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January 25, 2024 | Volume 28, No. 1 | Archives
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Medical Respite Care Moves into Mainstream Medicaid
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| In This Issue:
- FY2024 Budget Update
- Homelessness in the Federal Courts
- Administration Announcements
- More on Medicaid Unwinding: 15 Million Now Disenrolled
- Administration Announcements on Medicaid
- A Closer Look: Two New Briefs Show Medical Respite Moving into Mainstream Medicaid
- Substance Use In The News
- What We’re Reading (and Watching)
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A new year has arrived and with it another Continuing Resolution (CR) that prevented a Jan. 19 government shutdown. Here's the latest:
New Continuing Resolution: Congress avoided a government shutdown by passing a bipartisan stopgap continuing resolution that splits government funding into two new deadlines: March 2 for the departments of Agriculture-FDA, Energy-Water, Military Construction-VA, Transportation-HUD and March 8 for the departments of Labor-HHS-Education, Defense, State-Foreign Operations, Commerce-Justice-Science, Financial Services, Interior-Environment, Legislative Branch, and Homeland Security. Congress now has to agree on how to split $773 billion among non-defense discretionary programs that fund critical needs (e.g., the Special Supplemental Nutrition program for Women, Infants, and Children, housing vouchers, and Community Health Centers) write the spending bills, and shepherd them through both chambers to the President’s desk.
Passing the CR did not come without conservative House Republicans trying to block passage because it did not include further cuts. Republican Freedom Caucus members previously directed their anger at Speaker Johnson for agreeing with Democratic leaders on topline numbers for government funding without exerting more cuts, even threatening to oust him. Besides passing all 12 appropriation bills, two other showdowns between hard-line Republicans and Democrats will center around tying harmful ideological riders and border security anti-immigration policy to government funding. As the migrant crisis grows at the U.S.'s Southern border, Senate Democrat leaders have indicated that their border deal proposal might appease Republicans, even at the risk of angering progressives who consider any concessions on border policy as a betrayal. Speaker Johnson, however, has made his position very clear on this: Any border deal has to align with H.R.2 Secure the Border Act — a nonstarter for Democrats — if foreign funding for Ukraine and Israel has any chance of going through.
Importantly, related to the migrant crisis, there are harmful narratives developed by leaders at all levels of governance that blame the rise in homelessness on the migrant crisis. It is important that we uphold the human rights of everyone to receive health care, shelter, and housing regardless of their immigration status.
A note on community health center funding: Both the discretionary and mandatory funding for community health centers are now tied to the March 8 CR deadline. The Senate HELP committee passed the Bipartisan Primary Health Care and Workforce Act (S.2840) setting three-year mandatory funding levels at $5.8 billion, compared to the House Lower Costs, More Transparency ACT (H.R. 5378), which authorized health center funding at $4.4 billion per year for 2.5 years. The National Association of Community Health Centers (NACHC) has an advocacy campaign to reach out to your representatives advocating for maximum funding.
Related reading:
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| Take Action on Congress
- This is a great time to reach out to representatives' offices and ask them to push for the higher mandatory funding levels for community health centers passed in the Senate Bipartisan Primary Care and Workforce Act (S.2840), which set funding levels at $5.8 Billion per year over three years.
- Reach out to your representative and invite them to see your programs and talk about them on the floor.
- Use the materials from NACHC (linked above) to inform your outreach.
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| Homelessness in the Federal Courts
On Jan. 12, the U.S. Supreme Court announced it would hear the case of City of Grants Pass, Oregon v. Johnson — the most significant case on homelessness in more than 40 years. The case will decide whether cities can criminalize people for sleeping outside even when there are no alternative shelter options. The question of how cities address unsheltered homelessness and protect the civil rights of people experiencing homelessness was decided in Martin v. City of Boise where the U.S. Court of Appeals for the 9th U.S. Circuit Court of Appeals upheld that cities cannot punish unsheltered people for camping in public spaces. Soon after that decision, three individuals experiencing homelessness challenged the City of Grants Pass ban on public camping in an Oregon Federal Court. Unsatisfied with the 9th Circuit decision to not hear the case, the City took its case to the U.S. Supreme Court. Stay tuned for more information on this issue as we work with our partners at the National Homelessness Law Center to determine the role of the health care community to help fight criminalizing people simply for existing.
Related reading:
Also in the courts: We are keeping a close eye on how a SCOTUS challenge over federal power could affect health care. At stake is the overturning of a 40-year-old legal framework — the "Chevron Deference" — that defers to regulatory agencies to interpret ambiguous laws. Suhasini Ravi of Georgetown's O'Neill Institute for National and Global Health Law summarized the implcation of overturning Chevron Doctrine on health care policy in this amicus briefs summary: "The prospect of overrulling Chevron is especially concerning in health care policy, where agencies must leverage their expertise to address emergencies, adapt to ever-changing technology, and improve health outcomes."
Related reading on the courts:
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| Administration Announcements
- Final rule on prior authorizations: The Centers for Medicare and Medicaid Services (CMS) finalized the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) to Expand Access to Health Information and Improve the Prior Authorization Process. The final rule reduces patient and provider burden by streamlining and automating the prior authorization process, improving transparency and shortening the time for decision-making. It applies to Medicare Advantage (MA) organizations, state Medicaid and Children’s Health Insurance Program (CHIP) Fee-for-Service (FFS) programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan (QHP) issuers on the Federally Facilitated Exchanges (FFEs). Here is a helpful fact sheet that outlines the rule’s provisions. HHS Secretary Xavier Becerra praised the action by the Biden-Harris Administration: "Too many Americans are left in limbo, waiting for approval from their insurance company. Today the Biden-Harris administration is announcing strong action that will shorten these wait times by streamlining and better digitizing the approval process."
- Final rule on conscience rights: The Department of Health and Human Services (HHS) issued a New Nondiscrimination Final Rule to Protect Conscience Rights. The Final Rule clarifies the process for enforcing federal conscience laws and strengthens protections against conscience and religious discrimination. The new rule rolls back Trump-era policies that would have allowed medical providers to deny gender-affirming care and access to abortion services based on religious or conscientious objections. The new rule comes amid a wave of restrictive abortion access laws and attacks on gender-affirming care. This fact sheet offers helpful background and a summary of the final rule. NHCHC submitted comments on this rule back in 2018 and are pleased to see this rule rolled back.
Related reading:
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| More on Medicaid Unwinding: 15 Million Now Disenrolled
15,015,000 Medicaid enrollees have been disenrolled as of Jan. 21, 2024. Across states, procedural disenrollments account for 71% of coverage losses. In our December Mobilizer we mentioned a new rule issued by CMS that would take federal funding away for states that fail to comply with federal Medicaid policies. CMS issued specific guidance for states to protect people from losing coverage. A new research report focused on the unwinding efforts in Arizona, Pennsylvania, Indiana, and Florida shows the challenges and opportunities states face for improving Medicaid renewals.
Related reading:
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| Administration Announcements on Medicaid
- New CMS guidance: In the wake of continuing disenrollments, CMS released new state Medicaid and Children’s Health Insurance Program (CHIP) renewal data demonstrating that states that took up more of the federal enrollment strategies and prioritized auto-renewals (ex-parte) to reduce red tape for families have helped more eligible children renew Medicaid and CHIP coverage. They also showed how the failure to expand Medicaid has hurt children and youth. Particularly alarming is that as of Jan. 21, 2,854,000 kids have been disenrolled and 60% of disenrolled kids come from just nine states led by Republicans. The data release was accompanied by an informational bulletin outlining state guidance for federal eligibility requirements, available flexibilities, and a new Medicaid/CHIP Resource Hub for advocates, beneficiaries, state agencies and others to access Medicaid renewal and transition resources.
- New funding opportunity for Behavioral Heath Integration: CMS announced a New Model to Advance Integration in Behavioral Health in Medicare and Medicaid. The Innovation in Behavioral Health (IBH) state-based model’s goal is to connect adults with mental and/or Substance Use Disorder needs with the physical, behavioral, and social supports to manage their care. Community Health Centers appear to be eligible participants. Keep an eye out for A Notice of Funding Opportunity (NOFO) to be announced in spring 2024. Here is a helpful fact sheet and an overview of the model resource, including FAQs.
Related reading on Medicaid unwinding:
Related reading on other Medicaid actions:
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| Two New Briefs Show Medical Respite Moving into Mainstream Medicaid
By Barbara DiPietro, PhD, Senior Director of Policy
I’m excited to share two new issue briefs that focus on the role of Medicaid in paying for medical respite care. Our first brief — Status of State-Level Medicaid Benefits for Medical Respite Care — provides a current snapshot of the state-level Medicaid activity related to medical respite care. The map below shows the 14 states already paying for medical respite care through Medicaid—or actively getting ready to do so.
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| This is incredible progress for a field that has been operating for nearly 30 years yet has not been fully recognized by many health care stakeholders. Since 2014, the expansion of Medicaid to single adults in most states, the growing recognition of the impact of social determinants of health, and federal policy that allows Medicaid to cover a wider range of services have broadened the funding for new approaches to care. The medical respite community — led by the fiercely dedicated Respite Care Providers' Network and the Council’s rapidly growing medical respite team — has put in the time, advocacy, and research needed to make financial sustainability a greater reality. We are rapidly moving to make medical respite care part of the mainstream health care system — and funded accordingly.
California was the first to adopt Medicaid for recuperative care* as a statewide service. Our second brief — CalAIM Implementation of Recuperative Care Services: Lessons Learned — documents what is working well with the implementation of the CalAIM recuperative care service to date, what remains a challenge, action steps California should consider moving forward, and advice for other states looking to add a statewide Medicaid benefit for recuperative care. With New York, North Carolina, and Washington also in the implementation stage (and others close behind), this is a good time to learn from others’ experiences and advocate for strategies that make for easier transitions to statewide reimbursement.
However: Being part of the mainstream health care system in the U.S. comes with a significant downside. One of the key takeaways from the California brief is that billing insurance is a sizeable administrative burden, especially for smaller programs. Often this means hiring new billing/finance/IT staff to track claims, denials, appeals, different billing systems, EHR integration, etc., rather than adding clinical or support staff. Further, the reimbursement rate is likely to be too low to cover all operating expenses, meaning supplemental fundraising is still an ongoing need. Check out the brief for more on both the pros and cons. (Tips: See our principles for reimbursement and consider partnering a medical respite program with a health center).
Hence, while a grants-based program has both advantages (more flexibility) and disadvantages (short-term funding), Medicaid reimbursement may reverse these — offering greater long-term sustainability but likely with less flexibility. So, yes, while Medicaid coverage is an important policy goal to pursue (and let’s keep pursuing it!), it’s important to prepare for the realities of working with insurance plans.
Final thought: It’s easy to get caught up in the financing details, but the ultimate goal is to meet the significant health care needs of unhoused people requiring recuperative care. Adding medical respite care into state Medicaid plans gives more tools for financing programs, aligns programs with the broader health care system, and improves quality of care.
*“Medical respite care” and “recuperative care” are interchangeable terms.
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| Substance Use in the News
- State opioid settlement funds: Amid increasing nationwide opioid deaths, state and local governments are expected to receive $50 billion in opioid settlement funds in the next two decades. The Year in Opioid Settlements: 5 Things You Need to Know looked at how state and local governments have spent the funds in 2023 and found there isn’t a lot of transparency to how states are using this funding. Some states are increasing the number of rehab centers, covering uninsured patient costs, hiring more clinicians to prescribe medications for opioid use disorder, and funding naloxone distribution (AKA Narcan). However, other states are using funds for police department purchases of police patrol cars, phone hacking technology, and jail body scanners, or to address budget gaps. Federal lawmakers are also taking first steps toward oversight of settlement funds.
- Boston HCH Program’s safe bathroom innovation: A shoutout to Boston Health Care for the Homeless for employing ‘safe bathrooms’ innovative technology, now being replicated in other parts of the country, to prevent overdose deaths in public bathrooms. Ask your local public health commissioner or local government officials to consider utilizing the same technology in your city.
- New York’s OnPoint overdose prevention center: Mobilizer readers will remember we reported on the success of two Overdose Prevention Centers reducing crime and disorder in New York City while saving lives. We wanted to share with you OnPoint NYC’s full-year report which provides a comprehensive look at the first recognized Overdose Prevention Center in the United States.
- Upcoming SAMHSA webinar: REGISTER for SAHMSA’s webinar on Harm Reduction and Syringe Access for health centers and community-based organizations on Feb. 28, from 1-2:30 p.m. CST. The webinar will discuss the ways in which health centers can expand harm reduction services by offering syringe access to participants through direct service delivery and partnership.
Related reading on SUD:
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What We're Reading (and Watching)
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Join hundreds of practitioners of homeless health care, people with lived experience of homelessness, and advocates just like you at the 2024 National Health Care for the Homeless Conference & Policy Symposium in Phoenix, May 13-16. Use code EB15 by Jan. 31 to get 15% off your registration fees!
HCH2024 is an excellent opportunity for organizations that want to reach more than 1,000 attendees who work in the HCH field, 38% of whom are management and board members. Our 2024 Sponsor and Exhibitor Opportunities Prospectus outlines the many opportunities available and the demographics of our conference attendees. Learn more here.
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This publication and all HCH advocacy are funded by dues from Organizational Members of the Council and by private donations. Consider joining the Council or donating to support this work.
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