American Kidney Fund Continues Its Advocacy on Charitable Premium Assistance

The American Kidney Fund (AFK) and its Advocacy Network have been busy this year advocating on our top policy priority: changing federal regulation to require health insurers to accept health insurance payments made by charitable organizations on behalf of patients with chronic illnesses. AKF staff and patient advocates have met with lawmakers and staff on Capitol Hill and in their home district offices, with senior staff from state departments of insurance and with key administration and Health and Human Services (HHS) officials. As a result of our efforts, nearly 200 Congressional Democrats and Republicans signed a letter to Health and Human Services (HHS) Secretary Tom Price urging the department to protect the right of Americans to rely on help from charities to afford health insurance coverage. To read AKF’s statement on the letter, please click here.

AKF will continue its advocacy on this important issue as HHS considers a new regulation in the coming months. AKF’s efforts are strengthened when we can work with kidney patients, their caregivers and their loved ones to advocate on this and other vital issues. If you want to be a part of our Advocacy Network, please click here.

Senate efforts to repeal and replace the Affordable Care Act

After a series of votes during the week of July 24, Senate Republicans failed to pass legislation that would repeal and replace the Affordable Care Act. The following is a summary of the votes that occurred during the week:

  • July 25: With Vice President Mike Pence serving as the tie-breaking vote, the Senate approved a procedural motion to open debate on repealing and replacing the ACA.
  • July 25: The Senate voted down, in a 43 to 57 vote, a modified version of the Senate GOP’s repeal and replace bill, the Better Care Reconciliation Act. This version included Sen. Ted Cruz’s (R-TX) controversial “Consumer Freedom Option” which would have allowed insurers to sell bare bones, non-ACA compliant plans, and a proposal from Sen. Rob Portman (R-OH) that would have added $100 billion to help Medicaid expansion enrollees purchase private insurance.
  • July 26: In a 45-55 vote, the Senate rejected a GOP plan to repeal the ACA without an immediate replacement. The measure was similar to a 2015 GOP reconciliation bill that passed Congress but was vetoed by President Obama. The Congressional Budget Office (CBO) projected that legislation would have resulted in 32 fewer Americans with coverage and premiums to double over 10 years.
  • July 27: Senate Republicans released a slimmed-down ACA repeal bill referred to as a “skinny repeal.” The bill would eliminate the individual mandate, repeal the employer mandate for eight years, defund Planned Parenthood for one year, eliminate the ACA’s Prevention and Public Health Fund, temporarily repeal the medical device tax, amend the ACA’s 1332 waivers to allow states greater flexibility to roll back insurance regulations, and increase contribution limits to health savings accounts for three years. The skinny repeal bill failed to pass after Republican Senators Susan Collins (ME), Lisa Murkowski (AK), and John McCain (AZ) joined all 46 Democrats and two Independents in opposing the bill. The CBO projected the skinny repeal would have resulted in 16 million more uninsured Americans and a 20 percent increase in premiums over 10 years.

With Senate Republicans failing to pass various iterations of ACA repeal and replace—all of which were unpopular with the general public and were projected to result in large increases in the uninsured and the cost of coverage—it remains to be seen if Congress  can now work in a bipartisan fashion to stabilize the individual market. There are also questions as to how the Trump administration will proceed in carrying out the ACA, given the President’s and HHS Secretary Tom Price’s public attacks on the law.

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H.R. 3178: Medicare Part B Improvement Act of 2017

On July 25, the House of Representatives passed by voice vote H.R. 3178, the Medicare Part B Improvement Act of 2017. This legislation contains several targeted changes to Medicare Part B, including two provisions that would affect dialysis patients.

One provision would allow dialysis facilities to use independent accreditation agencies approved by the Secretary, and would direct the Department of Health and Human Services to conduct surveys and reviews on accrediting agencies and dialysis providers. Currently, in some areas of the country there is a backlog of facilities awaiting accreditation, but unlike hospitals, dialysis facilities cannot use third-party accreditors. By allowing the use of HHS approved third-party accreditors, this provision would help ensure kidney disease patients, particularly in rural communities, have access to dialysis treatments in a timely manner.

The second provision would expand the use of telehealth for Medicare beneficiaries with ESRD who receive home dialysis. Specifically, it would allow free standing dialysis facilities and a patient’s home to be originating sites for monthly telehealth clinical assessments, and would eliminate geographic restrictions that currently prohibit patients in non-rural areas from using telehealth for clinical assessments.  This provision would create an additional at-home option for patients to maintain their access to care.

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H.R. 3168: Special Needs Plan Reauthorization Act of 2017

On July 13, the House Ways and Means Committee approved H.R. 3168, the Special Needs Plan (SNP) Reauthorization Act of 2017. SNPs are Medicare Advantage plans that exclusively enroll beneficiaries with special needs. There are SNPs for dual-eligible beneficiaries (D-SNPs), institutionalized beneficiaries (I-SNPs) and beneficiaries with certain chronic conditions (C-SNPs), including C-SNPs for ESRD patients. The bill would permanently reauthorize I-SNPs and reauthorize D-SNPs and C-SNPs for five years. SNP reauthorization is set to expire at the end of 2018.

The bill is now being considered in the House Energy and Commerce Committee. The Health Subcommittee held a hearing on July 26 to hear from an expert panel on the need for SNP reauthorization. As of this writing, it remains to be seen if the Energy and Commerce Committee will amend the bill to permanently reauthorize all SNPs. Earlier this year the Senate Finance Committee approved a chronic care bill (S. 870) that includes a provision to make all three types of SNPs permanent.

Another option that Congress may pursue this year is to include SNP reauthorization to the reauthorization of the Children’s Health Insurance Program and other Medicare extenders.

C-SNPs for ESRD provide another coverage option for patients that may better suit their needs.

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House Appropriations Committee: Labor, HHS and Education 2018 appropriations bill

On July 19, the House Appropriations Committee approved its Labor-HHS-Education bill that would fund kidney research and programs for 2018.

Kidney disease research is done within the National Institute of Diabetes, Digestive, and Kidney Disease (NIDDK). The Appropriations Committee approved a funding level of $1.89 billion for NIDDK, which is an increase over last year of $29 million.

An important kidney program that the NIDDK reported in its budget request is called “Rebuilding a Kidney.” The program is a consortium of research projects aimed at enhancing kidney repair and promote the generation of new kidney cells. Investigators have developed laboratory-based procedures to isolate and expand the number of mouse kidney cells, capable of differentiating into different cell types by promoting cell renewal. Researchers reporting that kidney stem cells isolated from the adult mouse kidney collecting duct can self-renew in the laboratory.

The Rebuilding a Kidney program’s goal is to coordinate and support studies that will result in the ability to general or repair nephrons that can function within the kidney.

The House Appropriations Committee expressed interest in specific kidney disease research projects and made the following requests in its bill:

  • Pediatric Kidney Disease.—The Committee is encouraged by the current multicenter pediatric kidney disease research funded by NIDDK. While important strides have been made, further research is critical to the validation of new prognostic indicators, novel diagnostic biomarkers, and therapeutics necessary to better understand and treat kidney disease as children mature from newborns and ultimately transition to adulthood. The Committee requests that NIDDK report back in the fiscal year 2019 Congressional Justification on the steps taken to advance this type of collaborative research.
  • Health Disparities and Pediatric Kidney Disease.—The Committee recognizes that health disparities play a significant role in kidney disease in children, from the incidence and progression of kidney disease in children, to the long-term health outcomes, such as access to kidney transplant, access to living donors and disparate transplant survival. Children of minority populations are disproportionately impacted by kidney disease, and National Institute on Minority Health and Health Disparities work in this area is critical to defining the basis for these health disparities and developing mechanisms to address them. The Committee requests that NIMHD catalog the research being conducted in this area and report back on the research currently underway and research gaps in this area of study in the fiscal year 2019 Congressional Justification.

The bill also includes funding for the Chronic Disease Prevention and Health Promotion (CDPHP) for Chronic Kidney Disease. The amount is the same as last year and is used on State, Tribal, and community programs for health promotion.

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Medicare ESRD Prospective Payment System and Quality Incentive Program Proposed Rule

CMS published in the July 5 Federal Register a proposed rule that would update and make revisions to the ESRD Prospective Payment System (PPS) for calendar year 2018, and set forth requirements for the ESRD Quality Incentive Program (QIP) for payment years 2019 through 2021. Comments are due August 28. AKF will be submitting a response and will focus our comments and recommendations on ensuring patient access to dialysis treatment and high quality care.

A summary of the proposed updates to the PPS and QIP can be found in this fact sheet from CMS. In addition to those proposed changes, CMS is seeking stakeholder feedback on the following broader topics as CMS considers potential future changes to the Medicare ESRD program:

  • Accounting for social risk factors such as in the ESRD QIP. CMS understands that social risk factors such as income, education, employment, race and ethnicity, social support, and community resources play a significant role in health. CMS is seeking public comment on whether they should account for these factors in the ESRD QIP, and if so, what methods would be most appropriate for accounting for these social risk factors. Examples of methods include: adjustment of the payment adjustment methodology under the ESRD QIP; adjustment of provider performance scores; confidential reporting of stratified measure rates to facilities; public reporting of stratified measure rates; risk adjustment of a particular measure as appropriate based on data and evidence; and redesigning payment incentives (for instance, rewarding improvement for facilities caring for patients with social risk factors or incentivizing facilities to achieve health equity).
  • Solicitation of comments on the inclusion of Acute Kidney Injury (AKI) patients in the ESRD QIP. Currently, facilities are not required to report AKI patient data for any ESRD measure, but CMS intends to require facilities to do so in the future. CMS is seeking public comment on whether and how to adapt any of the current measures to include the AKI population, as well as the type of measures that might be appropriate to develop for future inclusion in the QIP that would address the unique needs of beneficiaries with AKI.
  • Request for Information on Medicare Flexibilities and Efficiencies. CMS is seeking ideas for regulatory, sub regulatory, policy, practice, and procedural changes to the Medicare program to better accomplish the goals of improving quality, lowering costs, improving program integrity, and making the health care system more effective, simple and accessible. Ideas could include payment system redesign; elimination or streamlining of reporting, monitoring, and documentation requirements; aligning requirements across programs; and enhancing operational flexibility and facilitation of individual preferences.

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