March 12, 2021: National Advocacy Update

On March 10, the House of Representatives voted to adopt the Senate’s amendments to the American Rescue Plan Act of 2021, and President Biden signed it into law on March 11. This extensive piece of legislation provides wide reaching relief for our nation’s public health workforce and works to provide additional resources to combat COVID-19, provide economic relief and care for the most vulnerable in our country.

The following are some of the provisions in the legislation:

• Provides significant funding increases for community health centers, teaching health centers, Medical Reserve Corps, National Health Service Corps Repayment Program and establishing, expanding and sustaining a public health workforce.
• Adds an additional $8.5 billion dollars to the Provider Relief Fund.
• Gives an option for states to provide 12-month post-partum coverage under State Medicaid and CHIP.
• Offers community grants for rural health and nutritional-related infrastructure and distribution critical to addressing the COVID-19 pandemic.
• Sustains funding for federal nutrition assistance programs including WIC and SNAP.
• Contains designated provisions for COVID-19 vaccine delivery and education activities to improve the vaccination rate.
• Gives funding for COVID-19 treatment, testing and contact tracing to help state and local public health departments.
• Supplies funding for grants that support community mental health and substance use disorder treatment, training of health care professionals and for health care providers to promote mental health among the health care workforce.
• Directs for the utilization of the Defense Production Act to boost domestic production of PPE, vaccines and onshore production of rapid COVID-19 tests.
• Expands and extends federal unemployment benefits.
• Provides a temporary (two-year) 5% increase in the Medicaid FMAP to states that enact the Affordable Care Act’s (ACA) Medicaid expansion and covers the new enrollment period per requirements of the ACA.
• Invests nearly $35 billion in premium subsidy increases for those who buy coverage on the ACA marketplace.
• Expands the availability of ACA advanced premium tax credits (APTCs) to individuals whose income is above 400% of the federal poverty line (FPL) for 2021 and 2022.
• Invests in trust and treaty obligations to provide essential safety-net programs that serve Native communities, which were historically underfunded prior to the start of the COVID-19 pandemic.
• Increases funding to waive copays for veterans during the pandemic and to provide support to veterans, including COVID-19 vaccine distribution, expanded mental health care, enhanced telehealth coverage, extended support for veterans who are homeless or in danger of becoming homeless and PPE and supplies for VA clinical employees.
• Adds $15 billion in new funding for Targeted Economic Injury Disaster Loan (EIDL) Grants to provide hard-hit, underserved small businesses with increased flexible monetary relief.

The AMA sent a letter in support of H.R. 8 the “Bipartisan Background Checks Act of 2021,” a bill that would expand the existing background check system to cover all firearm sales including those at gun shows, over the internet and through classified ads, while providing reasonable exceptions for law enforcement and family and friend transfers. The House passed the bill on March 10 but faces long odds in the Senate.

The AMA recognizes that firearm violence is a serious public health crisis in the United States and acknowledges that while the federal background check system is effective at preventing certain prohibited purchasers from accessing guns, it could be made more effective if unlicensed dealers and private sellers were also required to conduct background checks. By closing these loopholes, H.R. 8 can be an important tool in keeping guns out of the hands of those who are prohibited from having them and will help reduce gun violence and save lives.

As the COVID-19 pandemic continues to grip the country, America's physicians remain entrenched on the front lines, fighting to save their patients. After nearly a year of combating the deadly virus, there is a growing evidence of the toll it is taking on physician practices.

The continued negative fiscal impact of the COVID-19 pandemic on physician practices is undeniable. A recent AMA report analyzed Medicare claims data exclusive to physician services and found spending dropped as much as 57% below expected pre-pandemic levels in April 2020. During the first half of 2020, the cumulative estimated reduction in Medicare physician spending associated with the pandemic was $9.4 billion (19%).

Recognizing that the challenges associated with the pandemic continue, Congress included provisions in the Consolidated Appropriations Act, 2021, signed into law last December, that further postponed the Medicare sequester until March 31. Yet, it is clear that the COVID-19 pandemic will extend well beyond the first quarter of this year and, absent additional Congressional intervention, these harmful payment cuts will be re-imposed on April 1.

To make matters worse, as Congress prepares to pass an economic stimulus plan, physician practices confront an even greater threat of Medicare cuts in 2022. According to the Congressional Budget Office, final passage of the American Rescue Plan Act will set in motion PAYGO statute reductions in Medicare spending of 4% next year, totaling $36 billion.

Thankfully, H.R. 315 the “Medicare Sequester COVID Moratorium Act” has been recently introduced in Congress. This bipartisan legislation would continue the current Medicare sequester moratorium for the duration of the COVID-19 public health emergency.

If Congress does not act by March 31, the Medicare payment sequester will take effect, triggering a devastating financial impact on physician practices across the country, many of which are already strained to the breaking point. Call your senators now to stop these harmful Medicare cuts from going into effect.

With the coronavirus pandemic stretching into its twelfth month, Congress is refocusing its attention on promoting sound physician mental health and curbing burnout associated with prolonged treatment of patients afflicted with COVID-19. On March 4, Senators Tim Kaine (D-VA), Jack Reed (D-RI), Todd Young (R-IN) and Bill Cassidy, MD (R-LA) introduced S. 610, the Dr. Lorna Breen Health Care Provider Protection Act, comprehensive legislation dedicated to reducing and preventing suicide, burnout and mental health conditions among physicians and other health care professionals. An identical House companion bill, H.R. 1667, was introduced by Representatives Susan Wild (D-PA), Raja Krishnamoorthi (D-IL), Judy Chu (D-CA) and David McKinley (R-WV) on March 8. The legislation is named in honor of Dr. Lorna Breen, a physician from Charlottesville, VA, who, stemming from the stress and trauma of serving on the frontlines caring for COVID-19 patients in New York City, died by suicide in April 2020.

Federal lawmakers ultimately added the majority of the Dr. Lorna Breen Health Care Provider Protection Act to H.R. 1319, the American Rescue Plan Act of 2021, the $1.9 trillion COVID-19 relief package that President Biden signed into law March 11. H.R. 1319 includes:

• Grants to health profession schools for training students, residents or other health care practitioners in strategies to reduce and prevent suicide, burnout, mental health conditions and substance use disorders
• A CDC-developed education and awareness campaign targeting health care professionals to encourage them to seek support and treatment for mental and behavioral health conditions
• Grants to health care providers and associations to establish, enhance or expand programs and protocols to promote mental and behavioral health.

The AMA has worked diligently with members of the House and Senate to address physician suicide, burnout and mental health throughout the COVID-19 pandemic. In 2020, AMA supported and played a key role in developing both the Coronavirus Health Care Worker Wellness Act, bipartisan legislation introduced by Reps. Krishnamoorthi and John Katko (R-NY) that would have commissioned a multi-year study on health care worker mental health among other provisions and the. Dr. Lorna Breen Health Care Provider Protection Act.

In the current legislative session, lawmakers have consolidated their support around the Dr. Lorna Breen Health Care Provider Protection Act. AMA strongly supports the Dr. Lorna Breen Health Care Provider Protection Act and commends Congress for including the key components of this bill in the American Rescue Plan Act.

On March 9, the U.S. Department of Homeland Security (DHS) announced that the government will no longer be defending the 2019 public charge rule. The U.S. Department of Justice (DOJ) has also dismissed its pending appeals in the Supreme Court and Seventh Circuit and is in the process of dismissing its appeal in the Fourth Circuit. Following the Seventh Circuit dismissal, the final judgment from the Northern District of Illinois, which vacated the 2019 public charge rule, went into effect. As a result, the 1999 interim field guidance on the public charge inadmissibility provision is now in effect.

This means that an immigrant’s receipt of Medicaid, except for Medicaid for long-term institutionalization, is not grounds to deny them a green card. However, per the Administrative Procedure Act, the rule cannot be immediately suspended. Instead, the rule will have to be rewritten and go through the rulemaking process. Nevertheless, the Administration will not be enforcing the rule in the interim. The AMA is pleased to see this rule, which has caused individuals to not seek out much needed health care, be vacated. This change aligns with the advocacy that the AMA has been engaging in since 2018 (see comment letter (PDF), CA amicus (PDF), SDNY amicus 1 (PDF) and amicus 2 (PDF), WA amicus (PDF), comment letter (PDF) for more).

In response to the AMA’s advocacy, the Centers for Medicare and Medicaid Services (CMS) will hold physicians harmless from up to 9% Merit-based Incentive Payment System (MIPS) penalties due to the significant disruptions of the COVID-19 public health emergency on physician practices’ performance in 2020. The Extreme and Uncontrollable Circumstances Hardship Exception policy will be automatically applied to all MIPS eligible clinicians who do not submit any MIPS data for the 2020 performance period and avoid a 2022 payment penalty. CMS is also reopening the hardship exception application for group practices, virtual groups and alternative payment model entities who missed the previous 2020 deadline. The re-opened application deadline is March 31.

Groups and eligible clinicians who submit data in at least two MIPS categories will override the hardship exception and be eligible to earn a bonus from the exceptional performance bonus pool or potentially be subject to a penalty. While eligible clinicians will never be scored on 2020 cost measures under the hardship exception policy, groups and virtual groups will be unless they apply to reweight the MIPS cost category to zero. The AMA encourages all groups that are submitting MIPS data to consider applying to zero out the MIPS cost measures in 2020 due to unpredictable consequences of the pandemic that may inadvertently penalize practices on the frontlines and those who have seen fewer patients.

41 national specialty societies joined the AMA on a letter (PDF) to CMS Acting Administrator Liz Richter recommending CMS reinvent the status quo in MIPS in order to achieve the goal of improving outcomes for patients and giving patients information about where to go for high-quality, efficient care in MIPS Value Pathways (MVP).

Specifically, the AMA and specialty societies are urging CMS to work with specialty societies and other stakeholders to identify, develop and test new measure concepts to address the larger goal that the MVP will address, whether it is incentivizing care coordination or addressing avoidable costs. MVPs should not be one-size-fits-all and, in some cases, overly broad focused MVPs fail to account for sub-specialization and varying practice arrangements. AMA is urging CMS to provide more data to specialties so we can work together to model MVPs. AMA is also recommending CMS incentivize participation in MVPs, establish multi-category credit to reduce complexity, move to attestation in the Promoting Interoperability category and ensure MVP participation is voluntary.

The AMA thanks CMS for the ongoing dialogue between the agency and our organizations and urges CMS not to rush into implementation but rather ensure each MVP is well-designed with agreement from the relevant specialties.

Elizabeth Fowler, JD, PhD, has been appointed by the Biden-Harris administration as CMS Deputy Administrator and Director of the Center for Medicare and Medicaid Innovation (CMMI). Dr. Fowler has previously held senior positions with the Commonwealth Fund and Johnson & Johnson focused on health care delivery and payment system reform. She also served on the National Economic Council and at HHS in the Obama administration and was Chief Health Counsel to former Senate Finance Committee Chair Senator Max Baucus. Dr. Fowler brings deep experience in alternative payment models (APM) to her new role as CMMI Director. The AMA looks forward to working with her in this role to seek implementation of physician-developed, patient-centered models and build a more robust APM pathway in Medicare.

Under this new leadership, CMMI recently announced several delays in the rollout of models developed by the previous administration. It has pulled back the Geographic Direct Contracting model for review, delayed the Kidney Care Choices model until 2022, and announced that the seriously ill population component of the Primary Care First model will not begin as previously scheduled on April 1.

• March 12, 2021: State Advocacy Update
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