Governor's Budget

2017 WRHA Legislative and Policy Agenda



The Senate is on course to fast-track the bill to repeal the Affordable Care Act, weaken Medicare, and cut Medicaid. Majority Leader Mitch McConnell aims to bring a bill to a vote in the senate before July 4, with no hearings or public debate. Mobilizing NOW, and over the next few weeks, is critical to stop this bill that would gut health and oral health coverage!

What can you do to influence your senator?

  • Attend in person events and rallies in your state
  • Generate media coverage of this issue, including op-eds and letters to the editor
    • This is especially important as the country focuses on other issues like foreign relations
    • LTE template
  • Engage other policymakers (state and local) to add to the pressure
  • Use social media to reach senators, state and local policymakers and your networks
    • Shareable graphics:

Take these actions and ask your networks to do the same! Even though we’ve done many of these things before, it is important to keep the pressure up by doing them again at this critical time.


Protecting Medicaid, Defending the ACA and Holding Congress Accountable 

We have a one-week window (May 29 – June 2) to put pressure on the Senate to protect Medicaid, defend the ACA and to hold House members accountable for their votes to pass the American Health Care Act (AHCA). The Senate wants to move quickly. Our goal is to delay them from moving forward for as long as possible.

Talking points to tell your member of Congress:

  • Health care reform has not worked 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 have created a health care access and coverage crisis in rural America.
    • 70% of the 650 counties with only one insurer on the exchange are rural for 2017, and based on what we already know this is going to be worse in 2018.
    • Rural residents average per month cost exceeds urban ($569.34 for small town rural vs. $415.85 for metropolitan) and as market completion decreases these costs will rise further.
    • 80 rural hospitals have closed since 2010. One in three rural hospitals is financially vulnerable. These closures would result in 11.7 million patients losing access to their local emergency room; 99,000 direct health care jobs will be lost in rural communities; and $277 billion in GDP to rural communities will be lost, exacerbating rural America's economic decline
  • The 3 fixes that must be included in any modification to the Affordable Care Act are:

1.    Medicaid - Though most rural residents are in non-expansion states, a higher proportion of rural residents are covered by Medicaid (21% vs. 16%). For rural hospitals, it accounts for 15% of gross revenues.

  • Health care reform must protect the rural safety net by providing an option to a state to receive an enhanced reimbursement to account for the cost of providing care in a rural area. This will help maintain access to care for rural communities by limiting the loss to the hospital of providing care to the most vulnerable patients.

2.    Market Reform – Forty-one percent of rural marketplace enrollees have only a single option of insurer, representing 70 percent of counties that have only one option. This lack of competition in the marketplace means higher premiums. Rural residents average per month cost exceeds urban ($569.34 for small town rural vs. $415.85 for metropolitan).

  • Health care reform must address the fact that insurance providers are withdrawing from rural markets. This is especially concerning since rural Americans are more likely to need to purchase insurance on the individual market. Despite record profit levels, insurance companies are permitted to cherry pick profitable markets for participation and are currently not obliged to provide service to rural populations. In the same way that financial service institutions are required to provide services to underserved neighborhoods, profitable insurance companies should be required to provide services in underserved communities.

3.   Stop Bad Debt Cuts to Rural Hospitals – Rural hospitals serve more Medicare patients (46% rural vs. 40.9% urban), thus across the board Medicare cuts do not have across the board impacts. The fact that according to MedPAC "Average Medicare margins are negative, and under current law they are expected to decline in 2016" has led to 7% gains in median profit margins for urban providers while rural providers have experienced a median loss of 6%.

  • Congress must reverse the bad debt cuts they made to rural hospitals.

Here are some tips:

1) Contact the offices of your members of Congress and schedule a meeting to let them know the health care issues impacting their constituents. Share NRHA materials, but personalize it to tell them about your facility and the issues you and your community are facing.
2) Invite your member of Congress and staff to tour your facility.
3) Attend a town hall. Members of Congress list these on their webpage and often on Facebook or Twitter as well. If not, call the office and ask.
4) And remember, to have an "ask." Members of Congress want to know how they can help you and your facility.



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.