Washington Highlights: July 17,
2009
House Committees Mark Up Health Care Reform Legislation
Contents
Prior Issues
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The House Ways and Means Committee
(23-18) July 16 and House Education and Labor Committee (26-22)
July 17 passed amended versions of health care reform legislation.
The America's Affordable Health Choices Act (H.R.
3200) was introduced July14 by the Democratic leadership of
the Ways and Means, Energy and Commerce, and Education and Labor
Committees. While the introduced version of the package includes
many of the provisions previously outlined in the June 19 "tri-committee"
discussion draft
[see Washington Highlights,
June 26], it also incorporates several changes of interest to
medical schools and teaching hospitals. As introduced, the bill:
- Specifies that hospitals that currently exceed their Medicare
"cap" are among those that will receive preference under
the redistribution of residency slots;
- Reduces Medicare disproportionate share hospital (DSH) payments
beginning in FY 2017, if, between 2012 and 2014, the number of
uninsured individuals drops by over 8 percent. The Secretary could
then increase DSH payments to individual hospitals based on their
level of uncompensated care (excluding bad debt). The hospital
increases could not exceed half of the initial reduction;
- Reduces Medicaid DSH payments by $10 billion ($1.5 billion
in FY 2017, $2.5 billion in FY 2018, and $6 billion in FY 2019).
A new methodology will be used to implement the cuts, with the
largest portion of reductions coming from states with the lowest
uninsurance rates;
- Directs the Secretary to revise the geographic adjustment factors
used by the Medicare physician and inpatient hospital payment
systems;
- Clarifies the discussion draft's sustainable growth rate (SGR)
reform provisions regarding the definition of primary care services;
- Amends the membership of the Comparative Effectiveness Research
Commission to ensure that a majority of the members are physicians,
other health care practitioners, consumers or patients, and persons
with expertise in health disparities;
- Creates a new program under Title VII awarding grants to eligible
"teaching health centers" (such as community health
centers) that participate in the demonstration project under section
1502(d) of the bill. The grants would support developing new primary
care residency training programs;
- Extends through FY 2019 funding authorizations through the regular
appropriations process for the National Health Service Corps (NHSC)
and many of the Title VII programs; and,
- Incrementally increases funding deposited in a new Public Health
Investment Fund (PHIF) through FY 2019 and clarifies that funding
through the PHIF for the NHSC, Title VII, and other programs will
supplement funding through the regular appropriations process.
Additionally, at its July 16 markup, the Ways and Means Committee
adopted
language that requires an Institute of Medicine (IOM) study of geographic
variations in per capita health care spending. The study would review
spending among Medicare and privately insured individuals. The IOM
would be required to submit a report to Congress within three years
of enactment. The report must include recommendations "for
addressing variation in per capita spending by promoting high-value
care." The provision states that the IOM shall "specifically
address" whether (and how) Medicare payments for physicians
and hospitals "should be further modified to incentivize high-value
care."
Meanwhile, the Energy and Commerce Committee began considering
the legislation July 16. A manager's amendment
offered by committee Chair Henry Waxman (D-Calif.) eliminates many
of the revisions to the Title VII primary care loan program included
in previous drafts of the bill. However, the manager's amendment
retains a provision to update HRSA's student loan guidelines to
account for financial independence when determining the need for
parental financial information. The Energy and Commerce committee
is scheduled to continue its mark up during the week of July 20.
At a press conference held in conjunction with the July 14 release
of the bill, Chairman Waxman, Ways and Means Chair Charles D. Rangel
(D-N.Y.), and Education and Labor Chair George Miller (D-Calif.)
announced their intent to "vote on this legislation before
we leave for the August recess."
Information:
Christiane Mitchell, Director, Federal Affairs
AAMC Government Relations
cmitchell@aamc.org
(202) 828-0526
Travis W. Crytzer, Legislative Analyst
AAMC Government Relations
tcrytzer@aamc.org
(202) 828-0418
Tannaz Rasouli, Senior Legislative Analyst
AAMC Government Relations
trasouli@aamc.org
(202) 828-0525
AAMC Supports Legislation Promoting "Health Care
Innovation Zones"
Rep. Allyson Schwartz (D-Pa.), July 8 introduced the AAMC-supported
legislation titled the "Healthcare Innovation Zone Program
Act of 2009" (H.R.
3134). The bill establishes a health care innovation zone (HIZ)
program to promote health care provider integration and align health
care provider incentives to improve health and reduce costs. The
HIZs would comprise integrated health care delivery networks that
include a medical school and/or teaching hospital and provide a
full spectrum of inpatient, outpatient, post-acute and preventive
care to individuals, including Medicare beneficiaries.
Under the HIZ program, the Secretary of Health and Human Services
(HHS) will award between 10 and 25 planning grants between $250,000
and $1 million to entities for the purpose of designing an HIZ model.
The Secretary will then test an unspecified number of planning grant
proposals, under a three-year HIZ demonstration project. The demonstration
project will waive/exempt participants from certain legal and regulatory
barriers preventing integration and alignment.
In a statement on the House floor Rep. Schwartz said, "I have
introduced the Healthcare Innovation Zone Program Act to expand
opportunities for doctors and hospitals, including those based in
community and academic medical centers, to design, implement and
evaluate such models of care delivery." In a July 10 press
release, AAMC President and CEO Darrell G. Kirch, M.D., thanked
Rep. Schwartz for introducing the legislation "which will enable
providers to truly reform delivery systems and improve the health
of communities." He added that "our nation faces a complex
health care crisis of access, quality, and cost and there is an
urgent need to design and test large scale, innovative models to
transform the way we deliver and pay for care."
Information:
Travis W. Crytzer, Legislative Analyst
AAMC Government Relations
tcrytzer@aamc.org
(202) 828-0418
Christiane Mitchell, Director, Federal Affairs
AAMC Government Relations
cmitchell@aamc.org
(202) 828-0526
House Appropriations Panel Considers FY 2010 HHS
Funding
The House Appropriations Committee July 17 considered its FY 2010
Labor-HHS-Education appropriations bill. At press time, the committee
was considering amendments to the spending bill. The House Labor-HHS-Education
Appropriations Subcommittee approved the bill July 10 [see Washington
Highlights, July 10]. The bill is expected to go to the
House floor the week of July 20.
The bill includes $30.967 for NIH, an increase of $500 million
over the President's request, and $942 million over FY 2009. In
a July 14 letter,
AAMC President and CEO Darrell Kirch, M.D., thanked Appropriations
Committee Chair David Obey (D-Wis.) for his continued leadership
in support of NIH and "ensuring that all NIH institutes and
centers will receive funding to keep pace with biomedical research
inflation by rejecting the Administration's proposal to target NIH
funding." The AAMC also joined 156 organizations on a July
16 group letter
thanking Chairman Obey and Ranking Member Todd Tiahrt (R-Kan.) for
recognizing NIH "as a significant priority in the Subcommittee's
FY 2010 Labor-HHS-Education Appropriations bill."
The Senate Labor-HHS-Education Appropriations Subcommittee is expected
to take up its version of the bill the week of July 27.
Information:
Dave Moore, Senior Director
AAMC Government Relations
dbmoore@aamc.org
(202) 828-0525
Tannaz Rasouli, Senior Legislative Analyst
AAMC Government Relations
trasouli@aamc.org
(202) 828-0525
HIT Policy Committee Adopts "Meaningful Use" and
Certification Recommendations
The Health Information Technology (HIT) Policy Committee July 16
adopted by consensus the Meaningful Use Workgroup's second draft
definition of "meaningful use" and the Certification/Adoption
Workgroup's five high-level recommendations
regarding the certification process. The committee tabled the Health
Information Exchange Workgroup's recommendations pending further
revision. The Office of the National Coordinator of Health Information
Technology (ONC) and the Centers for Medicare and Medicaid Services
(CMS) will take the adopted recommendations into consideration in
drafting regulations to be released in December.
The Meaningful Use Workgroup released a second version of its "Meaningful
Use Matrix,"
making several significant changes to its first draft released at
the June 16 Policy Committee meeting [see Washington
Highlights, June 19].
Among other changes, the revised matrix recommends that incentives
be paid by "adoption year" rather than calendar year;
for example, "2011 Measures" would be linked to the first-year
incentive payment, regardless of when (prior to 2015) a hospital
or eligible professional becomes a meaningful user. The revised
matrix also recommends that hospitals be required to enter 10 percent
of all orders electronically to meet the first year adoption requirements.
The revised matrix does not address how specialists will meet meaningful
use requirements, but the committee recommended that CMS incorporate
specific requirements for specialists into the agency's regulations.
There will be no additional public comment period on the meaningful
use requirements until CMS publishes a proposed regulation on HIT
incentive payments in December.
The Certification/Adoption Workgroup presented recommendations
to the Policy Committee that reflect concerns the workgroup heard
in public testimony taken July 14 and 15. This testimony addressed
a wide variety of stakeholder perspectives on the certification
process and included a non-vendor products panel that discussed
the possibilities for certifying open source, modular, and homegrown
systems. The full Policy Committee adopted the following five high-level
recommendations on the certification process:
- Focus certification on meaningful use;
- Leverage the certification process to improve progress on security,
privacy, and interoperability;
- Improve objectivity and transparency of the certification process;
- Expand certification to include a range of software sources:
open source, self-developed, etc.; and
- Develop a short-term transition plan.
More specific recommendations regarding issues such as the number
of organizations permitted to perform certification testing and
the process for assessing "meaningful use gaps" between
already-certified products and the meaningful use requirements were
postponed pending further discussion. The agendas and all slide
presentations from the Policy Committee and Certification and Adoption
Workgroup meetings are available on the HIT Policy Committee Web
site.
Information:
Lori K. Mihalich-Levin, J.D., Senior Policy Analyst
AAMC Health Care Affairs
lmlevin@aamc.org
(202) 828-0599
Senate Passes SBIR Reauthorization
The Senate July 13 approved legislation by unanimous consent to
reauthorize the Small Business Innovation Research (SBIR) and Small
Business Technology Transfer (STTR) programs. The Senate passed
the SBIR/STTR Reauthorization Act of 2009 as H.R.
2965 after striking the text of the House-passed version of
the bill and substituting the text of S.
1233, which the Senate Committee on Small Business and Entrepreneurship
passed June 18 [see Washington
Highlights, June 26].
The Senate-passed bill includes a provision to increase the allocation
for the SBIR program from 2.5 percent to 3.5 percent of any federal
agency budget that provides more than $100 million for research,
including the National Institutes of Health. The AAMC opposes increasing
the allocation.
The House July 8 approved its version of H.R. 2965, which does
not increase the SBIR set-aside [see Washington
Highlights, July 10].
The House and Senate are expected to reconcile differences in the
bills through conference negotiations prior to July 31, when the
authorizations for the programs are set to expire.
Information:
Dave Moore, Senior Director
AAMC Government Relations
dbmoore@aamc.org
(202) 828-0525
HELP Committee Approves Health Care Reform Bill
The Senate Health, Education, Labor and Pensions (HELP) Committee
July 15 approved the Affordable Health Choices Act
by a 13-10 party-line vote, making it the first committee to mark-up
a comprehensive health care reform bill. The passage follows the
committee's month-long consideration of almost 500 amendments to
the bill [see Washington Highlights,
June 26]. According to a July 15 press release by HELP Committee
Acting Chair Christopher Dodd (D-Conn.), the committee adopted nearly
160 Republican amendments. The press
statement also includes a committee-prepared section-by-section
summary of the legislation that reflects adopted amendments.
Shortly before passage, the committee rejected along a party-line
vote an amendment offered by Sen. Orrin Hatch (R-Utah) that would
have eliminated the bill's proposed $1.1 billion authorization for
the National Health Service Corps (NHSC). Sen. Hatch argued that
Congress had just completed a NHSC reauthorization under the Health
Care Safety Net Act of 2008 (P.L.110-335)
[see Washington Highlights,
Sept. 26, 2008].
The bill also includes an amendment that provides for 12 years
of exclusivity for original biological products [see Washington
Highlights, July 10].
An amendment offered by Sen. Sherrod Brown (D-Ohio) would have granted
five to seven years of exclusivity. That amendment was voted down
in favor of the one that ultimately passed, offered by Senator Kay
Hagan (D-N.C.) and Ranking Member Mike Enzi (R-Wyo.).
Before the Affordable Health Choice Act proceeds to the Senate
Floor, the Senate HELP committee-approved language will be combined
with the Senate Finance Committee's version of the bill. The Finance
Committee is expected to release its draft legislation shortly.
Information:
Matthew Shick, Senior Legislative Analyst
AAMC Government Relations
mshick@aamc.org
(202) 862-6116
Abigail Schopick, Legislative Analyst
AAMC Government Relations
aschopick@aamc.org
(202) 828-0525
House Education Chair Proposes to Eliminate FFEL,
Graduate and Professional Subsidies
House Education and Labor Committee Chair George Miller (D-Calif.)
July 15 introduced
the Student Aid and Fiscal Responsibility Act of 2009 (H.R.
3221), highly anticipated legislation to implement the President's
proposal to eliminate the Federal Family Education Loan (FFEL) program.
Additionally, the bill would have significant impact on graduate
and professional student loans, including eliminating interest subsidies
of federal Stafford and Perkins loans.
Currently, medical schools originate federal Stafford student loans
through one of two programs: the FFEL program, under which private
lenders offer government subsidized loans; and the Direct Loan program,
under which students apply for loans directly through the Department
of Education. In line with the President's FY 2010 budget request
[see Washington Highlights,
May 8], H.R. 3221 eliminates the FFEL program and originates
all loans after July 10, 2010, under the Direct Loan program. While
a majority of institutions elect to participate in the FFEL program,
interest rates, origination fees, and borrower benefits offered
under the FFEL and Direct programs have been the same in recent
years. A primary concern among the financial aid community is the
quality of customer service that will be offered by the Department
of Education considering the expected substantial increase in Direct
loan volume.
The bill also would terminate the authority of the Department of
Education to make interest subsidized loans to graduate and professional
students. Currently, medical students are eligible for up to $8,500
in subsidized Stafford loans, which do not accrue interest during
in-school, grace, or deferment periods. The AAMC estimates this
interest subsidy saves a medical student graduating with $150,000
in debt (the median medical education debt) approximately $16,000
over the life of the loan.
According to a committee summary,
the bill restructures the Perkins loan program "providing the
program with more reliable forms of credit from the federal government."
However, as with the Direct Stafford loans, the bill eliminates
the in-school interest subsidy for Perkins.
The bill also proposes "simplifications" to the Free
Application for Federal Student Aid (FAFSA).
Information:
Matthew Shick, Senior Legislative Analyst
AAMC Government Relations
mshick@aamc.org
(202) 862-6116
CBO Warns Reform Legislation May Increase Health
Care Spending
Testifying July 16 before the Senate Budget Committee, Congressional
Budget Office (CBO) Director Douglas Elmendorf told
lawmakers that health reform legislation that has been reported
does not contain the "fundamental changes that would be necessary
to reduce the trajectory of federal health spending by a significant
amount." Responding to a question from Budget Committee Chair
Kent Conrad (D-N.D.), Elmendorf continued, "And on the contrary,
the legislation significantly expands the federal responsibility
for health care costs."
As an example, Elmendorf noted
that "the creation of new subsidies for health insurance, which
is a critical part of expanding health insurance coverage,…
raises federal spending on health care. It raises the amount of
activity that is growing at this unsustainable rate and to offset
that there would have to be very substantial reductions in other
parts of the federal commitment to health care, either on the tax
revenue side through changes in the tax exclusion or on the spending
side through reforms in Medicare and Medicaid." While he cautioned
that CBO is still analyzing the reforms in the just-released House
package and the Senate Finance Committee bill, the legislation they
have reviewed so far does not include "fundamental change of
the order of magnitude that would be necessary to offset the direct
increase in federal health costs from the health insurance proposals."
Elmendorf's prepared testimony repeated warnings that "Under
current law, the federal budget is on an unsustainable path-meaning
that federal debt will continue to grow much faster than the economy
over the long run." Elmendorf noted that rising costs for health
care and the aging of the U.S. population will cause federal spending
to increase rapidly under any plausible scenario for current law.
He told the committee, "Keeping deficits and debt from reaching
levels that would cause substantial harm to the economy would require
increasing revenues significantly as a percentage of gross domestic
product (GDP), decreasing projected spending sharply, or some combination
of the two."
According to CBO's analysis, when measured relative to the gross
domestic product (GDP), almost all of the projected growth in federal
spending other than interest payments on the debt comes from growth
in spending on the three largest entitlement programs: Medicare,
Medicaid, and Social Security. CBO projects that if current laws
do not change, federal spending on Medicare and Medicaid combined
will grow from roughly 5 percent of GDP today to almost 10 percent
by 2035. Elmendorf stressed that "slowing the growth rate of
outlays for Medicare and Medicaid is the central long-term challenge
for federal fiscal policy."
Information:
Dave Moore, Senior Director
AAMC Government Relations
dbmoore@aamc.org
(202) 828-0525
NIH Announces Seven New CTSA Recipients, Releases
First Progress Report
The National Institutes of Health (NIH)'s National Center for Research
Resources (NCRR) July 15 named
seven more institutions that will join the Clinical and Translational
Science Awards (CTSA) research consortium, bringing the total number
of funded centers to 46. These institutions will receive a total
of $171 million over five years from NCRR. The NCRR also released
the first progress report
highlighting the impact of the CTSA program in its first two years.
The seven new institutions include
the Medical University of South Carolina ($19.9 million); Mount
Sinai School of Medicine ($34.6 million); New York University School
of Medicine ($29.4 million); the University of Arkansas for Medical
Sciences ($19.9 million); the University of Florida ($25.7 million);
the University of Illinois at Chicago ($20 million); and the University
of Texas Medical Branch ($21.5 million). The University of Cincinnati
received its CTSA in April 2009 ($22.7 million).
Launched in 2006, the CTSA consortium now includes awardees in
26 states, expanding this year to Arkansas, Florida and South Carolina.
When the program is fully implemented, it will support 60 awards
across the nation. The CTSA consortium works to accelerate the process
that develops lab discoveries into treatments, to engage communities
in clinical research, and to train new clinical and translational
researchers.
"As the world's largest public funding agency for clinical
research, it is imperative that the NIH promote scientific innovation
and collaboration," NIH Acting Director Raynard Kington said
in a statement. "The CTSA consortium exemplifies this approach
by bringing together resources and expertise to translate new research
discoveries into tangible benefits for the American people."
Information:
Irena Tartakovsky, Senior Science Policy Analyst
AAMC Biomedical and Health Sciences Research
itartakovsky@aamc.org
(202) 862-6134
GAO Reports Grants.gov Has "Systemic Weaknesses
That Require Attention"
The U.S. Government Accountability Office (GAO) July 15 issued
a report on
Grants.gov, the central grant identification and application portal
for federal grant programs. Originally an Office of Management and
Budget (OMB) initiative, the Department of Health and Human Services
now manages the system. According to the report, 26 other federal
agencies use the system, but obtaining adequate funding from the
agencies has been difficult. GAO reported that the funding structure
"negatively affects system performance." GAO also found
that clear roles and responsibilities for Grants.gov are critical,
but lacking, and that Grants.gov
also lacks clear performance measures for important aspects of the
system. Lastly, the report notes that grantees lack a structured
forum for input on the Grants.gov system and urges that standardized
government-wide grant application policies be considered and designed,
"in part, to streamline the grants application process and
ease applicant burden." GAO made a number of recommendations
for executive agency actions to address its findings.
Information:
Tony Mazzaschi, Senior Director
AAMC Scientific Affairs
tmazzaschi@aamc.org
(202) 828-0059
House Passes VA Appropriations Bill
The House July 10 passed
(415-3) the FY 2010 Military Construction and Veterans Affairs appropriations
bill (H.R.
3082), which also includes advanced funding for VA medical care
in FY 2011. The House bill includes $44.5 billion for FY 2010 VA
medical care, a $4.1 billion (10 percent) increase over FY 2009;
and $48.2 billion for FY 2011 VA medical care, a $3.7 billion (8
percent) increase over FY 2010. VA research receives the President's
request of $580 million, a $70 million (13.7 percent) increase over
FY 2009. The House FY 2010 appropriations bill does not include
advanced funding for research or information technology.
The House report language directs the VA Under Secretary for Health
to provide a report to the House and Senate appropriations committees
on the recommendations of the VA
Blue Ribbon Panel on VA-Medical School Affiliations. The Blue
Ribbon Panel, chaired by former AAMC President Jordan Cohen, M.D.,
was created in 2006 to advise the VA "on issues related to a comprehensive
philosophical framework to enhance VA's partnerships with medical
schools and affiliated institutions."
The Senate Appropriations Committee July 7 approved its FY 2010
VA Appropriations bill (S.1407),
which includes $44.65 billion for VA medical care, a $4.25 billion
(10.5 percent) increase over FY 2009. The committee approved $580
million for VA research, matching the House bill. The Senate committee
bill provides FY 2011 advanced funding for VA medical care at $48.19
billion, a $3.54 billion (7.9 percent) increase over FY 2010, but
does not include advanced funding for VA research.
The advanced funding would be authorized under the June 23 House-passed
Veterans Health Care Budget Reform and Transparency Act of 2009
(H.R.
1016) to provide advanced funding for VA medical care, as well
as the Medical and Prosthetic Research and Information Technology
accounts [see
Washington Highlights, June 26]. The full Senate has
yet to take up its version of advanced funding authorization legislation.
The Senate Committee on Veterans Affairs May 21 reported
its version of the advanced appropriations bill (S.
423), which does not include VA research or information technology.
Information:
Matthew Shick, Senior Legislative Analyst
AAMC Government Relations
mshick@aamc.org
(202) 862-6116
President Nominates Surgeon General
President Barack Obama July 13 announced the nomination of Regina
Benjamin, M.D., M.B.A., as U.S. Surgeon General. In a July 14 statement,
AAMC President and CEO Darrell G. Kirch, M.D., praised Dr. Benjamin
as "a gifted physician with a strong commitment to caring for the
underserved and community health." Dr. Kirch noted that "this nomination
also appears to mark the first time that a former participant in
the National Health Service Corps (NHSC) could serve as our chief
public health official," observing that the program is "critically
important to America's future health care needs."
Dr. Benjamin is founder and CEO of the Bayou Le Batre Rural Health
Clinic in Alabama, a primary care facility that treats all patients
regardless of their ability to pay. Her service within the medical
community includes her work as the Associate Dean for Rural Health
at the University of South Alabama College of Medicine and as Chair
of the Federation of State Medical Boards of the United States.
In 1995, Dr. Benjamin became both the first female African-American
and first physician under forty elected to the American Medical
Association Board of Trustees, and in 2002 she became the first
African-American woman elected president of a state medical society
when she was chosen as President of the Medical Association of Alabama.
Her numerous awards and honors include both the Nelson Mandela Award
for Health and Human Rights (1998) as well as a MacArthur Genius
Award (2008).
On the Agenda in Washington...
July 21-22: HHS Office for Human Research Protections SACHRP
Meeting
Time: July 21 - 8:30 a.m. to 5:30 p.m., July 22 - 8:30 a.m.
to 3:30 p.m.; Sheraton National Hotel, 900 South Orme Street, Arlington,
Virginia
The Secretary's Advisory Committee on Human Research Protections
(SACHRP) will discuss the Office for Human Research Protections
ANPRM: Holding External IRBs Accountable; CTSA Pediatric Multisite
IRB Issues; Conflicts of Interest in Human Subjects Research; and,
Measurements of IRB Effectiveness. A full agenda is available online.
July 21: ONC HIT Standards Committee Meeting
Time: 9 a.m. - 3 p.m.; Holiday Inn Capitol, 550 C Street,
SW, Washington, DC
The HIT Standards Committee will hear reports from each of
its three workgroups.
July 21: Senate Panel Hearing on Stimulus Spending
Time: 10 a.m.; 342 Dirksen Senate Office Building
The Senate Homeland Security and Governmental Affairs Committee
is scheduled to hold a hearing entitled, "Follow the Money: An Update
on Stimulus Spending, Transparency, and Fraud Prevention."
A witness list is available on the committee Web
site.
July 21: House Panel Considers Student Loan Legislation
Time: 11 a.m.; 2175 Rayburn House Office Building
The House Committee on Education and Labor is scheduled to
mark up The Student Aid and Fiscal Responsibility Act of 2009 (H.R.
3221).
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