Federal budget woes and wins for seniors

Washington Watch

Lawmakers defend the federal budget, passed by Congress and signed by President Donald Trump at the end of March, by repeating a quotation attributed to Otto von Bismarck: "If you like laws and sausages, you should never watch either one being made."

In other words, the legislative process can be messy and extremely unappetizing, but it usually produces results. This budget bill to fund the government through Sept. 30, 2018, will be remembered as much for what's not in it as for what is. (An extensive list of wins and woes for seniors appears below.)

Trump further damaged his credibility with Congress with his unpredictable behavior on the budget bill. First, his team worked quietly with lawmakers to work out a middle ground between what the administration had proposed and what Congress wanted. Then Trump, undercutting his own negotiators with a last-minute veto threat, reversed that and signed it, and then vowed never to sign another bill like it.

The 2,232-page spending bill passed the Senate by a 65-32 vote, and the House, hours earlier, by 256-167. The bill directs $700 billion toward the military and $591 billion to domestic agencies. The military spending is a $66 billion increase over the 2017 level, and the non-defense spending is $52 billion more than last year.

Trump got blowback from conservative Republicans because the bill abandons GOP claims of fiscal discipline in a stark reversal of the promises many Republicans ran on in capturing control of the House in 2010 and the Senate in 2014.

Conservatives fumed at the generous increases for many agencies, but some lawmakers saw and called out the hypocrisy. As the always-quotable Sen. John Neely Kennedy, R-La., put it, “the Democrats love this bill like the devil loves sin," he said. "I don't understand why when President Obama does what we're about to do, it's bad for the country, but when we do it, it's good for the country."

Just days after complaining that he had to work with Democrats to get it passed, Trump is talking with Congressional Republicans about ways to rescind or effectively cut some of the funds they just approved.

As the bill moved toward passage, many lawmakers had real questions about the details of the mammoth funding bill, which was released less than 17 hours before the House voted.

"Nobody knows what's in it. I don't know what's in the damn thing," complained Louisiana's Kennedy. He added, "Whoever came up with this isn't qualified to run a food truck."

What makes this legislation so significant is that it is most likely the last major achievement ahead of the midterm elections in November. That “last train leaving the station” mentality increased the pressure to jam the bill full of odds and ends, with provisions addressing everything from gun safety to invasive carp.

With seven months to go before the November elections, what some call the "dead zone" period, almost any bill – even a bill with strong bipartisan support – has little chance of passage as congressional leaders in both the Republican and Democratic parties try to protect their vulnerable members by avoiding difficult votes because neither side wants to give the other side a political victory. Perhaps ironically, the government will run out of money again just five weeks before the November election and will need to find some way to fund itself.

With that perspective, it's easier to understand that some of the things that did not get funded were cut because they were controversial or difficult to find middle ground. In the course of getting the budget approved, Trump upset liberals, conservatives, Democrats and Republicans and even members of his populist base.

The funding bill does not fully pay for Trump's planned border wall, authorizing $641 million for new fencing, which is a mere fraction of the $25 billion Trump initially sought and that some Democrats had floated to him in return for extending protection from deportation to some 700,000 immigrants in the Deferred Action for Childhood Arrivals (DACA) program.

Trump announced in September he would end that program. But failure to resolve the problem leaves the DACA folks, who have all lived in the United States for most of their lives, facing deportation and unable to work legally in the U.S. while they await resolution of their status. The bill does not cut funding for funding for sanctuary cities, as some Republicans had wanted.

On health care, the funding legislation also does not include a bipartisan deal to shore up the Affordable Care Act health insurance markets for two years while Congress continues to grapple with GOP efforts to replace the law. Insurers had been lobbying hard to get a $30 billion reinsurance program included in the massive spending bill. Absent that lifeline, insurers will likely be raising premiums and rethinking their participation in the individual market in 2019. This is particularly important for anyone who purchases their own health coverage versus those who get it through their employer. Sens. Lamar Alexander. R-Tenn., and Patty Murray, D-Wash., the leaders of the Senate Health Committee had spent months working out a compromise, but it got sidetracked over an abortion issue.

What’s in it – or not – for you

So what is in the funding bill? It beefs up military and domestic programs, delivering federal funds to every corner of the country. It also has lots of new money for medical research, funding to fight the opioid epidemic, new money for addiction treatment and mental health care. It also orders the Army Corps of Engineers to keep working on trying to keep Asian carp, an invasive species, out of the Great Lakes.

A deep dive into what's actually in the legislation reveals several provisions of particular importance to seniors:

Unlimited therapy. For many years, there's been confusion about the conditions that Medicare will cover – physical, occupational and speech therapy. Some seniors with Parkinson's disease and multiple sclerosis have had their therapy discontinued because therapists weren't making sufficient progress. People recovering from strokes or traumatic brain injuries have been told they've reached an annual limit on services and could not qualify for further care.

Now Congress has lifted this threat by eliminating annual caps on how much Medicare pays for physical, occupational or speech therapy and streamlining the medical review process. It applies to people in traditional Medicare as well as those with private Medicare Advantage policies.

Since January 1, Medicare beneficiaries are eligible for therapy indefinitely as long as their doctor, or in some states physician assistants, or nurses confirm the patient’s need for therapy and they continue to meet other requirements, like having a doctor regularly reviewing your plan of care. Under a 2013 court settlement, seniors won't lose coverage simply because they have a chronic disease that doesn't get better.

"Put those two things together and it means that if the care is ordered by a doctor and it is medically necessary to have a skilled person provide the services to maintain the patient's condition, prevent or slow decline, there is not an arbitrary limit on how long or how much Medicare will pay for that," Judith Stein, executive director of the Center for Medicare Advocacy, told Kaiser Health News.

But there still will be some barriers for seniors in certain situations. Medicare got rid of the caps but is retaining the idea of "thresholds." After billing $2,010 in services (about 20 therapy sessions at $100 per visit) this year, a provider has to add an extra code to a bill. After billing $3,000, targeted medical reviews and the potential for audits can again be prompted.

Eliminating the caps should make things easier for seniors who need a time-limited course of therapy.

But whether therapists will be wary about approaching the $3,000 threshold, with its extra administrative burdens and potential risks, remains to be seen. If so, patients recovering from strokes or brain injuries and those with complicated chronic conditions, who need intensive therapy for an extended period, could be affected.

Chronic care. Another important change allows private Medicare Advantage plans in 2020 to offer special benefits to members who have a chronic illness and meet other criteria.

Currently, these private insurance plans, which limit members to a network of providers, treat all members the same. Under the budget law, benefits targeting those with chronic diseases do not have to be primarily health related, and only have to provide a "reasonable expectation" of improving health.

These include devices and services that assist people with disabilities, avoid emergency room visits or minimize the impact of health problems. The expanded range of benefits might help folks stay at home easier. But the changes only affect those in private plans, which is about a third of the 59 million people on Medicare.

Donut hole. Congress rebuffed drug companies' appeals to reduce how much they have to pay for some seniors' prescription costs – a rare defeat for the industry after an intense lobbying campaign. Drug makers had pushed Republicans to roll back a policy that makes them responsible for 70 percent of the prescription costs for seniors who hit the so-called donut hole threshold in 2019. The donut hole is a gap in Medicare drug coverage in which beneficiaries are on the hook for prescription costs once they've paid $3,750 for covered drugs.

When that happens, a patient's share of prescription drugs shoots up to 35 percent of brand-name drug costs. When beneficiaries' total yearly drug expenses reach $5,000, they enter the catastrophic coverage stage and pay just 5 percent of the costs. Falling in between is what they call the donut hole. The Affordable Care Act had called for the donut hole share to be narrowed to 25 percent by 2020, but the budget deal would have moved up that adjustment to 2019.

Social Security Administration added funding. Reversing cuts that had been happening since 2010 – which had caused excessively long waits on toll-free phone lines and in person at SSA field offices – the legislation increases the Social Security Administration's budget by $480 million over the previous year.

This includes $100 million intended to reduce the astounding backlog in Social Security Disability Insurance hearings. Between 2015 and 2017, 18,701 people have died while waiting for a judge's decision, according to federal data analyzed by the Washington Post. The rising death toll coincides with a surge in the length of time people must wait for a disposition, which swelled from a national average of 353 days in 2012 to a record high of 627 days in August 2017.

The budget bill also allots additional funds to the National Institutes of Health, including a $414 million increase for Alzheimer's disease research and provides $59 million more for Older Americans Act Senior Nutrition programs, and an increase of $250 million for the Low Income Health Energy Assistance Program, which helps assist many seniors in the winter months with their energy costs.

Community health centers will also see an increase of $135 million over last year, part of a $2.8 billion push to expand addiction prevention and treatment of opioid addiction. Medicare doctors will also see a quicker resolution to their Medicare appeals with Congress funneling $182 million toward reducing a backlog of more than 500,000 appeals.

Also contributing to this report were: Kaiser Health News; Washington Post; AP and

Modern Healthcare.

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