Year-End Advocacy Wrap-Up

Thank you to all of our advocates for your efforts in fighting for the 30 million Americans with kidney disease. Whether it was contacting your representative or senators via email, phone or in-person, or encouraging someone to get screened for kidney disease, the American Kidney Fund (AKF) could not serve its mission without the important work of its Advocacy Network.

In 2017, AKF had more than 150 meetings on Capitol Hill with congressional staff and members, and had 26 in-district meetings that included the participation of AKF advocates. We also had several meetings with administration officials at the Department of Health and Human Services (HHS) and meetings with the office of state insurance commissioners in 10 states. In March we held our biggest Advocacy Day ever, in which we brought a group of our advocates to Washington, D.C. for advocacy training and meetings with their elected officials on issues important to end-stage renal disease (ESRD) patients on dialysis.

The focus of many of our meetings was charitable premium assistance and how AKF’s Health Insurance Premium Program (HIPP) helps so many people with kidney disease access health coverage. We advocated for changing federal regulation to require health insurers to accept health insurance payments made by charitable organizations on behalf of patients with chronic illnesses. As a result of our efforts, nearly 200 Congressional Democrats and Republicans signed a letter to the HHS Secretary urging the department to protect the right of Americans to rely on help from charities to afford health insurance coverage. In October, legislation was reintroduced in the House of Representatives that would require insurers to accept charitable premium assistance from non-profit organizations like AKF.

We look forward to continued collaboration with our advocates in 2018 in helping fight kidney disease and to improve the lives of those affected by it.

H.R. 3976: Access to Marketplace Insurance Act

Rep. Kevin Cramer (R-ND) reintroduced legislation that would require insurers to accept health insurance premium payments from non-profit charitable organizations like AKF. H.R. 3976, the Access to Marketplace Insurance Act, would prohibit insurance companies from discriminating against individuals with end-stage renal disease (ESRD) and other chronic conditions, and protect a patient’s ability to choose the coverage that best fits their needs. The bill was introduced with 15 original co-sponsors, both Republicans and Democrats, and now has 70 co-sponsors.

AKF has worked closely with Rep. Cramer’s office over the last few years on this bill, dating back to when it was first introduced in 2015.   One addition that was made to this year’s bill is language that authorizes the Secretary to make and enforce regulations that ensures individuals eligible for Medicare and Medicaid receive proper education regarding all of the coverage options, including qualified health plan coverage.

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H.R. 3867: Creating Chronic Kidney Disease Medicare Demonstration Programs

Rep. Markwayne Mullin (R-OK) introduced legislation that would create two voluntary care management demonstration programs in Medicare for chronic kidney disease. H.R. 3867 aims to improve the early detection and treatment of patients with chronic kidney disease through coordinated care, improved patient engagement, and a monthly care management payment to providers linked to performance measures. The bill’s original co-sponsors are Reps. George Holding (R-NC), Linda Sanchez (D-CA), and G.K. Butterfield (D-NC), and the bill currently has 10 co-sponsors.

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H.R. 4143: Dialysis PATIENTS Demonstration Act of 2017

Rep. Jason Smith (R-MO) reintroduced legislation that would establish a demonstration program for Medicare beneficiaries with ESRD. Under H.R. 4143, the Dialysis PATIENTS Demonstration Act of 2017, the ESRD Integrated Care Demonstration Program would assess the effects of alternative care delivery models and payment methodologies on patient care improvements. Eligible participating providers, including renal dialysis facilities, nephrologists, and physicians, and eligible participating partners, including Medicare Advantage plans, may form an ESRD Integrated Care Organization to integrate care and serve as the medical home for an eligible beneficiary under Medicare Parts A and B. The bill’s original co-sponsors are Reps. Cathy McMorris Rodgers (R-WA), Earl Blumenauer (D-OR) and Tony Cárdenas (D-CA), and the bill currently has 114 co-sponsors.

Companion legislation, S. 2065, was also reintroduced in the Senate by Sen. Todd Young (R-IN), who was the lead sponsor of the House bill in the last Congress when he was a representative. The Senate bill’s original co-sponsors are Sens. Bill Nelson (D-FL), Dean Heller (R-NV), and Michael Bennet (D-CO), and the bill currently has 6 co-sponsors.

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Tax Reform Legislation

Congress passed sweeping tax reform legislation on December 19-20 along party lines and the President will soon sign it into law. Health care-related issues have played a prominent role in the tax reform debate, particularly in securing the vote of Sen. Susan Collins (R-ME). The final bill includes a repeal of the Affordable Care Act’s (ACA) individual mandate, which requires individuals to purchase health insurance or pay a penalty. The Congressional Budget Office (CBO) has estimated that repeal of the individual mandate would result in budget savings of $338 billion over 10 years, due to decreased government spending on subsidized ACA coverage. CBO also estimates that 13 million more people would be uninsured and premiums would increase by 10 percent, as healthier people choose to go without coverage, resulting in a less healthy and therefore more expensive risk pool.

To assuage her concerns on repealing the individual mandate and to secure her vote on the tax reform bill, Collins demanded and received assurances from Senate Majority Leader Mitch McConnell (R-KY) and the President that they would support passage of two separate bills to stabilize the ACA insurance markets: legislation introduced by Sens. Lamar Alexander (R-TN) and Patty Murray (D-WA) that would fund cost-sharing reduction subsidies for two years, and a bill introduced by Collins and Sen. Bill Nelson (D-FL) that would fund short-term, state-based high-risk pools or reinsurance programs. Collins believes these stabilization bills will help mitigate the negative effects of repealing the individual mandate. However, CBO has estimated that passage of the Alexander-Murray bill would do nothing to blunt the effects of repealing the individual mandate, and Democrats argue that the long-term damage caused by eliminating the mandate far outweighs any positive effects of passing the two short-term stabilization bills. Another matter of uncertainty is when and how the House and Senate would pass these bills—if they may be included in must-pass spending legislation, and whether opposition from House Republicans will prevent their passage.

Another notable health care provision in the final version of the tax reform bill is that it preserves the deduction for medical expenses that exceed 10 percent of an individual’s adjusted gross income, and for two years decreases that threshold to 7.5 percent. While most Americans do not claim this deduction, it does provide tax relief for many middle class people with high-cost chronic illnesses, people caring for family members with a disability, and individuals paying for long-term care.

A significant concern underlying Congress’ tax reform efforts is that the bill’s passage will trigger automatic spending cuts to mandatory spending programs, including Medicare. 2010 “Pay as you go” (PAYGO) legislation requires that all passed bills cannot collectively increase the estimated national debt. If a passed bill does violate PAYGO, then an automatic cut across mandatory spending programs would be required to offset the cost, including cuts to Medicare capped at 4 percent. Because the tax reform bill is scored to increase the deficit by about $1.5 trillion over the next decade, it would trigger a Medicare cut of $25 billion per year. Congress can waive PAYGO rules through legislation, but it requires 60 votes in the Senate. Republican leadership in the House and Senate have insisted that they will not let an automatic cut go into effect, and they may include a PAYGO waiver in must-pass spending legislation.

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CMS Final Rule: Medicare ESRD Prospective Payment System and Quality Incentive Program

On November 1, the Centers for Medicare and Medicaid Services (CMS) published a final rule that implements updates and revisions to the ESRD Prospective Payment System (PPS) for calendar year 2018, and sets forth requirements for the ESRD Quality Incentive Program (QIP) for payment years 2019 through 2021. CMS also released an accompanying fact sheet. In the rule, CMS:

  • Finalized a 0.5 percent pay rate increase for dialysis facilities for calendar year 2018.
  • Finalized its proposal to shorten and simplify the Performance Score Certificate (PSC) and reduce the amount of information beneficiaries will have access to on the PSC (AKF had opposed this proposal in our comment letter on the proposed rule).
  • Finalized ESRD QIP measures for payment year 2021 that address anemia management, dialysis adequacy, vascular access type, patient experience of care, infections, mineral metabolism management, safety, pain management, depression management, and hospital readmissions. CMS is replacing the two existing Vascular Access Type (VAT) measures with newly National Quality Forum (NQF)-endorsed Hemodialysis Vascular Access: Standardized Fistula Rate Clinical Measure and the Hemodialysis Vascular Access: Long-Term Catheter Rate Clinical Measure. CMs is also revising the Standardized Transfusion Ratio (STrR) Clinical Measure to align it with specification updates endorsed by NQF.

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CMS/HHS Proposed Rule: ACA Notice of Benefit and Payment Parameters for 2019

On October 27, CMS released a proposed rule (and fact sheet) on the 2019 Notice of Benefit and Payment Parameters. This is an annual Affordable Care act (ACA) rule that pulls together all the major changes that CMS intends to implement for the next plan year for the marketplaces (in particular, the federally facilitated exchange (FFE) and SHOP marketplaces), the premium stabilization programs, and the health insurance market reforms generally.

Proposed changes in defining the essential health benefits (EHB) package may be the most significant proposal outlined by CMS, as the agency seeks to provide states with additional flexibility in how they select their EHB-benchmark plans for benefit years 2019 and beyond.  For the 2014 plan year and again for the 2017 plan year, CMS directed states to select their EHB-benchmark plan from among 10 CMS-specified plan options, or default to their state’s largest small group plan based on enrollment. Under its new proposal, CMS would allow states to change their EHB benchmark plan on a yearly basis, and states would have four different options in doing so: maintain the current 2017 EHB-benchmark plan, select another state’s 2017 EHB-benchmark plan, replace one or more EHB categories from another state’s 2017 EHB-benchmark plan, or select a new EHB-benchmark plan altogether, provided that the new EHB-benchmark plan does not provide more benefits than a set of comparison plans and is equal to the scope of benefits provided under a typical employer plan.

AKF submitted a comment letter to CMS expressing our concern that the proposed changes in defining the EHB package could weaken the level of meaningful health coverage available to individuals with a chronic disease.

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