State Legislative Conference

1. AAFP Government Affairs Update
Bob Hall
State Legislative Conference
Dallas, TX
November 3, 2017

2. AAFP Division of Government Relations
Bob Hall * Director, Government Relations
Shelby King Manager, Center for State Policy
Teresa Baker* Senior Government Relations Representative
Andrew Adair* Government Relations Representative
Sonya Clay* Government Relations Representative
Robert Bennett* Manager, Federal Regulatory Affairs (based in Austin)
Mark Cribben* Director, FamMedPAC
Jeanette Contreras Manager, Strategic Advocacy Communications
Rhonda Carter FamMedPAC Administrative Coordinator
Lorlita Alexander Executive Assistant
Tia Johnson Senior Office Executive
*Registered Federal Lobbyists

3. AAFP Top Issues for 2017
• Promote physician payment reforms that
value primary care.
• Defend gains in health insurance coverage.
• Reduce administrative and regulatory
burdens.
• Improve physician well-being.
• Increase family physician workforce.
• Support population health improvement.

4. US House
US Senate
194 Dems
46 Dems
239 Reps
52 Reps
+7
+2
-8
-2
115TH CONGRESS

5. 174
11
6
3
1
12
23
25
180
Solid Democrat
Likely Democrat
Lean Democrat
Toss-Up
Lean Republican
Likely Republican
Solid Republican
■ Republican held seats (240) ■ Democrat held seats (194)
2017-2018 House races
Democrats need to pick up over 20 seats
to take back the House in 2018
Source: Cook Political Report.
Cook Political Report ratings

6. Democrats need a three-seat net gain to win a 2018
Senate majority; Republicans are defending fewer seats
Source: The Cook Political Report.
States with Senate elections, 2018
OH
WV
VA
PA
NY
ME
NC
SC
GA
TN
KY
IN
MI
WI
MN
IL
LATX
OK
ID
NV
OR
WA
CA
AZ
NM
CO
WY
MT ND
SD
IA
UT
FL
AR
MO
MS AL
NE
KS
AK
HI
DE
RI
VT
NH
MA
CT
NJ
MD
DC
■ Democrat incumbent ■ Independent incumbent ■ Republican incumbent
Analysis
• Democrats will be defending 25 seats in 2018, while
Republicans are defending only nine
• Of the nine Republican seats, just Nevada, held by
freshman Sen. Dean Heller, is in a state won by
Democrats in the 2012 or 2016 presidential elections
• No other GOP-held seat appears in danger, which
means Republicans are likely to hold onto their majority
• Democrats will likely be on defense in North Dakota (a
state Romney won by 20 points and Trump won by 36)
and West Virginia (a state Romney won by 27 points
and Trump won by 42)

7. 7September 25, 2017 | Daniel Stublen
IN SEPTEMBER OF EACH PRESIDENT’S FIRST TERM
Gallup comparative presidential approval ratings
Pres. Trump’s approval numbers are lower than any other
modern presidents’ at this point in their respective terms
Source: Gallup, September 13, 2017.
Election Wild-Card

8. Trump Administration Priorities: Health care
Sources: National Journal Research, 2017
CSR payments
• In October, President Trump announced
that he would be ending CSR payments
• Sens. Lamar Alexander (R-TN) and Patty
Murray (D-WA) announced a bipartisan
proposal that would extend CSR payments
for two years and give states more flexibility
Repeal and replace ACA
• Graham-Cassidy bill did not receive enough
support to be voted on in the Senate
• Congressional leaders are now focused on tax
reform
■ Completed ■ In progress ■ Stalled ■ No action
Trump’s HHS confirmations
• With Tom Price’s resignation, there is still
speculation for next HHS secretary
• Alex Azar, a former HHS and pharmaceutical
industry executive, is currently the front-runner
for the position
The opioid crisis
• President Trump has not yet invoked a specific
act to free up funding to fight the national
emergency
Drug pricing
• Congress passed the FDA Reauthorization Act,
allowing the FDA to continue collecting user fees

9. AAFP Policy Health Care for All
Current Sources of Health Insurance Coverage
(Millions)

10. Insurance Evolution

11. July 28, 2017 The Senate fails to pass the “skinny repeal”
Final health ACA repeal proposal, fails 49-51, with McCain (AZ), Murkowski
(AK) and Collins (ME) voting against it
Key health care dates and deadlines Other issues with
unspecified timeline
• Legislation reducing the
cost of prescription
drugs is popular with
constituents; however, at
present no such legislation
is set to pass through both
chambers of Congress
• President Trump has
acknowledged the severity
of the opioid crisis, but
he has not yet invoked any
legislation to allocate
funding to fight the
epidemic
Nov. 1, 2017 Beginning of open enrollment period
The Trump administration cut outreach and enrollment
funding and shortened the length of the open enrollment
period. It will end on Dec. 15, 2017
Aug. 25, 2017 All counties have at least one on-exchange insurer
Sources: National Journal Research, 2017.
ACA Repeal legislation stalled
but Obamacare markets may still be in trouble
Oct 19, 2017 Alexander Murray CSRs Legislation Introduced

12. $5.00 $5.00
$10.60
$12.50
$13.50
$15.00
$17.40
$19.10
$21.10
$19.30
$20.40
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
CHIP funding peaked in 2015, MACRA extended it for
two years while lowering levels slightly
Children's Health Insurance Program (CHIP) funding, by fiscal year
Values in billions
Sources: Jim Hahn and Kirstin B. Blom,”The Medicare Access and CHIP Reauthorization Act of 2015,” Congressional Research Service, November 10, 2015; “Federal Chip
Financing,” Government Publishing Office, September 2011;
Funded through
CHIPRA
Funded through
ACA
Funded through
MACRA

13. CHAMPION Act CHIP funding
13
Congress has a bipartisan, bicameral
deal to extend funding for a program
that covers over 9 million children
through 2022
Key Components
• MOE
• 23% FMAP increase
Other Key AAFP Priorities
• Teaching Health Centers
• Community Health Centers
• National Health Service Corps
Offsets
• Redirect money from the ACA’s prevention and public
health
• Shorten the grace period for ACA enrollees who don’t
pay their marketplace premiums from 90 days to 30
days
• Charge higher Medicare premiums for seniors
earning more than $500,000
• Allow states to dis-enroll lump sum awardees from
Medicaid
• Make it easier for state programs to avoid medical
costs if they’re already covered by private plans or
other government programs

14. Tax Reform
• Top GOP agenda item, goal by January 1, 2018
• Would be first large-scale overhaul of tax code since 1986
• Principal goal: lower rates, simplify code, spur economic growth
• ACA provisions (individual mandate, premium tax credits) unlikely
• Remote possibility for changes to Health Savings Accounts
• Primary Care Enhancement Act (HR 365 / S 1358) would allow
patients with HSAs to access direct primary care

15. Primary Care Benefit
• AAFP White Paper May 2017
• Policy: Individuals with HDHP would have access
to designated primary-care physician, with no cost
sharing.
• Inspired by Covered California
• Harmonizes somewhat with “Value Based Insurance
Design” push on Capitol Hill

16. Telehealth
• Legislation
– CONNECT for Health Act of 2017 would give CMS flexibility to
expand eligible sites for telehealth (now mostly rural, HPSA, etc.)
– CHRONIC Act of 2017 (passed Senate; could pass House this
year) would expand telehealth for MA plans and Medicare ACOs
• Regulatory
– Proposed PFS for CY2018: CMS would pay via telehealth for:
• G0506 - comprehensive assessment of and care planning for patients
requiring CCM services,
• CPT 96160 / 96161 - reporting for health risk assessments,
• CPT 90839 / 90840 - psychotherapy for crisis (60 minutes / 30 minutes)

17. Appropriations
• Agency for Healthcare Research and Quality
• HRSA Title VII, Section 747 Primary Care
Training and Enhancement
• HRSA Title X, Family Planning
• Prescription Drug Monitoring Program Grants
• Centers for Disease Control and Prevention
– Tobacco Prevention
– Chronic Disease Prevention and Health Promotion
– Immunization and Respiratory Diseases
• U.S. Department of Education – Public Service
Loan Forgiveness

18. Teaching Health Center GME
• 2010 - Authorized within the Affordable Care Act
– $230 M/five years
• 2015 - Reauthorized within MACRA
– $60 M/two years + $26 M (additional HHS funding)
• 2017 - Disaster Tax Relief and Airport and Airway Extension Act (H.R. 3823)
– Funded the THCGME program until December, 2017
• 2017 - Community Health and Medical Professionals Improve Our Nation
(CHAMPION) Act (H.R. 3922)
– Included the THCGME reauthorization bill
– Approved in the E&C Committee (10/4)
– Floor vote: pending this week
18

19. Teaching Health Center GME/CHAMPION Act
• Training the Next Generation of Primary Care Doctors Act
– H.R. 3394 - Reps. Cathy McMorris Rodgers (R-WA) and Niki Tsongas (D-MA)
– S. 1754 - Sens. Susan Collins (R-ME) and Jon Tester (D-MT)
– Bipartisan cosponsors: 75 (House), 19 (Senate)
• Fully funds current residency slots
– $126.5 Million/732 slots = $157K per resident amount (PRA)
– Current PRA = $116K
• Maintains accountability standards
– Number of patient visits
– Residents in primary care and treating rural/underserved patients
• Authorizes new program applicants
19

20. Public Health Priorities
2016
Helping Families in Mental Health Crisis Act - enacted
Opioids/Comprehensive Addiction and Recovery Act - enacted
Safe Drinking Water/Flint recovery funding - approved
Vaccine education – hearings
Concussions - hearings
2017
• Opioids
• Hurricane assistance
• Political footballs: DACA, abortion, gun safety, tobacco regulation
2018
• Farm Bill
• Transportation bill
• Disaster preparedness: Pandemic and All-Hazards Preparedness Act Reauthorization
• USPSTF Defense: Rep. Blackburn’s (R-TN) USPSTF Transparency and Accountability Act (H.R. 539)
20

21. Prescription Drug Pricing/Spending
21

22. Prescription Drug Pricing
• 2017 – AAFP joined the Campaign for Sustainable Rx Prices
• Bipartisan agreement
– Lower costs = Higher Competition
– No one-size-fits-all solution
– Delivery system = highly complex!
• Major drug pricing proposals
– Reducing costs – Medicare Part D negotiation, value-based contracting,
Medicaid generic drug rebate
– Increasing access to generic drugs – REMS, anti-trust practices
– Promoting transparency – drug hikes, pharm benefit managers
22

23. Prescription Drug Pricing/Impact
23

24. Regulatory Advocacy
• MACRA
– Final 2018 rule put on display 11/2.
– Impacts reporting requirements and policies for the Merit-based Incentive
Payment System (MIPS) and Alternative Payment Models (APMs).
– AAFP comments sent to CMS on August 18, 2017.
• Medicare Physician fee schedule
– Final 2018 put on display 11/2.
– Impacts payment rates and policies for 2018.
– CMS recognized that E/M documentation guidelines are complex and
ambiguous; AAFP called for no E/M documentation guidelines for PCPs.
– Other policies include site-of-service neutrality, appropriate use criteria, value-
based modifier, and misvalued codes.
– AAFP comments sent to CMS on August 30, 2017.

25. Administrative Simplification:
Why AAFP is Engaged
• Practice burdens have now eclipsed compensation as
the biggest single reported concern of AAFP
membership.
• Burden can shrink the FP workforce by diminishing the
appeal of the specialty.
• Burden can impact patient care if FPs exhibit signs of
“burnout.”

26. Administrative Simplification:
What AAFP is Doing
• Advocacy to the Administration
– Asking CMS to remove / reduce Documentation Guidelines for E/M, CCM, TCM, and other
primary-care service codes; streamline and reduce prior authorization requirements; pay
physicians for costs such as translation services
– Asking VA to address Authority of Health Care Providers to Practice Telehealth
– AAFP leadership continue meetings with senior Administration and Congress policymakers
• Advocacy to Congress
– Asking Congress to make optional the upcoming Medicare requirement to consult clinical
decision support tools for ordering advanced imaging
– Asking Congress to address PAMA cuts to Medicare clinical laboratory fee schedule payments
in 2018
• Advocacy to Private Sector
– Asking health plans to adopt uniform set of primary-care quality measures established through
multi-stakeholder process
26

27. Administrative Simplification:
Selected Highlights to Date
• Administration
– CMS established “Pick Your Pace” reporting options under MIPS for
2017/2018
– As CMS implements removal of SS#s from Medicare cards, CMS is
creating secure tools for providers to look-up new Medicare numbers
– CMS delayed the upcoming Medicare requirement to consult clinical
decision support tools for ordering advanced imaging to Jan. 1, 2019
• Congress
– 21st Century Cures Act (Dec. 2016) gives HHS OIG power to investigate
and penalize EHR vendors for data blocking
– Ways and Means “Medicare Red Tape Relief Project” is expected to move
forward in 2018.
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28. Center for State Policy Scope of Work
• AAFP Congress of Delegates Initiatives
• Chapter Advocacy Casework
– State Legislative Conference
– Chapter Advocacy Days
• Model Legislation Library
• Policy Analysis
• State Legislative Tracking
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29. Chapter Resources
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30. Chapter Resources
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31. Chapter Resources
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32. Chapter Resources
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33. Chapter Resources
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34. • As issue experts and constituents, your
elected officials want to hear directly
from you.
• Reaching them has never been easier.
• Lobby Days and Hill Visits
• Emails and letters
• Phone calls
• Social Media
• If you have a relationship with your
Congressman we need you to be a Key
Contact
Please Act - Grassroots Impact

35. On-Line Resources

36. Unite ● Organize ● Engage
Join the
Family Physician Action Network
Visit www.aafp.com/grassroots to join
Access Network-only content
Coordinate with other family physicians
Lead Social Media campaigns
Engage in Congressional office visits
Gain recognition at AAFP conferences and lobby days
Work With Other Family Physicians to Cut Through The Noise

37. The ONLY political organization that promotes family medicine.
Elect candidates to the United States Congress who support AAFP’s
legislative goals and objectives.
Since 2005, FamMedPAC raised and contributed over $5 million to more
than 400 candidates.

38. 2016 Election Cycle Campaign Contributions
$1,020,200 To 154 Candidates
(New Record!)
56 % Democrats, 44 % Republicans
(90% won!)
2018 Election Cycle Campaign Contributions
$236,500 To 50 Candidates
65% Democrats, 35% Republicans
2016 Election Cycle Fundraising
$975,000 received from 3,576 AAFP Members
(New Record!)
2018 Election Cycle Fundraising
*$417,174 (as of 10/31/2017)
* Ahead of last year’s pace!
If every AAFP member contributed just $100, we
would have more than $10 million –FamMedPAC
would be the largest medical PAC in the country.

39. On-Line Resources

40. Save the Dates
• Family Medicine Advocacy Summit–
Washington, DC
 May 21-22, 2018
• State Legislative Conference –
Ft. Lauderdale, FL
 October 25-27, 2018

41. Questions?
Bob Hall: Rhall@aafp.org
571/438-3137 (cell)