions that the government will take over the next year.
• A National Institutes of Health workshop on elder abuse research featuring researchers, clinicians and others.
• An online course launched by the Centers for Disease Control and Prevention offering continuing education credits to medical professionals about how to make falls prevention a routine part of care.
• The Health Resources and Services Administration will award $35 million to health profession training programs to expand geriatrics education to prepare the health care workforce to respond to the needs of an aging population.