Governor's Budget

2017 WRHA Legislative and Policy Agenda


House passes AHCA; Tell Your Senators to Oppose Bill
Despite opposition of WRHA and nearly every other provider and patient advocacy group, the House of Representatives today passed the American Health Care Act (which repeals and replaces the Affordable Care Act) by a vote of 217 to 213.  The House had an opportunity to fix the many issues in the ACA that did not work for the 62 million who live in rural America (lack of plan competition in rural markets, exorbitant premiums, deductibles and co-pays, the co-op collapses, devastating Medicare cuts, and the lack of Medicaid expansion), but instead passed a bill that will make health care access worse and more expensive in rural communities. 

It is now up to the Senate to address the needs of rural America, who are per capita, older, poorer and sicker.  Please join our grassroots efforts and tell your Senators that any health reform bill must include:

1). Reforming Insurance Markets -  Any federal health care reform proposal must address the fact that insurance providers are withdrawing from rural markets;

2). Stabilizing the Rural Health Safety Net -  Rural Americans are disproportionately dependent upon Medicaid.  Any federal reform care bill must ensure that states can continue unique Medicaid payment programs established to help rural Americans maintain access to care;

3). Stopping the Rural Hospital Closure Crisis -- Congress needs to act now and stop the devastating rural hospital closure crisis.  Any reform bill must include provisions to stop Medicare bad debt cuts to rural hospitals, which are disproportionately harm rural hospitals because of the ACA.


Legislature Heads into Special Session
The 2017 Washington regular legislative session officially adjourned on Sunday, April 23rd.  However, Governor Jay Inslee immediately called the Legislature back into special session to negotiate a solution to the 2017-2019 operating budget.  The House and Senate remain far apart on the total spending amount and funding mechanisms for the budget.  Priorities for mental health system funding will be part of the negotiations.  Resolution is unlikely before June.  The legislature will also continue discussions on budget-related policy items including paid family leave and balance billing.

We are hopeful for a compromise will include some additional spending beyond the Republican budget and not all the taxes included in the House budget.  While the House budget included a B&O tax increase for hospitals, we are not expecting it to be carried forward into the compromise solution.  A compromise budget may include a proposal to have the state develop a single preferred drug list and a pharmacy benefit manager for Medicaid patients.  This was included in both the House and Senate budgets, the governor will be busy signing policy bills that passed during the regular session, including priorities on extension of the safety net program, reducing opioid abuse, mental health care coordination, the WHRAP program, Certificate of Need exemption for psych beds, joint self-insurance for hospitals, the interstate medical licensure compact, and others. 

Capital Budgets Include Major Funding for Mental Health and Dental Access
The state House and Senate capital budgets contain major investments for community projects to increase access to mental health services across the care continuum.  WRHA is very pleased to see these funding levels that will help spur new services for some of the most complex patients.  Both budgets also provide funding for the addition or expansion of dental chairs to certain provider clinics.  Dental problems, like mental health, are a top reason people visit the emergency department.  The budgets contain different funding levels for facilities.  Also, April 12 was the deadline for most bills to pass the opposite chamber of the state legislature.

HCA Considers New Bundles; Share Feedback for the RFI
The Health Care Authority is committed to moving forward with a push on value-based purchasing, including implementing payment bundles for its state employee program and possible for Medicaid.  Now is the time to provide feedback to the HCA as it considers where the program should head in the future.  HCA is anticipating another bundled episode to be implemented starting in 2019.  HCA is soliciting comments through a Request for Information process. Responses are due by May 21st

Last year HCA implemented a payment bundle for total hip and knee replacement and selected Virginia Mason Medical Center as the center of excellence.  Several Washington hospitals expressed concerns about the process, in terms of the limited period for responses, the selection of only one hospital to provide services, and the impact on access to care in rural areas.  In response to the concerns, HCA has taken a more deliberative approach as it considers expanding the program and is seeking input.  Many of the questions in the RFI ask about the types of episodes that hospitals are currently offering.  It’s is very important for hospitals without any bundles to complete this questionnaire as well and discuss both barriers to bundles and unanticipated consequences to bundles.

Accountable Communities of Health Seek Provider Input for Medicaid Transformation Projects
The nine Accountable Communities of Health are in the process of designing and selecting projects this summer related to the Healthier Washington Demonstration, with applications to be submitted by September.  Over the next five years, the state Health Care Authority will be distributing up to $1.1 billion through the Heathier Washington demonstration.  By the end of this year, the Authority has initially indicated it will distribute up to $240 million statewide to jump start this work.  Most of the dollars will flow to providers that participate in approved projects through their ACH.  We encourage hospital and health systems to ensure they are in contact with their local ACH and involved in the process.

Tell them NO on the American Health Care Act
Call your members of Congress and tell them to no on the American Health Care Act (AHCA).  The health bill does nothing to improve the health care crisis in rural America, and will lead to poorer rural health outcomes, more uninsured and an increase in the rural hospital closure crisis.

The AHCA was modified last week, and some reports show that that the House could vote on the bill as early as tomorrow.  This bill falls woefully short in making health care affordable and accessible to rural Americans.  One of the provisions of the amendment would allow states to waive essential health benefits such as maternity care and emergency room visits.  WRHA is concerned this may result in less care for enrollees, especially in rural America. 

Many provisions in the Affordable Care Act (ACA) are not working effectively in rural America.  Unfortunately, the AHCA does nothing to address these problems and instead provides coverage for fewer rural Americans leading to poorer rural health outcomes and an increase in the rural hospital closure crisis.

Congress is listening to the rural voice and it’s time to act now - tell your member of Congress to vote NO on the AHCA.


House budget overview on top WRHA priorities

2017-2019 Biennium Budget Highlights

No cuts to Medicaid payments for hospital-based clinics. Hospital-based clinics will be able to continue to provide access in their communities to primary and specialty care for Medicaid patients.

Medicaid waiver funding. The House appropriates the federal funds provided for the demonstration project.  The demonstration provides considerable additional resources for Washington state to engage in transformational projects as part of Healthier Washington.
Post-discharge placement for complex patients ($20.3 million total). The budget provides additional funds for increased payment rates for patients with behavioral health needs, making it easier for nursing facilities or adult family homes to accept complex Medicaid payments. This allows these patients to move out of the hospital setting.
Nursing home care in small rural hospitals. Increased Medicaid payment rates will help support four rural nursing homes in public hospital districts, enabling those residents to stay in their home communities. The budget directs the department to fund this need ($112,000) out of its existing appropriation. 
Medicaid payment for integrated behavioral health in primary care ($4 million). The budget funds the new collaborative care codes for Medicaid that are currently recognized by Medicare.
Essential services in small rural hospitals ($2.1 million).  Additional funds for the hospitals involved in the Washington Rural Healthcare Preservation Program (WRHAP). The spending includes both state and federal dollars.
Improve the Prescription Monitoring Program ($1.1 million) The funding will enable the Department of Health to provide opioid prescribing reports to hospitals, clinics, and providers. This data will help identify opportunities to reduce over-prescribing of opioids. The funds also support a program to reduce overdose deaths by notifying a patient’s primary care provider and any prescriber of an opioid when a patient experiences an overdose event.

Other Key Health Care Spending

Health care is a big part of the state's budget, and there are several other health care items to be aware of. 

  • Managed care rate increase at a level of two percent per year and $214 million for the biennium
  • Opioids – the proposed budget acknowledges about $3 million dollars for a pain management call center and nurse case managers to support medication assisted treatment
  • Increased hepatitis C funding
  • High risk pool funded
  • Health homes for patients who are dual-eligible for Medicare and Medicaid
  • Increased newborn screening fee to add a new screen to the panel. Estimated to be approximately $1 million would be paid by hospitals for Medicaid patients.
  • Additional funding to DOH for Pharmacy Commission rulemaking and oversight for the nurse staffing legislation
  • Funding for foundational public health and DOH infrastructure ($40 million)
  • Depression screening for new mothers

Next Steps

Development of a common budget is likely to take time. The next revenue forecast is scheduled for June 15, but that may be moved sooner so that new revenue numbers can be used to determine and pass the budget before the fiscal year begins on July 1.