Debt Ceiling Deal: What’s in, What’s Out of the Agreement to Avert US Default

AP News | By Kevin Freking and Farnoush Amiri

WASHINGTON (AP) — President Joe Biden and House Speaker Kevin McCarthy have reached an agreement in principle on legislation to increase the nation’s borrowing authority and avoid a federal default.

Negotiators are now racing to complete the bill’s text. McCarthy, R-Calif., said the House will vote on the legislation on Wednesday, giving the Senate time to consider it before June 5, the date when Treasury Secretary Janet Yellen said the United States could default on its debt obligations if lawmakers did not act in time.

While many details about the deal are unknown, both sides will be able to point to some victories. But some conservatives expressed early concerns that the compromise does not cut future deficits enough, while Democrats have been worried about proposed changes to work requirements in programs such as food stamps.

A look at what’s in and out of the deal, based on what’s known so far:

TWO-YEAR DEBT INCREASE, SPENDING LIMITS
The agreement would keep non-defense spending roughly flat in the 2024 fiscal year and increase it by 1% the following year, as well as provide for a two-year debt-limit increase — past the next presidential election in 2024. That’s according to a source familiar with the deal who provided details on the condition of anonymity.

VETERANS CARE
The agreement would fully fund medical care for veterans at the levels included in Biden’s proposed 2024 budget blueprint, including a fund dedicated to veterans who have been exposed to toxic substances or environmental hazards. Biden sought $20.3 billion for the toxic exposure fund in his budget and Republican negotiators ensured Sunday that funding was left untouched.

WORK REQUIREMENTS
Republicans had proposed boosting work requirements for able-bodied adults without dependents in certain government assistance programs. They said it would bring more people into the workforce, who would then pay taxes and help shore up key entitlement programs, namely Social Security and Medicare.

The agreement would expand some work requirements for the Supplemental Nutrition Assistance Program, or SNAP, formerly known as food stamps. It would raise the age for existing work requirements from 49 to 54, similar to the Republican proposal, but those changes would expire in 2030. The White House said it would at the same time reduce the number of vulnerable people — including veterans and people who are homeless — of all ages who are subject to the requirements.

Many of those changes will sunset in 2030, allowing Congress to measure the effectiveness of these changes and make changes if need be.

UNSPENT COVID MONEY
The agreement would rescind about $30 billion in unspent coronavirus relief money that Congress approved through previous bills, with exceptions made for veterans’ medical care, housing assistance, the Indian Health Service, and some $5 billion for a program focused on rapidly developing the next generation of COVID-19 vaccines and treatments.

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Big Win: CMS Extends Temporary Telehealth Use to All Facility-Based Settings

APTA

In what now amounts to a total reversal of its initial post-public health emergency policies around telehealth, the U.S. Centers for Medicare & Medicaid Services has listened to APTA and other organizations and will allow the provision of telehealth services across a range of facilities, just as they were permitted during the PHE. The major advocacy win means that PTs in skilled nursing facilities, home health, and rehab agencies can continue to provide remote services under Medicare Part B — although CMS has yet to say when those allowances might end.

As with an earlier clarification around hospital-based settings, the latest news from CMS comes by way of an FAQ document on post-PHE policies (see question 22). In the latest iteration of the resource, CMS says that therapy providers working across the range of facility settings can continue to provide telehealth services as they did via waivers granted during the PHE. The announcement follows an earlier, more limited reversal that applied only to telehealth provided in hospital-based facilities.

Originally, CMS' post-PHE telehealth policies appeared to exclude any facility-based provision of telehealth from coverage if that facility used a particular claim form, the UB04. APTA was among the first organizations to call attention to the inconsistencies and patient access problems with this position, and was joined by the American Speech-Language-Hearing Association and the American Occupational Therapy Association in advocacy to press CMS to maintain telehealth allowances across the board. While CMS warned that it could take some time to provide definitive guidance, in the end the agency's decisions arrived relatively quickly.

While the guidance from CMS is clearly good news for the physical therapy community and its patients, one major detail was left out — namely, if and when these telehealth allowances would end. In its earlier hospital-based telehealth decision, CMS stipulated that telehealth could continue through the end of 2023 in those settings. That ending date, opposed by APTA, doesn't jibe with telehealth end dates for PTs and PTAs in private practices, which are expected to be extended through Dec. 31, 2024. APTA, ASHA, and AOTA are pushing for answers, which CMS will most likely provide when it issues the 2024 proposed Medicare Physician Fee Schedule. Meanwhile, APTA and other organizations are pushing for lawmakers to permanently include PTs and PTAs in the list of providers allowed to provide telehealth services under Medicare.

"The conversations we were able to have with representatives from [the U.S. Department of Health and Human Services] were extremely beneficial in helping CMS understand why it's so important to maintain telehealth allowances after the PHE, particularly for patients in rural and underserved communities," said Kate Gilliard, JD, APTA's director of health policy and payment. "We're extremely happy that CMS sees the value in continuing coverage."

In Wheelchair Win, CMS OKs Power Seat Elevation for Power Chairs

HomeCare News

Calling it a "landmark decision," the Centers for Medicare & Medicaid Services (CMS) announced May 16, 2023 that it had, for the first time, made power seat elevation for power wheelchairs eligible for reimbursement as durable medical equipment (DME). 

CMS said effective immediately, seat elevation for Medicare-covered power wheelchairs is now considered a clinically meaningful benefit to people with Medicare who perform transfers from power wheelchairs or use their chairs for mobility-related activities of daily living such as dressing, grooming, toileting, feeding and bathing. DME advocates, mobility manufacturers and members of the disability community had urged CMS to issue the Benefit Category Determination (BCD) and National Coverage Decision.

“For too long, many people who use a power wheelchair could not access everyday items in their homes and may have struggled to get in and out of their device,” CMS Administrator Chiquita Brooks-LaSure said in a statement. “This landmark Medicare decision to cover seat elevation is a major milestone that will improve the quality of life for so many who rely on this technology.”

Advocates called the decision a "win for wheelchair users and their caregivers." American Association for Homecare (AAHomecare), NCART, the ITEM Coalition and a wide variety of mobility user groups pushed hard for the move, spurring more than 5,000 public comments in two response periods. 

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ChatGPT in Medicine: STAT Answers Readers’ Burning Questions About AI

Stat News | By Lizzy Lawrence, Mohana Ravindranath and Brittany Trang 
 
Artificial intelligence is often described as a black box: an unknowable, mysterious force that operates inside the critical world of health care. If it’s hard for experts to wrap their heads around at times, it’s almost impossible for patients or the general public to grasp.
 
While AI-powered tools like ChatGPT are swiftly gaining steam in medicine, patients rarely have any say — or even any insight — into how these powerful technologies are being used in their own care.
 
To get a handle on the most pressing concerns among patients, STAT asked our readers what they most wanted to know about generative AI’s use in medicine. Their submissions ranged from fundamental questions about how the technology works to concerns about bias and error creeping further into our health systems.
 
It’s clear that the potential of large language models, which are trained on massive amounts of data and can generate answers to myriad prompts, is vast. It goes beyond ChatGPT and the ability for humans and AI to talk to each other. AI tools can help doctors predict medical harm on a broader scale, leading to better patient outcomes. They’re currently being used for medical note-taking, and analysis of X-rays and mammograms. Health tech companies are eager to tout their AI-powered algorithms at every turn.
 
But the harm is equally vast as long as AI tools go unregulated. Inaccurate, biased training data deepen health disparities. Algorithms not properly vetted deliver incorrect information on patients in critical condition. And insurers use AI algorithms to cut off care for patients before they’re fully recovered.
 
When it comes to generative artificial intelligence, there are certainly more questions than answers right now. STAT asked experts in the field to tackle some of our reader’s thoughtful questions, revealing the good, the bad, and the ugly sides of AI.
 
As a patient, how can I best avoid any product, service or company using generative AI? I want absolutely nothing to do with it. Is my quest to avoid it hopeless? 
 
Experts agreed that avoiding generative AI entirely would be very, very difficult. At the moment, there aren’t laws governing how it’s used, nor explicit regulations forcing health companies to disclose that they’re using it.
 
“Without being too alarmist, the window where everyone has the ability to completely avoid this technology is likely closing,” John Kirchenbauer, a Ph.D. student researching machine learning and natural language processing at the University of Maryland, told STAT. Companies are already exploring using generative AI to handle simple customer service requests or frequently asked questions, and health providers are likely looking to the technology to automate some communication with patients, said Cobun Zweifel-Keegan, managing director of the International Association of Privacy Professionals.
 
But there are steps patients can take to at least ensure they’re informed when providers or insurers are using it.
 
Despite a lack of clear limits on the use of generative AI, regulatory agencies like the Federal Trade Commission “will not look kindly if patients are surprised by the use of automated systems,” so providers will likely start proactively disclosing if they’re incorporating generative AI into their messaging systems, Zweifel-Keegan said.
 
“If you have concerns about generative AI, look out for these disclosures and always feel empowered to ask questions of your provider,” Zweifel-Keegan said, adding that patients can report any concerning practices to their state attorney general, the FTC and the Department of Health and Human Services.

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