Washington Update

Republicans Offer an Alternative to the Affordable Care Act

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Sens. Richard Burr (R-NC), Tom Coburn (R-OK) and Orrin Hatch (R-UT) have unveiled the Patient Choice, Affordability, Responsibility, and Empowerment (CARE) Act with the idea of repealing the Affordable Care Act and offering this plan in its place. Some highlights of the bill follow: The proposal would repeal the ACA’s requirements on individuals and employers to purchase health care coverage. Also, it would eliminate the health insurance marketplaces set up under the ACA.  Lifetime limits would still be prohibited and the proposal would ensure the ability to keep dependent coverage up to the age of 26, although a state could opt out of enforcing dependent coverage on the insurers that it regulates. Individuals could not be charged more for preexisting conditions unless they have a gap in coverage at which time they could be subject to medical underwriting where insurers could charge them more for coverage based on medical history. Employers could fully deduct the cost of providing health insurance.  However, some employees getting generous coverage would have to pay taxes on the value of some benefits.  The ACA’s ban on charging an older, sicker person more than three times what a younger, healthier person is charged is replaced with a 5:1 ratio, and states would be able to decide whether they want a different rating rule.  The proposal envisions adopting or incentivizing states to adopt a range of solutions to tackle the problem of so-called “junk lawsuits” and defensive medicine.  Given the fact that any proposal that seeks to repeal and/or radically modify provisions of the ACA face a certain veto by President Obama, the prospects for the proposal’s serious consideration and passage are not promising.

Model Assesses Return on Investment of Electronic Health Records

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With increasing numbers of health care organizations adopting electronic health records (EHRs), the National Academies’ Institute of Medicine (IOM) has released a discussion paper proposing a model to calculate the financial implications, benefits and costs of implementing EHRs and related technologies. Return on Information: A Standard Model for Assessing Institutional Return on Electronic Health Records notes that health care has been “a reluctant late adopter” of information technology, lagging behind other industries. Nevertheless, the paper asserts that enactment of the Affordable Care Act (ACA) has spurred greater innovation in delivery systems, making standards-based, interoperable IT systems increasingly necessary in the future. According to the paper, the goal of the proposed model is “to provide a clear framework and propose a standard model for evaluating institutional investment in EHRs and related technologies to enable inter-organizational comparisons, help identify best-in-class implementation approaches, and prioritize process redesign endeavors.” A standard assessment model would make possible for the first time the direct comparison of vendor technologies or products based on a standard set of cost/benefit assumptions.

Senator Reintroduces Data Privacy Bill

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Senate Judiciary Committee Chairman Patrick Leahy (D-VT) introduced the latest version of a bill aimed at enhancing personal information and privacy. The Personal Data Privacy and Security Act of 2014, was first introduced by Leahy in 2005. The bills states that business entities that comply with both the Health Insurance Portability and Accountability Act of 1996 and the Health Information Technology for Clinical Health (HITECH) Act, would be in compliance with the legislation’s standards. These business entities include vendors of personal health records and third-party service providers. The bill requires companies that have databases with sensitive personal information to establish and implement data privacy and security programs. It would also establish a single national standard for data breach notification and require notice to consumers when their personal information has been compromised. The bill would make it an explicit felony to damage critical infrastructure systems or information, with violators subject to as much as 20 years of imprisonment. An earlier version of the bill passed the Judiciary Committee in the 112th Congress, but never saw Senate floor action. The new legislation is cosponsored by Sens. Richard Blumenthal (D-CT), Al Franken (D-MN) and Charles Schumer (D-NY).

Administration and Congress Reach a Budget Deal

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A compromise bipartisan federal budget plan, H.J. Res 59, that sets overall funding levels for the next two years and temporarily removes the threat of another government shutdown was approved in December by Congress and signed into law by President Obama. The budget plan calls for spending $1.012 trillion in FY14 and $1.014 trillion in 2015.

House Appropriations Committee Adds Three New Members

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The powerful House Appropriations Committee has added three new Republican members following the resignation of two members earlier this year and the death of longtime Florida Rep. C.W. Bill Young in October. 

Affordable Care Act Numbers for Health Insurance Coverage Improves

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Under the Affordable Care Act (ACA), those who wanted coverage to begin by January 1, 2014 had to sign up by December 23, 2013. The deadline for signing up for health insurance and avoiding a tax penalty, however, is March 31, 2014. Social scientists and those who have studied similar government programs with a lengthy sign-up period say many people naturally procrastinate until a deadline looms. Washington Post economics reporter Ezra Klein notes that the ACA is similar to the Massachusetts health reforms and Medicare Part D—and that this experience shows that enrollment “begins as a trickle and spikes at the end.” Medicare Part D, which provides prescription drug coverage, began as a polarizing national law and also had a terrible rollout, he says. But today, more than 90% of seniors say they are happy with the program and consider it a success. Optimists note that the number of people who chose insurance policies run by the federal government or the states, more than doubled between November and October. Skeptics, however, say those combined enrollment figures are still well below the administration’s March 2014 target of 7 million new enrollees. And they add that the law’s poor rollout has hurt its standing among millennials, who are generally healthy. Income from the premiums of young enrollees is essential to offset the cost of insuring more expensive, older adults. Despite the current enrollment numbers, interest in the ACA appears to be growing rapidly. “The website, HealthCare.gov and phone center (1-800-318-2596) are fielding a large number of inquiries, which could be a positive indicator for future enrollment growth,” David Howard, a Professor of Health Policy at Emory University in Atlanta, told MedPage Today. According to the publication’s December 11 article, nearly two million more consumers have applied for and been told they are eligible for a plan.

Efforts are Underway to Curb the President’s Regulatory Agenda

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Though it will go down as the least productive Congress in modern history, House Republicans insist they are proud of their 2013 campaign to disable President Obama’s regulatory agenda. According to a December 8 article in The Hill, House Republicans are not shy about touting their efforts to block legislation. As a result of the gridlock, President Obama decided to use his regulatory authority to pursue his key policy goals. House Republicans held dozens of committee and subcommittee hearings in 2013 aimed at critiquing new regulations. House Democrats say that the campaign is nothing more than old-fashioned obstructionism, the same thing that created October’s 16-day federal government shutdown and debt ceiling debate. A study issued by the respected, nonpartisan Congressional Research Service provided ammunition for each point of view. The May 1, 2013 report showed that the number of final rules issued by the Obama administration through last year was fewer than all those issued during President George W. Bush’s first term. But the report also noted that more “major rules” — those with an annual economic impact of more than $100 million — were enacted in 2010 than in any year since 1997.  Given the Administration’s interest in higher education, any focus on regulatory authority could potentially impact academic dentistry, positively or negatively.

Millions Could Gain Dental Coverage Through the Affordable Care Act

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With the inclusion of pediatric oral health services as an essential benefit under the Affordable Care Act (ACA), millions of children are poised to gain dental coverage over the next five years. Some adults will also receive dental benefits as the law is implemented. The American Dental Association (ADA) estimates that 8.7 million children will receive dental coverage through the ACA, but according to a November article in The Wall Street Journal, some experts place that number at 5 million. The ACA is expanding Medicaid eligibility in many, though not all, states. Twenty-nine states currently offer at least some dental coverage to adults through Medicaid. The other states offer adults emergency-only coverage or none at all. Consumers purchasing insurance through the new health insurance marketplaces have the option of purchasing dental coverage separately or as part of their medical insurance plan. The Journal reports that these plans vary considerably in how they structure their deductibles. As a result, some plans may cost consumers more than they would pay out-of-pocket for the care they receive. Out-of-pocket maximums also vary by state, but stand-alone pediatric dental plans in the federally-run exchanges have limits set at $700 for one child and $1,400 for two or more children. Medicare does not cover routine dental care, and it is anticipated that many consumers, especially older adults, will continue to rely on charitable and subsidized care for their dental needs.  Oral Health America has launched a website, toothwisdom.org, to link older adults with oral health resources in their states, including care sites, financial tools and social support services, such as transportation. The Wall Street Journal also quoted Dr. Richard W. Valachovic, D.M.D., M.P.H., ADEA President and CEO, on the safety-net role that dental schools play in providing routine and specialty oral health care at reduced fees.

Stricter Gainful Employment Rules May be on the Horizon

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In order to participate in federal student aid programs, the Higher Education Act (HEA) requires career education programs to “prepare students for gainful employment in a recognized occupation.” Under gainful employment regulations, Title IV loans can only be disbursed to eligible students enrolled in programs that lead to gainful employment in a recognized occupation. The HEA defines the programs subject to this requirement as non-degree programs at all colleges and most degree programs at for-profit colleges. As for academic dentistry, gainful employment regulations apply to allied or advanced dental education programs that terminate with the awarding of a certificate but not a degree. Currently, the Department of Education (DE) is convening negotiated rulemaking sessions. On November 8, DE convened its second Gainful Employment Negotiated Rulemaking session. The department released draft rules for discussion purposes a week prior to the three-day meeting. The draft rules which federal negotiators debated in the November meeting would judge programs based not only on their graduates' student-loan-debt burdens, but also on their former students' ability to repay their loans, whether or not the students graduated. Furthermore, the rules would require risky programs to seek federal approval to award aid and would require all programs to have the necessary state and accreditor approvals to qualify students to sit for licensing examinations. Programs at risk of losing eligibility at the end of a year would have to set aside money for borrower relief, either through a letter of credit, a state guarantee or the federal withholding of student-loan dollars. It could be months or longer before a Notice of Proposed Rulemaking is published. In the meantime, stakeholders are certain to continue making their views known on the proposed standards. For more on this topic, see last month’s coverage in the ADEA Washington Update.

Democrats Split Over House Health Insurance Bill

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By a wide margin, the House of Representatives passed legislation that would give insurance companies one more year to sell policies that do not meet the requirements of the Affordable Care Act. The House bill, formally known as the Keep Your Health Plan Act of 2013, is not expected to be taken up by the Senate. President Obama has also promised to veto it, which means it has no chance of becoming law. The November 15 vote was 261 to 157, and included the backing of 39 Democrats who broke ranks with their leadership. In the past month, millions of Americans have received notices that their insurance policies would be cancelled because they did not meet the minimum requirements set forth in the ACA, setting off a storm of criticism against the administration and President Obama, who had said repeatedly that Americans could keep their health insurance if they liked it. The two-page House bill was an attempt to fix that problem. But insurance company executives and Democratic congressional leaders made clear that allowing two types of plans—those that meet the ACA requirements and those that don’t—would make it far more difficult for the new plans offered by the state health insurance exchanges to attract enough customers (especially young and healthy ones) to make the new plans viable. Prior to the vote, Democratic leaders predicted that no more than 25 Democratic Representatives would defect. Many of the 39 Democratic votes came from members who will be in tough reelection fights next year. Nineteen of the Democratic votes came from members who had not yet been elected to the House when the ACA became law in 2010.

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