Health Centers on the Hill

by Heather Foster, MPH

The Congressional Health Centers Caucus was established in the U.S. House of Representatives over a decade ago as a means for Members of Congress to identify themselves as health center supporters, educate their colleagues on the importance of health centers, share information on health center priorities, and champion the Health Centers program.

From its inception, the caucus was bipartisan. Last year, freshman Representative Tim Griffin (R- AR) announced that he would step up to fill a co-chair vacancy in the caucus—joining co-chairs Mike Capuano (D-MA), Kay Granger (R-TX), and Danny Davis (D-IL),.

Joining the Caucus is a great way for Members of Congress to stay apprised of any legislative efforts that could impact the health centers in their district. For health center advocates, increasing the number of Community Health Center Caucus members is a key way to demonstrate the broad bipartisan support for health centers in the House.  The Caucus also serves as an educational tool by disseminating pertinent information to interested Members of Congress and their staffs.

This month is a great time to ask your Representative to join the Caucus as the co-chairs are currently seeking new Members!  A list of the current Community Health Center Caucus membership can be found here and a Dear Colleague letter asking Members to join the Caucus can be found here.

by Heather Foster

This week marks the first week that Congress will officially be back in session since the holidays, although it will be a short session both this week and next as the Republican and Democratic Caucuses will each spend the next two weekends respectively coming together to discuss their goals for the year and try to come together as a party.  This means that relatively little will happen during the rest of January, although we do know that the 20 representatives from both chambers and both parties who have been named as “conferees” on the Payroll Tax cut and physician payment extension are working together behind the scenes to develop a longer-term extension of these and other provisions. A deal on this package should be hammered out in just a few short weeks.  It is also likely that we will see true efforts on both sides of the aisle to change to the auto-sequestration (automatic across-the-board cuts) established as part of the Budget Control Act and which we blogged about last year.  As you’ll remember, the spending cuts are scheduled to go into effect in January , 2013 and would mean a significant reduction of the defense budget so it is likely we will see proposals resurface in an attempt to forestall some of these and other cuts.

Beyond that, the conventional wisdom in Washington is that it is unlikely that much substantive work will get done in Congress this year.  It will be a contentious year as both parties gear up for a derisive election come fall, and it is safe to assume that we will see more of the same in terms of spending fights and deficit reduction efforts.  The Bush-era tax-cuts are also set to expire at the end of this year, which undoubtedly will also influence the ongoing rhetoric and create yet another deadline for some kind of action, likely in a lame-duck session after the election.

What this means for health center advocates is that we should not expect significant legislative changes to the programs we care about this year, but we will have a busy year nonetheless, focusing on annual funding bills and continuing to lay the groundwork for future significant action on health care policy issues. On the local front, this is the year to continue to focus on getting Members of Congress and Hill staffers out to your health center, and to increase your advocacy efforts, using our new and improved Campaign for America’s Health Centers website.  Check it out today and stay tuned for updates all year here at Health Centers on the Hill!

by NACHC Federal Affairs

Brief Overview

As we look back on 2011, a year that has seen so many twists, turns, dips, peaks, and valleys, it certainly seems like we’ll remember this as a year that could give the scariest amusement park ride a run for its money. And speaking of money, the lack thereof has been the central focus for Congress. This was a year in which we saw two appropriations cycles crammed into one legislative year, a debt crisis, a Super Committee, countless deficit reduction gangs and proposals, and those are only the main storylines.

What has all this meant for health centers? In this year-end post, we’ll recap what these various events have meant for health centers and the patients and communities we serve. But first, a few big picture takeaways from this year.

First, in this new era of austerity, no existing health centers saw a reduction in their federal grant in either of this year’s enacted appropriations bills. Indeed, while the growth of the Health Centers program envisioned under health reform was significantly scaled backed this year, overall, the program continued to grow both in FY2011 and FY2012.

Second, the Health Centers program has maintained bipartisan support, even in this increasingly polarized climate.

Third, the need for health center expansion is not going away. The demand for affordable and high quality primary care services delivered in the very communities where people live continues to grow. Over 700 communities still have applications pending for new health centers and many more are eagerly awaiting the next opportunity to apply. Virtually every existing health center has identified unmet needs in their community that could be met with additional funding.

Lastly, but perhaps most importantly, when the health center grassroots rally and are united in telling the health center story, success is possible, even in the most challenging of climates. NACHC’s Campaign for America’s Health Centers website launched this year to empower health center advocates with new resources to be successful.

2011 has been a wild ride and coming into 2012, we can expect another active year on Capitol Hill. Health Centers on the Hill will continue to be your resource for what is happening in the nation’s capital and how it impacts health centers.  But first, let’s take a look back at 2011.

Way Back at the Beginning. . .

This year has been so jam-packed that it is almost hard to remember where it all began last January. 2011 saw a new House Republican majority assume power on Capitol Hill and a Senate Democratic majority that was significantly decreased in size. In the House, there were over 80 new freshman members, many self-identified as “Tea Party Republicans,” arriving in Washington with a determination to lower spending. The House and Senate were now held by two different parties and an era of divided government had returned to Washington, DC. What followed was a year of showdowns, standoffs, and a number of bruising battles on spending and revenue as the two sides sought to enact their competing visions for the country.

FY2011 Appropriations (aka 2011 Round One) 

One of the first major pieces of legislation the new divided Washington had to tackle was the FY2011 Appropriations bills which the previous Congress had failed to resolve before it adjourned.  The two sides started miles apart. The House proposed over $100 billion in cuts as compared to President’s Obama’s budget request and over $60 billion in cuts as compared to FY2010. The Senate proposed exponentially smaller cuts. For health centers, the House proposal would have meant a $1 billion reduction in Health Center discretionary funding, and though the Affordable Care Act (ACA) Health Center Fund would have lessened the impact of this proposal, ARRA-funded New Access Points (NAPs) and Increased Demand for Services (IDS) funding were fully at risk. The Senate proposal kept health centers’ discretionary funding whole, allowing ACA’s entire FY2011 Health Center Fund to be used for both the continuation of ARRA activities and growth as envisioned in health reform.

The final FY2011 appropriations bill, negotiated as the government teetered on the brink of shutdown late last winter, included nearly $40 billion in cuts to discretionary spending. For health centers, this package included a $600 million reduction to discretionary spending.  This new discretionary funding level, together with the $1 billion in FY2011 funding available for health centers through the Community Health Center (CHC) Fund from the Affordable Care Act (ACA), meant a net increase of approximately $400 million in funding for FY2011. Most of this increase, however, was needed to continue ongoing operations. Specifically, this funding was needed to build the 127 ARRA NAPs and all IDS activities into the Health Centers program’s base operations (at a cost of $250 million), meaning continued access to care for the over 3 million new patients added through these grants. Another $55 million was needed to keep the FTCA fund solvent.

The agreement left less than $100 million to support expansion efforts, efforts we had hoped would total over $700 million. HRSA had previously announced several FY2011 funding opportunities, including $250 million for NAPs, $270-$335 million for expanded services (ES) for existing centers, and $10 million for planning grant awards. Over 800 health centers submitted NAP applications, and virtually every health center nationwide applied for ES funding. As a result of the FY2011 reduction, 67 NAPs were funded instead of the planned 350 and no ES awards were able to be funded. Planning grants were funded as planned. The new era of austerity had an immediate and sizable impact on health center expansion plans.  

The Debt Limit and Super Committee (aka 2011 Rounds Two and Three)

As you’ll remember, this year also featured an unprecedented debate on Capitol Hill about whether to raise the Federal “debt ceiling.”  The debt ceiling sets a limit on the United States’ borrowing authority and is usually raised by Congress with limited debate. This year was a marked departure from past precedent.

The debt ceiling was used as a leverage point by Congressional Republicans to force action on deficit reduction and ultimately led to the bipartisan Budget Control Act of 2011. The Budget Control Act provided the means for Congress to raise the debt ceiling but also created a select group of Senators and Representatives (known as the Super Committee) charged with finding at least $1.2 trillion in deficit reduction which then would need to be approved by Congress writ-large. If the Super Committee failed to reach its goal, a series of automatic, across-the-board spending cuts known as sequesters would go into effect to reach the $1.2 trillion target.

After numerous proposals were traded back and forth during months of work, the Super Committee ultimately was not able to reach agreement.  Republicans insisted on cuts to and restructuring of entitlement programs such as Medicaid and Medicare, and Democrats insisted on significant revenue increases in order to consider these changes. Neither side was willing or able to meet the other’s demands.

Throughout the process, the Medicaid program was one of the programs most vulnerable to potential cuts thanks to the fact that it was exempted from any automatic across-the-board cuts (as would a number of other programs meant to benefit low-income individuals and families).  Accordingly, NACHC was very concerned about significant cuts to Medicaid writ-large or changes that could undermine the health center Medicaid prospective payment system (PPS).  NACHC engaged with our Partnership for Medicaid to push back on large-scale changes or cuts to Medicaid, including a Capitol Hill strategy as well as print and radio ads. In addition, NACHC mounted a large advocacy campaign to make sure that Members of Congress—particularly those on the Super Committee— were familiar with the PPS and why it is so important to health centers’ very viability. 

While the Super Committee ultimately failed to reach consensus, many documents were leaked throughout the process and based on those documents and other reports, we do not believe health centers were targeted in any of the draft proposals. Without all of the significant grassroots efforts with Senators and Members of Congress throughout the process, there might have been a very different outcome.  As we look to the coming year, we don’t expect that these broader deficit reduction issues will go away; many Members of Congress vehemently object to the across-the-board cuts that are now slated to go into effect in 2013, so we expect to see additional deficit reduction discussions arise in the context of altering these cuts.

FY2012 Appropriations (aka 2011 Round Four)

After Congress finally completed the bruising and nail-biting FY2011 Appropriations process, it was hard to believe there was still a whole year’s worth of appropriations work to do, but do it they did.

For health centers, NACHC put forward a FY2012 ask that sought to restore $200 million of our base appropriation that had been cut in FY2011, but also to ensure that the ACA Health Center Fund be left intact. With the Health Center Fund’s $1.2 billion for FY2012, this would lead to an overall FY2012 increase of $400 million.

The process started out on a positive note with bipartisan letters in both the House and Senate supporting health center funding, a rarity in this climate. In the House, Reps. Gus Bilirakis (R-FL) and Frank Pallone (D-NJ) led the effort and in the Senate, Senators Debbie Stabenow (D-MI) and John Boozman (R-AR) authored the health center support letter.

As the process continued, the House and Senate both forward bills that protected all existing health centers from reductions, though they got there in very different ways. The Senate acted first, with Labor-HHS Appropriations Subcommittee Chairman Tom Harkin (D-IA) introducing a bill that would have kept health center discretionary funding level, while also protecting the Health Center Fund; the result was a total program level of $2.8 billion, an increase of $200 million. That bill passed the Labor-HHS Subcommittee and the Full Appropriations Committee but not the full Senate. House Labor-HHS Subcommittee Chairman Denny Rehberg went next, posting a draft Labor-HHS bill online which would have provided health centers with a $995 million discretionary increase while eliminating the ACA Health Center Fund FY2012 allocation. The result would have been a restoration of the FY2011 base cut, but a total program level of $2.6 billion or level program funding.  That bill did not move any further due to the concerns of some on the committee that it did not cut enough overall.

The final bipartisan FY2012 conference report was released in December. After months of Hill and grassroots advocacy, the final bill mirrored the Senate proposal and provided the Health Centers program with nearly $2.8 billion, meaning a $200 million increase. This was a tremendous outcome, particularly in this period of fiscal austerity. The conference report left HRSA with the flexibility to decide on the distribution of the program increase. NACHC expects to see what HRSA’s plans are for this funding in the coming months.  

Conclusion

All in all, after a wild ride, health centers ended up the year on very positive note. As we turn the page to 2012, and what promises to be another interesting year (see our blog on the year ahead here), we can say for sure that 2011 is a year we won’t soon forget.

by Heather Jinkins

As you may have read, Congress approved the FY 2012 Omnibus Appropriations Act over the weekend. NACHC’s statement on its release last week can be found here. The White House stated today that the President will sign the measure once he officially receives it, which given the time consuming process of proofreading such a large bill  before it is transmitted to the President can take several days. The President is expected to receive and sign the bill by tomorrow.

In what is now a separate fight, Congress has been wrangling over an extension to the payroll tax cut. The House rejected the Senate-passed plan today and is now requesting a House-Senate conference to hammer out differences. A recent NACHC blog about the Payroll Tax, the “Doc Fix” and “Extenders” can be found here.

To  clarify, the two measures were initially tied together politically, but not substantively, but now have been separated for all practical purposes. This is important to note in light of speculation that the President would hold his signature on the omnibus as leverage for the payroll tax cut extension. The White House dispelled such speculation as Kenneth Baer, communications director at the Office of Management and Budget stated today, “The president is focused on getting the business of the American people done, and once we receive the omnibus funding bill, he will sign it.”

by Heather Foster

After years of slow Medicaid payments to providers, two California Representatives—Rep. Brian Bilbray (R) and Rep. Anna Eshoo (D)—introduced legislation that would require that all providers, including health centers, be paid in a timely manner.  Current law requires that many providers be reimbursed for 90% of services within 30 days of receiving claims and 99% of services within 90 days. While this protection applies to health care practitioners practicing in individual or group practices and shared health facilities, it does not apply to health centers, despite their having a disproportionate number of patients insured through Medicaid.  H.R. 3587, the Fair Pay to Medicaid Providers Act would extend these protections to all providers—including hospitals, nursing homes, and health centers. 

As many of you are all-too-aware, withholding or delaying Medicaid payments undermines health centers’  financial stability given their high volume of Medicaid patients and relatively small cash-flow as compared to many larger providers.  Extending the same payment protections that currently apply to other Medicaid providers to health centers is a commonsense, fair, and no‐cost change to existing law.

We will continue to keep you apprised of any developments with this legislation and any efforts to pass it on Capitol Hill.  Similarly, please keep us posted if you have had trouble receiving timely Medicaid payments in your state.  Please email Heather Foster at hfoster@nachc.org with any examples of delayed payments so that we can be sure to give legislators on Capitol Hill the most accurate information on the impact this would have for health centers.  Thank you!

 by Heather Foster

On Saturday, Congress seemed poised to wrap up 2011 with a bang and pass one final piece of compromise legislation that would address any as yet unresolved issues and unextended programs.  The Senate passed legislation by a vote of 89-10 that would extend many programs for two additional months—allowing sufficient time for Congress to debate how to pay for longer-term extensions.

Included in the legislation was the “doc fix,” or adjustment to the Medicare Sustainable Growth Rate (SGR) formula to prevent a reduction in Medicare payments to most physicians (though not physicians practicing in health centers) of nearly 30 percent.  In addition, the bill included an extension of Unemployment Insurance and Transitional Medical Assistance, or “TMA,” which provides benefits for individuals transitioning from welfare to work.  Most notably was the “Payroll Tax Extension,” which would save most working individuals approximately $1,000 annually on taxes.  The legislation was paid-for entirely with fees on mortgages paid for by Fannie Mae and Freddie Mac. 

The Senate passed this legislation on Saturday with a bipartisan vote of 89-10 and with the expectation that the House would shortly do so as well, however, rank and file House Republicans expressed their outrage at the legislation over the weekend and have said that they will not vote for this legislation.  The House prefers  a year-long extension that it recently passed which includes significant spending cuts as offsets. That bill would resolve the outstanding issues until after the 2012 elections.  Information on the House-passed bill, the Middle Class Tax Relief and Job Creation Act can be found here. 

It is unclear exactly how this disagreement will play out in the final days of 2011, but the House plans a vote related to this legislation later today so keep your eyes on the blog and we will be sure to keep you posted!

by Kaitlin McColgan

On Monday, word got around Washington that the House and Senate appropriators had worked through the weekend and all but reached an agreement on an omnibus appropriations bill containing the nine remaining spending bills for FY2012, including the Labor-HHS bill which also funds the Health Centers program. The expectation was that the agreement would be posted Monday night.

However, as of this writing, the final conference report has not been released. Some reports indicate there are still a couple of outstanding issues to be negotiated, but the more likely reason for delay is the separate ongoing dispute over extending the payroll tax holiday. The White House and Senate are far apart from the House in terms of how to extend the payroll tax and other expiring provisions, or more specifically how to pay for them.  The omnibus appropriations bill, which seems to have bipartisan support ,is now seemingly being delayed until the payroll tax issue can be negotiated as well. The White House had signaled it will not approve an omnibus until presented with a payroll tax bill the President can sign.

So, once again, appropriations seems  to be at an impasse. The good news is that this time, the delay does not seem to be because of intractable differences between the two sides on funding. The bad news: no one seems to know what the next steps are on the payroll tax and appropriations seems to be in an indefinite holding pattern for the moment.

The waiting game continues, but hopefully with an end in sight.

by Heather Jinkins

Appropriators continue to work on a final spending package to complete the nine remaining appropriations bills for FY 2012. As you’ll recall, the President signed into law Nov. 18 the first year-long FY 2012 spending package which included funding for Agriculture/FDA, Commerce-Justice-Science and Transportation-HUD. The package included another short term Continuing Resolution (CR) to keep remaining programs funded through Dec. 16, when it is set to expire. This leaves eleven days to complete a final package encompassing nine bills and submit it to floor action. Congressional staff are said to be working on a final package, it is still entirely possible that we will see another CR, either short-term or year-long.

Please check back with Health Centers on the Hill for the latest on the Appropriations process!

By Kaitlin McColgan

As Alex Sange reported previously, the Joint Select Committee on Deficit Reduction (better known as the Super Committee) has now officially failed to reach agreement on a proposal of any size to reduce the deficit. As we reported, under the Budget Control Act (BCA), the law that established the Super Committee, this will prompt a process known as sequestration- more on that later. This does not mean, however, that deficit reduction efforts in DC are over or that sequestration as outlined in the law is a done deal. While much can change in the months ahead, here are some key factors that health center advocates should be aware of in light of the Super Committee’s failure.

Proposals Raised in the Super Committee Are Not Going Away
You might call it gone but not forgotten. Even though the Super Committee failed to reach agreement on a final plan, the draft proposals the two parties traded – and in particular cuts to programs that appeared on both sides’ lists, will continue to serve as a starting point whenever spending offsets (or “pay-for’s”) are needed for larger packages or as part of future deficit reduction efforts. In addition, if Congress looks to alter BCA’s sequestration (see below), proposals from the Super Committee are likely to be candidates for a replacement effort. This makes the fact that health centers were not targeted directly in any Super Committee proposals all the more important.

Sequestration is a Complicated Process, the Specific Impact of Which Has Not Been Officially Estimated To-Date
In general, the Budget Control Act now calls for a process known as “sequestration” in order to reach the $1.2 trillion in deficit reduction the Super Committee failed to come up with. Half of the savings ($600 million) are supposed to come from security spending and the other half from non-security spending. In theory this is achieved through an across the board cut to all programs in government occurring in January 2013. However, given the many excluded programs and limitations in the law, as well as the fact that in the non-security realm the cuts will need to be applied to both mandatory and discretionary spending, the process gets more complicated. Of note, Medicaid is completely exempted from the sequester.

NACHC has been working for months to ensure that any cut to health centers is minimized. It is our interpretation that the cuts to both Health Centers program discretionary and mandatory spending are limited to 2%. This is important given estimates that in general, non-security programs may be facing cuts in the realm of 9.3% or more. That said, it is impossible to know how the sequester will be applied to individual programs until the Office of Management and Budget (OMB) offers its official judgment, which we hope will occur sometime early in the New Year.

Some in Congress Are Already Challenging BCA’s Sequestration Process
And yet, all of these interpretations are based on the notion that the BCA’s sequester will be implemented. At this juncture, many Members of Congress have begun to raise questions about the impact of the sequester, such as what impact the defense cuts would have on national security. There is a possibility that before the cuts go into effect in January 2013, they will be altered in some way. If so, the $1.2 trillion figure would likely not be altered (indeed President Obama has indicated he would veto anything that undid that deficit reduction total), meaning new cuts will have to replace any blunting of BCA’s sequester. As part of a replacement effort, everything in government would likely be “back on the table,” though items that were in the Super Committee’s various proposals would likely be a starting place.

Discretionary Budget Caps Are Still in Place
Finally, it is also important to note that one major deficit reduction component of BCA is already in effect: hard caps on discretionary spending. These caps mean the law now requires Congress to meet certain annual spending targets. One immediate example of the impact of these limits is the current continuing resolution the government is operating under, which funds programs at 1.5% below FY2011 levels- a necessity in order to comply with BCA.

All in all, many DC observers expect the year ahead to be highly contentious as the two sides dig in during an election year. After the election, with the Bush tax cuts slated to expire and the sequester looming, there may be one more effort to strike the “grand bargain” on deficit reduction that has so far eluded Congress. Stay tuned in the months ahead as Health Centers on the Hill works to keep health center advocates up to speed on all the latest developments here in DC.

by Joe McKelvey, Capital Link; and Alex Sange, NACHC

As noted here, last week, President Obama signed a so-called FY12 “minibus” appropriations bill into law, which included funding for several less controversial FY12 Appropriations bills including the Agriculture Department (USDA).

Historically, health centers in rural areas have benefited from several programs within USDA Rural Development including grants, loan guarantees and direct loans for facility improvements and construction.  The new law will dramatically reprioritize these programs within USDA.  Specifically, the Direct Loan program, which provides extremely low interest loans for health centers and other community facilities, has been dramatically expanded from slightly less than $300 million in FY11 to $1.3 billion in FY12.  These loans are currently available at historically inexpensive rates – 3.75% for 40 year terms.  Health centers and other essential community facilities in towns or rural areas with populations up to 20,000 can apply, and loan funds can be used for construction, expansion, or improvement of a community facility.  This could even include costs to acquire land, to pay professional fees, to purchase equipment and, in some cases, to refinance existing debt.

Unfortunately, while the FY12 legislation increases the amount available for direct loans, it reduces the amount available for Rural Development loan guarantees and grants.  Effectively, this means USDA will be steering applicants toward their direct loan program and away from loan guarantees and grants.  More information about the USDA Rural Development Direct Loan and other financing assistance programs is here.