Light, as distinguished
Finds strength from its source; no yield
Cedes nothing to dark
Publication Notice: Congress is departing for a two-week summer recess, and so is our newsletter! We will return to our regular publication schedule the week of July 10th.
For breaking news in the meantime, please follow us on Twitter @DukeGovRel or join the Duke Health Advocacy Teams channel (more information below).
The Rundown
- Appropriations, Defense policy reauthorization, and other key priorities
- Congressional hearings focus on health policy reauthorizations, MACRA, VA community care, and artificial intelligence
- MedPAC releases report with site neutral payment recommendations
- Dr. Mandy Cohen officially nominated to lead the CDC
- Senate Majority Leader Schumer releases A.I. innovation framework
- The latest from our desks
- June virtual office hours - Monday, June 26th
- Join the Duke Health Advocacy Network!
Federal Updates
Less money, mo’ problems
What’s an agreement anyway? In the world of contract law, there are parameters, and concepts such as notice, consideration, promise, breach, and associated penalties and remedies for adhering to, or not, the underlying deal. On Capitol Hill, the truth is far more definitional, driven by circumstance, and written in purposeful ambiguity. Policymakers need “wiggle room,” and they take every inch available. Their “agreements” – even in legislative text can be more fleeting and only as good as the next vote – but there is also some freedom in the gray areas, allowing for adaptability, perspective, and a potential shift at just the right moment. This is exactly where we find ourselves now with several key priorities in a post-debt limit debate world, including what’s next on efforts to fund the federal government for the next fiscal year.
FY 2024 Appropriations
It’s as simple and as complicated as this. There is a framework for the next two years on top-line discretionary spending. It was the framework that was agreed in in the debt limit deal signed into law earlier this month that capped non-defense spending at current levels for FY 2024. These levels can increase by 1% in FY 2025.
House Republican leadership views that framework as a ceiling, with plenty of operational space below to make individual determinations on spending levels. House Appropriations Chair Kay Granger (R-TX) is setting that level at the FY 2022 spending level, which means big cuts to healthcare spending. Senate Democratic leadership views that framework as the operating guidance. Those are the targets that must be hit, and the space below is a little more directed. Right now, about a $100 billion gap exists between House and Senate Appropriations Committees’ top lines – and we haven’t even gotten to some of the bigger ticket and more controversial markups, including the bill that funds workforce programs and biomedical research. The original agreement also included an incentive to get work done as quickly as possible – a big stick disguised as a carrot in an automatic continuing resolution with a 1% budget cut that will go into effect if Congress is unable to pass all 12 appropriations bills by January 1, 2024.
The current fiscal year ends on September 30th. There are already fears of power plays and temporary shutdowns. We don’t know how this is going to go yet, but the truth is that we never do, which is why our team continues to work with Duke Health leadership and the NC congressional delegation to emphasize the critical importance of federal support for health systems, the health care workforce, research, and other Duke Health federal funding priorities as part of the FY 2024 appropriations process.
NDAA
Let’s talk about the National Defense Authorization Act (NDAA), why it matters to Duke Health, and how this year’s debate might complicate everything else. The NDAA formally authorizes broad programmatic and spending initiatives at the Department of Defense (DOD), including the Defense Health Program, which supports and funds DOD medical research, as well as the Defense-supported medical workforce. The debt limit agreement places caps on defense funding, and in this case, there isn’t much disagreement between the House and Senate on adhering as closely as possible to the very top of the defense spending cap for FY 2024. Everything else is in the details – which might be a problem. The House Armed Services Committee completed its markup of its version of the NDAA on Thursday morning, which included some controversial messaging amendments that are unlikely to survive a future conference with the Senate. The Senate Armed Services Committee plans to wrap its work today.
There will be some sticking points on priorities, as well as leverage points with a more set and limited pot of funding this cycle. This work could threaten to take up a lot of time in the fall but may also be one the few major bipartisan priorities moving before the end of the year. Typically, the NDAA has not become a vehicle of a broader omnibus. Might that change this year?
Congress has managed to pass a version of the NDAA on time (before January 1) every year for the past sixty-plus years, and they’re on the clock. Tick, tick...
Other
We also have some other critical policy priorities facing reauthorization battles before their expirations at the end of September, including the Pandemic and All-Hazards Preparedness Act (PAHPA) and the SUPPORT Act, which is discussed in more detail below. We might as well throw in the Farm Bill and work on Federal Aviation Administration reauthorization. There is limited calendar time to wade through and reconcile these and many other issues. Are we headed for overtime, or will July be a lot more productive than we expect?
Heard on the Hill
It was another week of healthcare focus for key committees and perhaps a peek into the end of the world as we know it (Skynet, anyone?). Here’s a quick rundown of a few hearings that we were following this week.
House Energy & Commerce Committee
Health Subcommittee holds SUPPORT Act reauthorization hearing
On Wednesday, the House Energy and Commerce Subcommittee on Health held a hearing entitled, “Responding to America's Overdose Crisis: An Examination of Legislation to Build Upon the SUPPORT Act.” The original SUPPORT Act was enacted in 2018 to respond to the opioid crisis. The hearing also examined the Fentanyl crisis, which is a part of this year’s reauthorization efforts.
“Among key policies in SUPPORT Act are public health programs across the Health Resources and Services Administration (HRSA), Substance Abuse and Mental Health Services Administration (SAMHSA), and Centers for Disease Control and Prevention (CDC) that sought to increase education on substance use disorders (SUD) and opioid use disorders (OUD), train health care providers to treat patients diagnosed with two SUD and/or OUD, and help provide wraparound services for patients in treatment and recovery…Additionally, the law extended Medicare and Medicaid payments for vital treatment and recovery options, including coverage for medication-assisted treatments (MAT) and residential care in Medicaid, and extending coverage for methadone and telehealth options in Medicare.”
Reauthorization of the National Child Traumatic Stress Initiative at SAMHSA is being considered as part of the Committee’s SUPPORT Act. NCTSN is coordinated by the UCLA-Duke University National Center for Child Traumatic Stress (NCCTS). Our office has been engaged in these efforts and working with key leaders and members of Congress on this provision of the bill.
Several bills were on the agenda as part of the hearing, which can be viewed in the link above. Current SUPPORT Act programs expire at the end of this fiscal year.
Oversight and Investigations examines MACRA
On Thursday, the House Energy and Commerce Subcommittee on Oversight and Investigations held a hearing entitled, “MACRA Checkup: Assessing Implementation and Challenges that Remain for Patients and Doctors.” The hearing focused on the implementation and effectiveness of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which intended to move away from the Sustainable Growth Rate (SGR) that threatened physicians with significant cuts to payments, to a more stable system of physician Medicare payments through alternative and merit-based systems.
While noting we are better off than we were prior to 2015, Subcommittee Chair Morgan Griffith (R-VA) said the hearing will show what is working, what is not working, what is showing promise, and what unexpected challenges have come to light. One example Chair Griffith used to illustrate challenges was CMS’ implementation of MACRA, which he said has created additional levels of administrative complexity and costs that has slowed down adoption of MACRA quality payment programs. Rep. Michael Burgess (R-TX), who led MACRA policy development to replace the SGR for the Republicans in 2015, said it took him personally 13 years to address the issue. He said with a program as complex as MACRA, it was short sided of Congress to think that the need for oversight would stop after the signing ceremony.
Subcommittee Ranking Member Kathy Castor (D-FL) said that to adequately pay physicians for the care they provide, we need to be confident that the measures we use to assess and compare performance are meaningful and incentivize physicians to participate in new payment models. Full Committee Chair Frank Pallone (D-NJ) stressed that establishing a system that increases accountability and efficiency while maintaining quality patient care is a vision we must continue to pursue. He said that Congress needs to ensure that any changes made will help to better evaluate the quality of care that patients are receiving without overwhelming physicians with administrative requirements.
The full hearing and witness testimony can be viewed at the link above.
House Science, Space, and Technology Committee
On Thursday, the House Science, Space, and Technology Committee held a hearing entitled, “Artificial Intelligence: Advancing Innovation Towards the National Interest.” Witnesses included representatives from academia and industry. The conversation focused on promoting and protecting U.S. innovation and investment in emerging technologies while recognizing that international competitors are gaining ground with new advances to solve foundational problems. There was also discussion of the need to develop and prepare a new workforce that can harness and maximize the potential of these new technologies, as well as a regulatory framework that promotes responsible use and proliferation.
Three members of the NC congressional delegation – Reps. Deborah Ross (D-NC-02), Valerie Foushee (D-NC-04), and Jeff Jackson (D-NC-14) – serve on the Space, Science, and Technology Committee, and our team is continuing to engage with their staffs on Duke Health-led A.I. innovation and principles for effective governance.
Senate Veterans Affairs Committee
On Wednesday, the Senate Veterans’ Affairs Committee held a hearing entitled, “Examining the Effectiveness of the Office of Integrated Veteran Care.” Witnesses included leadership of the Office of Integrated Care (IVC) and the VA Under Secretary for Health, Shereef Elnahal, MD. In 2018, the VA MISSION Act expanded community care opportunities with healthcare partners outside of traditional VA settings. The IVC is responsible for coordinating these community care efforts. The discussion focused on issues ranging from wait times and accessibility to regional differences in quality and IVC oversight.
Duke Health providers across the Triangle serve as community care partners with the VA, and our institution has benefited from an enduring relationship with the Durham VA Medical Center. Our team and leadership are engaged with and carefully monitoring any potential proposed changes to VA community care standards or operations proposed in Congress.
MedPAC releases report with site neutral payment recommendations
The Medicare Payment Advisory Commission (MedPAC) released its June report to Congress with several recommendations, including site-neutral payment policies. Specifically, MedPAC recommended that “Congress should more closely align payment rates across ambulatory settings for selected services that are safe and appropriate to provide in all settings and when doing so does not pose a risk to access.” The recommendation would be budget-neutral, redistributing $7.5 billion. In its release about the recommendation, the American Hospital Association noted that the impact would be most pronounced on rural hospitals.
Dr. Mandy Cohen Officially nominated to lead the CDC
In case you missed it, on July 16, President Biden officially nominated Dr. Mandy Cohen as Director of the Centers for Disease Control and Prevention. In his statement, President Biden highlighted her achievements as Secretary of the North Carolina Department of Health and Human Services. He stated that “Dr. Cohen is one of the nation’s top physicians and health leaders with experience leading large and complex organizations, and a proven track-record protecting Americans’ health and safety.” He also acknowledged that she has been recognized by leaders from both parties for her ability to find common ground and put complex policy into action.
Starting in 2025, the position of CDC Director will require Senate confirmation. Dr. Cohen will be assuming the role amid reorganization launched by outgoing Director, Dr. Rochelle Walensky.
Schumer unveils A.I. innovation framework
This week, Senate Majority Leader Chuck Schumer (D-NY) unveiled his “SAFE Innovation Framework” that is intended to help guide congressional efforts to develop federal regulations and guardrails for Artificial Intelligence. The acronym stands for security, accountability, foundations and explain, which together make up four of the five principles underpinning the framework’s legislative philosophy. The fifth principle, innovation, reflects Leader Schumer’s priority to invest in the development of U.S.-led technologies.
He also announced plans to convene a series of “AI Insight Forums'' starting this fall. The meetings would convene top A.I. experts with briefing Congress on topics including: workforce, national security, privacy, and “doomsday” scenarios. More details on these forums are expected later this summer.
It is notable that in many of the broader conversations, regulations and protections for healthcare A.I. are not often mentioned explicitly but rather folded into debates over data integrity and privacy. Our team has been coordinating meetings with key congressional offices with Duke AI Health leadership and Duke Health leaders to highlight healthcare A.I. and proactively position our work and expertise as resources for policymakers to better inform the development of legislative and regulatory proposals.
From our desk(s): Duke Health GR this week
This week our office organized a meeting for Dr. Vincent Guilamo-Ramos, Dean and Professor of the Duke University School of Nursing and Vice Chancellor for Nursing Affairs at Duke University, to meet with majority staff for the Senate Health, Education, Labor and Pensions Committee and discuss the School’s work to mitigate social determinants of health.
Our office took part in the Association of American Medical Colleges (AAMC) Graduate Medical Education (GME) day of action, tweeting support for the Resident Physician Shortage Reduction Act.
Members of our team also participated in strategy calls with Duke Health leaders and national partners on key issues, including: 340B, trauma center support, healthcare workforce support, Medicare reimbursement, telehealth, and data privacy.
Coming Monday – Virtual “Office Hours” on June 26th
Duke Health (federal) Government Relations is once again partnering with our Duke State Relations colleagues to hold our second open, virtual "office hours" in May. Open to members of the Duke Health Advocacy Network, these “office hours” are not formal presentations but instead an opportunity to talk about some of things on deck for us to learn more about the issues that are at the forefront for you and your work.
Date: Monday, June 26, 2023
Time: 12:00pm
A link to access the event has been published in the Duke Health Advocacy Network Teams Channel.
Not yet a member of the Duke Health Advocacy Network? No problem! Learn more about how to join below.
Join the Duke Health Advocacy Network!
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We encourage you to explore the channel, as we will post relevant news items, policy updates, questions, advocacy resources, and opportunities for engagement. As importantly, this is your space to do the same and to help grow the community.
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