Live from DC: A Federal Policy Update

1. Live from DC:A Federal Policy Update Amy Gotwals, Senior Director, Public Policy & Advocacy National Conference for Caregiving Coalitions, Denver, CO July 10, 2012

2. n4a’s 2012 Policy Priorities • Reauthorization of the OAA • Enhancing the Health of Older Adults • Care Transitions/Care Coordination • Medicaid Managed Care • ADRCs • Prevention and Wellness • Fiscal Year 2013 Appropriations • Livable Communities for all Ages • Senior Mobility Options

3. 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

4. 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)

5. Budget & FUNDING

6. 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

7. 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

8. 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 Status of FY 2013 Appropriations

9. 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

10. 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

11. Health CARE

12. 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.”

13. 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

14. 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

15. 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

16. 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?

17. OAA REAUTHORIZATION

18. 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

19. 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)

20. 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

21. 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

22. 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

23. 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…

24. Senator Kohl’s Bill • Strengthening Services for America’s Seniors Act (S. 1819), Sen. Herbert Kohl (D-WI) & 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!)

25. OAA Reauthorization Timeline • 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!

26. LIFESPAN RESPITE

27. 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.

28. 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

29. Alzheimer’s plan (NAPA)

30. 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

31. MEDICAID MANAGED LTSS

32. 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

33. Percent Change in State Tax Revenue 2007 to 2011 ME WA MN ND NH MT VT NY WI MI OR MA SD WY ID RI CT PA IA NV NJ OH IL NE UT IN WV MD DE VA CO MO KY KS CA NC TN AZ NM OK AR SC Percent Change -30% to -20% -20% to -10% -10% to -5% -5% to -1% 1% to -1% 1% to 6% Above 6% TX GA AL MS LA AK FL HI Source: NASUAD’s analysis of data from U.S. Census Bureau, Survey of State Government Tax Collections, 2007-2011 reports.

34. What is Medicaid Managed LTSS? 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) MMLTC is Delivery Model States Use in Lieu of Fee-for-Service StateMedicaidAgency ManagedCareContractor Providers Capitated Payment NegotiatedPayments(FFS, Per Diem, etc.) Source: AARP Public Policy Institute Issue Brief, Medicaid Managed Long-Term Care, 2005.

35. 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.

36. 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.

37. Contact Info. Amy E. Gotwals, agotwals@n4a.org www.n4a.org/advocacy www.twitter.com/n4aACTIONwww.twitter.com/amygotwals