Advocacy

Briefing Room:
Keeping you posted on Washington and its effects on academic family medicine.

January 25

Last night President Obama delivered his third State of the Union address.  Though healthcare reform is certainly among the president's most significant domestic legislative accomplishments, it received little attention in last night's speech.  He signaled his continued commitment to making sure we "do not go back to the days when health insurance companies had unchecked power to cancel your policy, deny you coverage, or charge women differently from men" and cited healthcare legislation as an example of his willingness to reach across party lines, as the law "relies on a reformed private market, not a government program."  As expected, President Obama chose to focus the bulk of his speech on jobs and the economy, laying the groundwork for his coming re-election campaign.

December 23

In a last minute vote before the holiday weekend, Congress passed a bill allowing a two month extension of the the payroll tax holiday and unemployment benefits. Also included in the bill is a temporary fix to delay the 27.4% cut to Medicare physician payments that was set to go into effect January 1st.  This is a temporary, two month patch, and we continue to wait for a permanent, sustainable solution.

December 16

After a day of difficult negotiations, last night the leadership of both parties announced agreement on a conference report for FY 2012 appropriations.  The House and Senate are expected to vote on the conference report today, just in time to avert a government shutdown when the current continuing resolution expires at midnight.  The conference report includes level funding for Section 747, primary care training under Title VII, continuing our current level of just over $39 million.  This will leave approximately $4 million available for new grants, but HRSA has not yet decided how those funds will be used.  For more information on health appropriations, see the tables available on pages 95-126 of the document available here.

December 7

Tomorrow, December 8th, the House and Senate plan to hold a joint Conference Committee meeting on the outstanding fiscal year 2012 appropriations bills.  With the current continuing resolution set to expire December 16th, both parties want to achieve passage of the funding bills to avoid having to deal with them next year or having to pass more temporary spending fixes.  One of the more contentious bills the Conference Committee will consider is the Labor/HHS appropriations bill, which contains funding for the Title VII primary care cluster.  On the House side, the primary care cluster was zeroed out for 2012, while the Senate version maintains current appropriations levels.  Tomorrow's bipartisan, bicameral meeting will attempt to reconcile the two sides on this and other issues.

November 22

Yesterday, members of the supercommittee officially admitted defeat.  Formally known as the Joint Select Committee on Deficit Reduction, the bipartisan group, made up of members of both the House and Senate, was unable to reach an agreement on how to cut $1.2 trillion from the deficit over the next decade.  While their failure may not be in the best interests of the country as a whole, this does mean no immediate threat of cuts to Medicare graduate medical education funding (GME).

November 18

This morning President Obama signed the Consolidated and Further Continuing Appropriations Act, which contains a continuing resolution providing funds that will allow the government to continue operating until December 16, 2011.  The bill passed in the House by a vote of 298-121 and in the Senate by a vote of 70-30.  This will not affect key STFM programs, like Title VII, and as Congress will be unable to pass additional funding measures before the December recess, we expect to see another continuing resolution in December.

November 10

In a letter sent today, The Advisory Committee on Training in Primary Care Medicine and Dentistry (ACTPCMD) urged Congress during the ongoing deficit negotiations to seek fiscally responsible ways to sustain funding for graduate medical education (GME) and prioritize primary care GME. They asked Congress to seriously consider the importance of the training of primary care physicians, for patient care and the US health care system in order to help meet the nation’s growing health care demands. With rising projections of workforce shortages to meet the health care needs of a growing and aging population, ACTPCMD supports the expansion of GME positions in the area of primary care, where there is substantial current demand and anticipated growing shortages – especially in rural and underserved areas. Read the letter

September 22

Today, just a day after soundly defeating a bill that would have kept the government running after September 30, the House passed a new version of the continuing resolution (CR). Labeled “Dead in the Water” by Senate democrats, this new version was defeated in the Senate today. The bill had more disaster aid than the previous version, but was paid for by cuts to programs such as one designed to advance clean energy innovation. We are back to square one with time running out. House and Senate are off this coming week, with no plans to return until Monday, October 3, three days after the current fiscal year ends and funding to keep the government going runs out.

September 21

The House of Representatives voted down a measure that would keep the government running beyond the end of this fiscal year. September 30 marks the last day for Congress to pass and the President to sign a continuing resolution (CR) that funds government programs until November 18, giving time for Congress to finalize the FY2012 spending bills. If they fail to meet that target date the government will shut down. Complicating the matter is a scheduled recess next week coinciding with the Jewish New Year. At issue is the desire of republican members of the House to cut additional spending, and concern from democratic members that more needs to be spent on disaster aid.
 
Also, the Senate Appropriations Committee produced a Labor/HHS Appropriations funding bill for FY2012. It includes small cuts to NIH, a small increase in funding for Community Health Centers, and level funding for most health professions programs and the National Health Service Corps. Actual dollar amounts for Title VII programs are not available in writing however, so it’s difficult to confirm this. The House has not met to draft its version of a FY2012 Labor/HHS appropriations bill, and is likely not to do so in the near future. Read the Committee’s press release 

September 15

August 18

To meet the goals of the new Budget Control Act of 2011, the Office of the President sent a memo to heads of departments and agencies providing guidance on fiscal year 2013 budgets. The memo asked that 2013 budgets be at least five percent below 2011 enacted discretionary appropriation unless the agency had been given explicit direction otherwise. The memo went on to request that submissions also identify additional reductions that would bring budgets to a level at least 10 percent below 2011 enacted discretionary appropriation. Agencies were asked to look at eliminating low-priority and ineffective programs while consolidating those that are duplicative. Read the memo.

August 16

Last week, CMS sent letters to hospitals in certain states notifying them about the distribution of additional residency positions under the Affordable Care Act. The ACA reduced the caps for certain teaching hospitals not training to their cap and authorized the redistribution of these caps. States that will get some of these slots include Montana, Idaho, Alaska, Wyoming, Nevada, South Dakota, Mississippi, Florida, Puerto Rico, Indiana, Arizona, Georgia, Louisiana, Alabama, and New Mexico. Hospitals in these states should receive letters by the end of the week. To see more information about the redistribution of these residency positions go here.

August 12

The 11th Circuit Court of Appeals* today ruled that the health care reform law’s requirement that nearly all Americans buy insurance is unconstitutional. The suit was brought by 26 states — nearly all led by Republican governors and attorneys general. The panel also said that the law’s expansion of Medicaid is constitutional, ruling against the states. The federal government will have 90 days to appeal to the Supreme Court or ask the entire 11th Circuit to review the ruling. The Department of Justice is expected to appeal.

*Established by Congress in 1981, the US Court of Appeals for the Eleventh Judicial Circuit has jurisdiction over federal cases originating in the states of Alabama, Florida, and Georgia. The circuit includes nine district courts with each state divided into Northern, Middle, and Southern Districts.

August 12

Congressional leadership made their selections this week for the Supercommittee created by the Budget Control Act (the debt limit legislation). The co-chairs of the Committee will be Senator Patty Murray (D-WA) and Representative Jeb Hensarling (R-TX). The Senators on the Committee will be Democrats Max Baucus (MT), John Kerry (MA), and Jon Kyl (AZ), and Republicans Pat Toomey (PA), and Rob Portman (OH). The Representatives will be Republicans Dave Camp (MI), and Fred Upton (MI), as well as Democrats, James Clyburn (SC), Xavier Becerra (TX), and Chris Van Hollen (MD). Interestingly, Michigan and Texas each have two members represented out of 12.

August 9

This morning, HHS Secretary Sebelius and HRSA Administrator Wakefield announced awards of $28.8 million to 67 community health centers for new access points in 23 states and Puerto Rico. Sec. Sebelius described the CHC program as a top priority of the Obama Administration and said they are taking steps to improve the health care workforece, eliminate copays and deductibles on preventive services and promoting health lifestyles with the First Lady's Lets Move program.

Sec. Sebelius and Dr Wakefield said these grants will provide 286,000 new patients with access to CHS services. Of the 67 grants to establish new access points, Dr. Wakefield said 10 are brand new sites. In total, HRSA received 810 grant applications. The full press release and more information can be found here.

August 1

Late Sunday, President Obama came to a tentative agreement with Congressional leaders on a plan to increase the debt limit before the August 2nd deadline and work to reduce the deficit. As part of the plan, the debt limit would be raised $2.4 trillion in a multi-part process, with an initial increase of $400 billion and subsequent automatic increases through 2012 that can only be stopped through 2/3 votes by both the House and Senate. In exchange for the debt limit increase, domestic discretionary funding will be decreased by around $900 billion over 10 years. Further cuts proposed by a 12 member committee are expected to reach $1.5 trillion. If cuts do not reach $1.2 trillion, automatic cuts would be enacted, split 50-50 between defense and domestic programs including Medicare payments. Votes for the agreement are expected to begin as soon as this afternoon, but passage is not assured as Speaker of the House John Boehner (R-OH) is trying to wrangle a majority.

July 26

Over the weekend, bi-partisan negotiations to raise the debt ceiling and pay down the deficit broke down. Speaker of the House John Boehner (R-OH) and Senate Majority Leader Harr Reid (D-NV) then each unveiled plans to raise the debt ceiling and work on reducing the deficit. It is unclear what specific cuts are part of each plan. 

The plan by Sen. Reid would increase the debt ceiling by $2.4 trillion immediately, while reducing discretionary spending by $1.2 trillion, $400 billion in interest savings, and $100 billion in mandatory cuts. The $100 billion in mandatory savings includes $40 billion from reducing fraud and abuse, $30 billion in reforms to Fannie Mae and Freddie Mac, between $10 and $15 billion in agricultural reforms, and cuts to higher education programs. 

The plan put forth by Speaker Boehner would raise the debt ceiling by $2.5 trillion in a two-step process. The first debt limit increase of between $900 billion to $1 trillion would be accompanied by discretionary spending caps designed to achieve 10 year savings of $1.2 trillion from annual appropriations bills. The second installment of up to $1.6 trillion would be contingent on first achieving $1.8 trillion in savings largely from government benefit programs and entitlements such as Medicare and Medicaid.

July 22

From Politico- "The Senate has blocked the conservative version of a deficit reduction plan known as "Cut, Cap and Balance" on a party line 51-46 vote. The procedural vote was to "table" the bill, meaning a "yes" vote would yank the bill from the Senate floor. The House passed the same plan earlier this week, and the Senate rejection comes as House Speaker John Boehner and President Barack Obama have already moved on to negotiations on a different deficit reduction plan."

July 21

Bi-partisan talks to cut the deficit and raise the debt ceiling got a boost of momentum when the "Gang of Six," a bi-partisan group of Senators, unveiled a joint plan to cut the deficit by 3.7 trillion over ten years. The proposal is light on specific details necessary to reach this figure but tasks committees to find savings in six months time and immediately cuts $500 billion for FY 2012. The Finance Committee would have to reform the tax code, permanently reform or replace the SGR with full offsets, and find an additional $202 billion/ $85 billion in savings while maintaining essential health care services. President Obama endorsed the plan, but House Republicans have yet to signal whether they support the plan. A full summary can be found here.

July 7th

Today, President Obama and Vice President Biden will meet with Democratic and Republican leaders from the House and Senate in hopes of coming closer to an agreement to raise the debt ceiling and reduce deficits and debt. Politico is reporting that tentative agreements from previous meetings include about $1.1 trillion in savings from future defense and domestic appropriations and up to $400 billion in savings attributed to Medicare and Medicaid savings. It has been rumored that Medicare GME is on the table and targeted for cuts. Disagreements on increasing tax revenue and the total cuts have hampered discussions. The treasury department has said a deal must be reached by August 2nd to avoid default.

June 28th

Today, Sen. Joe Lieberman (I-CT) and Sen. Tom Coburn (R-OK) introduced legislation designed to save Medicare a reported $600 billion over 10 years, according to the CBO, the President's Bipartisan Fiscal Commission, and internal Senate estimates. Savings would come from restructuring benefits, raising the eligibility age, increasing Part B premiums based on income, and phasing out Medicare payments for bad hospital debt. The summaries provided by the Senators do not give any indication that Medicare GME is targeted by this proposal, but we will continue to monitor the progression of the proposal. A summary of the proposal can be found here while a summary of savings can be found here.

June 27th

Today, President Obama is scheduled to meet separately with Majority Leader Reid and Minority Leader McConnell in an effort to broker a deal that will allow for a vote to raise the debt ceiling and address the deficit. The Treasury Department says that the ceiling must be raised by August 2nd to prevent the US from defaulting. One of the items said to be on the table to reduce the deficit is cutting Medicare GME funding. CAFM and AAFP sent a joint letter to President Obama and Congressional leaders today on possible cuts to Medicare GME funding and can be seen in the Advocacy in Action page.

June 23rd

Majority Leader Eric Cantor (R-VA) and Senate Minority Whip Jon Kyl (R-AZ) withdrew from the bi-partisan deficit negotiations led by Vice President Biden. They stated it was because there was an impasse over Democrats insistence on raising taxes. The bi-partisan group is trying to negotiate a deal to allow for a vote to raise the debt ceiling, which the Treasury Department says needs to be done by August 2nd.

June 16th

This week, the Medicare Payment Advisory Commission (MEDPAC) issued its report to the Congress, titled "Medicare and the Health Care Delivery System." The report deals with issues including the Sustainable Growth Rate and FQHC's. A link to the full report can be found by clicking here

June 15th

On June 13th and 14th, the HRSA Advisory Committee on Training in Primary Care Medicine and Dentistry met via webinar to edit their upcoming 9th report, titled Innovations and Incentives to Prime the Pump of Primary Care. On the 14th and 15th, the Council on Graduate Medical Education met via webinar to discuss the topic of GME financing in a time of reduced financial resources and to work on the development of a topic for the publication of a 21st report sometime next year. The meeting discussed topics including legislative updates, how to develop alternative financing mechanisms and introduce accountability into Medicare Graduate Medical Education.

The Congress is continuing to work on the development of the FY 2012 agency budgets, with action expected at the committee level by the end of July, but this is dependent on the ongoing debt ceiling negotiations which will dominate the news until the August 2nd deadline. Government Relations staff is closely monitoring these negotiations and tracking if programs that affect academic family medicine will face cuts.

June 7

Comment period for Accountable Care Organization Proposed Rule Closes. Yesterday, STFM, along with the other CAFM organizations and the AAFP submitted comments on the CMS proposed rule. Our major concerns regarding the proposal as written relate to the impact on graduate medical education, particularly for primary care training if Medicare GME is included as part of the shared savings benchmarks, how primary care is defined, and the viability of primary care practices to be involved due to overly burdensome reporting measures and lack of clarity regarding distribution of shared savings to primary care practices. Read our Comment Letter here.

May 18th

Yesterday, agencies submitted their FY 2011 spending plans, as required by the Continuing Resolution agreed to on April 15th. HRSA received funding at $6.274 billion. Title VII is funded at a level of 272.5 million, with $39 million for Section 747 Primary Care workforce development. Other program funding levels include $314 million for the National Health Service Corp and $2.185 billion for Community Health Centers. A full chart outlining FY 11 funding levels can be found here

April 18th

On Friday, Congress passed the agreed to budget funding the government for the rest of FY 2011. In this agreement, $38 billion is cut from FY 2010 levels. HRSA is funded at $6.274 billion, but it is unclear what level programs like Title VII will receive funding wise. Agencies now have 30 days to submit funding levels to the Congress, and at that point we will know what program specific funding levels will be. 

Also on Friday, the House of Representatives passed Rep. Paul Ryan's (R-WI) proposed budget for FY 2012. In his proposed budget, $5.8 trillion is cut from FY 2010 funding levels. Funding for Function 550 discretionary public health programs, which includes Title VII, fluctuates over a 10 year span with a low of $376 billion in FY 2016 and a high of $405 billion in FY 2021. The budget also makes changes to Medicare and Medicaid, changing the programs to a "voucher based system" and block grant program respectively. The budget faces considerable opposition in the Senate and is not expected to pass.

April 11

Late Friday night, President Obama, House republicans, and Senate Democrats came to an agreement on the FY 2011 budget. Under the agreement, the budget is expected to cut around $38 billion from FY 2010 levels. Specific details are still being worked out, but a few of the cuts include cutting $13 billion from the Departments of Health and Human Services, Department of Education, and Department of Labor. The bill also would cut $2 billion used to establish private non-profit health insurance cooperatives and a program designed to allow low income workers use employer money to buy coverage through the exchanges, both created as part of the Affordable Care Act. 

The government was operating under a Continuing Resolution, funding the government at FY 10 levels. If an agreement was not reached by Friday at midnight, there would have been a government shutdown for the first time since 1995. 

We will relay details of the budget agreement as they emerge.

April 6

Yesterday, Rep. Paul Ryan (R-WI), Chairman of the House Budget Committee, released his proposed budget for FY 2012. In his budget, he proposes cutting $6.6 trillion in the next ten years compared to President Obama's proposed budget and $5.8 trillion from current funding levels. He also proposes ten years of funding for function 550 discretionary public health programs which includes four years of cuts to a level of $376 billion in FY 2016 then increases to $405 billion by FY 2021. 

The budget includes drastic changes to Medicare and Medicaid, converting Medicare to a "premium support" system that subsidizes private plans beneficiaries choose while Medicaid would be converted to a block grant for states. There is no mention of changes to Medicare GME in the budget from what we can tell in the sparse details. 

Other measures include a proposed ten year fix to the Sustained Growth Rate and medical liability reform that caps non-economic damages in medical liability lawsuits. The budget also includes a full repeal of the Affordable Care Act and all its components and funding.