October 17, 2017Volume 23, Number 10
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House VA Committee Holds Hearing on Asset Review Proposed Legislation
On October 12, 2017, the House Committee on Veterans’ Affairs conducted a legislative hearing to review a draft bill—the “Asset and Infrastructure Review (AIR) Act.” This legislation was originally discussed during a full Committee round table in September. Carl Blake, Associate Executive Director (AED) of Government Relations, testified on behalf of Paralyzed Veterans of America (PVA). PVA generally supports the intent of the legislation; however, we expressed some significant concerns with the proposal as presented.
The draft bill would require the Department of Veterans Affairs (VA) to undertake an asset review process that mirrors the BRAC process previously used in the Department of Defense (DOD). During the hearing, PVA expressed our support for the notion of rightsizing the VA’s infrastructure footprint. However, we emphasized that a BRAC-style process is not necessarily the optimal process to achieve that end. Representatives from the Government Accountability Office (GAO) and the Congressional Research Service (CRS) explained that the key to making the process work is spending all the time necessary to do advance planning, laying out the desired end goals and the processes needed to analyze the complete VA health care system. GAO explained that DOD had fully three years before a BRAC Commission was empaneled to consider the infrastructure alignment of DOD. Meanwhile, this bill establishes a process whereby the VA will complete all of its preparatory work within one year and the Commission will then submit its final recommendations to Congress within six months following that date (by May 2019), effectively giving VA and the Commission only 18 months to outline the complete realignment of the infrastructure footprint of the Veterans Health Administration (VHA). The draft legislation essentially ignores what GAO identified as the most critical point to ensure success of this process—time.
Moreover, this legislation appears to be putting the cart before the horse. We strongly believe that VA should have the opportunity develop and put into operation its integrated health care network before any decisions are made about what the footprint of VA should look like. It makes no sense for VA to make decisions about what its infrastructure alignment will be without first understanding what its capacity to deliver services currently is and how an integrated network must be designed to enhance that capability. Central to that effort is the completion of a thorough market assessment before the network can be fully established and implemented. With that in mind, the draft bill requires modification to its overall timeline in order to accommodate more time for market assessment.
We also have serious concerns that fitting a BRAC model to VA presumes that the nature of the VA health care system is not fundamentally different from the DOD base alignment that was considered during its own BRAC process. This proposal ignores the fact that the DOD BRAC addressed a static military population and simply consolidated and moved units to fit its planned infrastructure alignment. It was relatively easy, though not politically, to simply move military families to new locations to support the force realignment. This fact does not apply to the VA health care system and the population it serves. Decisions to close or downsize a VA medical facility will have a direct impact on the veteran population being actively served in that selected community.
Our last concern is the impact initiating a BRAC process will have on current major and minor construction activities at VA. When VA initiated its Capital Asset Realignment for Enhanced Services (CARES) process nearly 15 years ago, the most devastating result of this process was the moratorium placed on virtually all construction for a two-year period while the process was conducted. Congress has compounded that problem every year since that time by woefully underfunding the major and minor construction requirements of VA. Many facilities are now in serious decline simply because they were not upgraded or modernized, and because Congress continues to provide inadequate funding for VA’s infrastructure needs, and now many of those facilities face the possibility of closure because of that neglect.
With the establishment of an Asset and Infrastructure Review Account we believe that Congress will continue to ignore its responsibility to provide critically-needed funding for ongoing construction projects in an effort to wait for the outcome of the Commission. This is an unacceptable proposition for PVA.
The prospects for this legislation remain uncertain. The Senate Committee on Veterans’ Affairs is much less inclined to take up similar legislation. The bill may also be unnecessary as the Secretary has already laid out plans to deal with unused and underutilized facilities.
To read PVA’s full written statement, please visit http://www.pva.org.
House VA Committee Conducts Roundtable on Choice Reform Legislation
On October 3, 2017, the House Committee on Veterans’ Affairs conducted a round table to discuss a draft bill that would make the Veterans Choice program permanent. The bill presumably reflects bipartisan efforts of both Chairman Phil Roe (R-TN) and Ranking Minority Member Tim Walz (D-MN). Carl Blake, AED of Government Relations, represented PVA at the round table and was accompanied by Lana McKenzie, AED for Medical Services, who offered key insights into the ideas being considered by the Committee and how the provision of spinal cord injury (SCI) care will fit into this proposal.
PVA generally supports the draft bill that has been presented. The bill authorizes the development of an integrated health care network to support the VA health care system. Veterans would be assigned a primary care provider either within the VA or in the community dependent upon availability. Access to the community would then be governed by a determination of clinical need between the veteran and his or her primary care provider, the availability of services at the local VA medical center or in the community, and the performance of the local VA in providing those services in a timely, quality manner. Veterans needing specialty care must be referred into the community. Much of the structure of this proposal mirrors the concepts of an HMO.
Our emphasis during the round table was on ensuring proper coordination of care, particularly when veterans with catastrophic disabilities such as spinal cord injury are referred to providers in the community. We also recommended that the Committee revise the draft bill to allow more time for the completion of market assessments that will outline the capacity of VA to provide services. We do have concerns that those market assessments are focused too much on examining a way to allow for the community to provide more care when gaps are identified, rather than also outlining potential alternatives that will expand VA’s internal capacity.
The bill also lacks an urgent care benefit that many veterans’ service organizations and key stakeholders have recommended in the past. In fact, the VA’s draft community care plan presented earlier this year included an urgent care benefit. We have argued that urgent care options for veterans would potentially relieve significant pressure on the emergency care and primary care functions at the VA.
This legislation will be considered in a legislative hearing by the House VA Committee later in October. It remains unclear how the House and Senate VA Committees will resolve the significant differences that currently exist between the bills they are considering.
Of note, at the end of the round table, Chairman Roe emphasized that the notion of unfettered choice is a false choice. He explained that the only people who get unfettered choice in their health care in America are those who pay completely out of pocket. Otherwise, all other people seeking health care do so through a type of managed care. This is a critical point as some continue to advocate for unfettered choice within VA.
Amendment Addressing Passengers with Disabilities Added to TSA Modernization Bill
On October 4, 2017, the Senate Commerce, Science, and Transportation Committee marked up S. 1872, the “Transportation Security Administration (TSA) Modernization Act.” At the markup, the Committee accepted a PVA-supported amendment on improving the screening of passengers with disabilities. The amendment was sponsored by Chairman John Thune (R-SD), Ranking Member Bill Nelson (D-FL), Senator Roy Blunt (R-MO), and Senator Maria Cantwell (D-WA).
The amendment includes several provisions that would improve the travel experience for people with disabilities. One provision would require TSA to work with disability and veterans’ service organizations to develop specific training requirements for TSA personnel regarding the proper screening of passengers who use wheelchairs, indwelling medical devices, prosthetics, and service animals. As part of this process, TSA would be required to revise its current training to implement needed changes.
Another provision would require TSA to record each disability-related complaint, identify the most frequently concerns raised or accommodations requested, and determine the best practices for addressing the most frequent complaints and accommodation requests. The amendment would also require signage at security checkpoints informing passenger with disabilities of their right to request assistance with disability-related complaints. Importantly, it would also improve accountability by requiring TSA to report to Congress on an annual basis metrics related to the experiences of passengers with disabilities.
PVA will continue to work with Committee staff in the coming weeks to ensure additional protections for passengers with disabilities in transiting security are addressed before the bill heads to the Senate floor.
House and Senate Budget Resolutions Assume Cuts to Medicare, Medicaid and Social Security
On October 4, 2017, the House of Representatives approved its 2018 budget resolution that lays the groundwork for its tax reform plans through the process known as reconciliation. Adopting an overall $4.1 trillion spending plan for the federal government for fiscal year 2018, the budget resolution contains a set of instructions to Congressional committees to turn the budget resolution into implementing legislation.
Contained in the budget resolution are instructions to House committees to find $487 billion in savings over ten years from Medicare, $1 trillion in savings from Medicaid and $5.4 billion from Social Security. Proposed changes for Medicare include a gradual increase in the eligibility age from 65 to 67, raising income related premiums for Parts B and D (the physician services and prescription drug programs])of Medicare and converting this program for older Americans and people with disabilities to a premium support system of financing. If enacted, Medicare beneficiaries would be given a flat payment or voucher with which to buy health insurance either under traditional Medicare or through the private market. All plans competing in the program would have to match the benefits and services of traditional Medicare and insurers could not deny coverage to any beneficiary. Although the impact on beneficiaries of this plan is unclear, previous analyses by the Congressional Budget Office have indicated that a premium support system would increase costs for those enrollees in traditional Medicare. The $1 trillion in cuts to Medicaid are assumed to come from adoption of provisions that were included in previous House-passed health care reform bills such as turning Medicaid into a block grant to the states and ending the Medicaid expansion.
For Social Security, the budget resolution proposes reducing Social Security Disability Insurance (SSDI) benefits to those beneficiaries receiving Unemployment Insurance compensation. Such a move could prove to be a work disincentive for SSDI recipients who attempt a return to work but lose their jobs through no fault of their own. The vote in the House in favor of the FY 2018 budget resolution was on a nearly party-line voted of 219 to 206.
The Senate is expected to take up a similar budget resolution as soon as the week of October 16. Passing the budget resolution through both chambers sets in motion the process known as reconciliation by which changes to the tax code can be passed with a simple majority of 51 votes in the Senate. The changes proposed in the budget resolution to Social Security, Medicare and Medicaid are only a road map for authorizing committees to turn into legislation. However, PVA remains concerned over their potential harm to beneficiaries and will oppose measures that adversely affect the earned benefits of older Americans and people with disabilities.
Advocacy Staff Participate in Site Visit on Improving Air Travel Accessibility
In October, PVA Associate General Counsel Heather Ansley and Senior Associate Advocacy Director Lee Page travelled to Minden, NV, to meet with Peter Axelson of Beneficial Designs. The meeting was meant to educate our staff regarding Mr. Axelson’s research into accessible air travel. Specifically, Mr. Axleson and Beneficial Designs received a 2014 award from PVA’s Research Foundation to investigate assistive technology for non-ambulatory passengers in air travel. Staff had the opportunity to walk through the research protocol and learn more about the various boarding chairs and lift systems designed to help people with disabilities board and deplane an aircraft.
While in Nevada, staff also had the opportunity to meet with John McGuinness of HAYCOMP of Australia, a company that manufacturers lift devices for persons with disabilities including aviation lifters. Information about their product can be found at: http://www.haycomp.com.au/aviation-lifters/. The lift device is able to assist a person with complete immobility on an off an airplane as an alternative to the standard aisle chair. HAYCOMP is working with the PVA Florida Gulf Coast Chapter and the coordination committee for the 38th National Veteran Wheelchair Games that will be held in Orlando, FL, from July 29-August 4, 2018. The lift will be available in Orlando to assist veterans who need the assistance it provides to board and deplane in a safe and effective manner.
President Issues Executive Order to Expand Health Insurance Options
In the wake of Congressional inaction on repealing the Affordable Care Act (ACA), President Donald Trump signed an executive order (EO) on October 12 directing several federal agencies to issue regulations to broaden Americans’ access to lower cost health insurance options. The EO focuses on promoting greater use of three different types of health coverage plans: so-called association health plans (AHPs), short-term, limited-duration insurance (STLDI), and health reimbursement arrangements (HRAs).
The Labor Department (DOL) is given 60 days to develop proposed regulations to make it easier for small businesses and individuals to join together to purchase health insurance through nationwide association health plans. Association health plans already exist but DOL could amend rules so that these plans fall under similar regulations governing large-employer health insurance policies. Large employer health insurance plans are not required to abide by all of the ACA mandates such as coverage of prescription drugs, rehabilitation services or other essential health benefits. While this move could allow AHPs to restrict coverage based on medical history, the administration has said that employers participating in these plans would not be allowed to exclude employees or develop premiums based on health conditions.
DOL as well as the Departments of Treasury and Health and Human Services were assigned the two other tasks covered by the EO. Within 60 days, they are to devise proposed regulations to expand the availability of short-term health insurance policies, which also don’t have to comply with ACA protections, for those with pre-existing conditions. Typically used by persons who are between jobs, these STLDI plans are not required to offer the comprehensive set of benefits called for under the ACA and were limited by the ACA to no longer than 90 days. The order extends the term of these plans to a year. Within 120 days, these same three agencies are directed to propose regulations or revised guidance to increase the use of HRAs, to expand the ability of employers to offer HRAs to their workforces, and to allow HRAs to be used in conjunction with non-group coverage.
Critics of these proposals are concerned that allowing these health plans to sell more limited benefits and exclude persons with high cost health conditions may draw younger and healthier people to them, leaving older persons and those with disabilities or chronic conditions in the ACA health exchanges. That in turn would cause insurance premiums in ACA plans to spike, making insurance increasingly unaffordable and possibly leading to greater numbers of people without insurance.
All of the proposals contained in the executive order must go through the regulatory rule-making process so it may be at least six months before any changes are finalized by Labor, Treasury and HHS.