End of the Year Health Law Wrap-Up Webinar December 14, 2017 Jenifer Brown (317) 236-2242 jenifer.brown@icemiller.com David Nie (317) 236-2300 david.nie@icemiller.com Christopher S. Sears (317) 236-5891 christopher.sears@icemiller.com Myra Selby (317) 236-5903 myra.selby@icemiller.com Kevin C. Woodhouse (317) 236-2154 kevin.woodhouse@icemiller.com 1 icemiller.com icemiller.com
AGENDA Immigration Update (After Supreme Court Travel Ban Decision) 501(c)(3) and Advance Refunding Bonds under Tax Reform Bills Future of Medicare and Medicaid (View of Recent CMS Officials) Mental Health Update The Opioid Epidemic: Legal and Policy Considerations Results of Study on Value Based Purchasing Models Update on Status of Affordable Care Act 2 icemiller.com
Immigration Update 3 icemiller.com
Where are we? Travel Bans – issued, revised, re-issued Buy American, Hire American Premium Processing Suspension DACA Rescission Other Shifts in Policy – USCIS and USCBP icemiller.com
Travel Ban 3.0 Country Immigrants Nonimmigrants Visitors Enhanced Screening Chad X X Iran X X* X X Iraq X Libya X X North Korea X X X Somalia X X Syria X X X Venezuela X* Yemen X X *For Iran, F, M and J nonimmigrants are not included but are subject to enhanced screening. For Venezuela, admission to the US is suspended for certain government officials and their visiting families. icemiller.com
H-1B Cap Exemptions and Alternatives Cap Exemptions Institutions of Higher Education Affiliated Non-Profits Non-Profit or Governmental Research Institutions Certain J-1 Physicians Employed “at” cap exempt location Previously counted against annual quota Concurrent H-1B Employment icemiller.com
Hire American Executive Order Analysis of U.S. immigration system and proposal of recommendations to address fraud and abuse (policy) Reform H-1B visa program to award most-skilled and highest paid beneficiaries (rulemaking/ legislation) Transition to merit/skills-based system Agency Discretion Interpreting H-1B specialty occupations & cap exemptions Interpreting employer analysis of US candidates within PERM labor market testing icemiller.com
Hire American (example) New USCIS memo regarding computer programmers and other IT-related occupations Definition of specialty occupation Compensation and prevailing wage selection Reconciling entry-level wage and complex job duties How broadly applied? Reach of agency discretion? RFE’s on wage and complexity of positions icemiller.com
H-1B Enforcement Why? Fraud, Abuse and Reverse Discrimination What? Fraud indicators, including wage, duties, experience and work location(s) How? Site Visits USCIS cannot confirm basic business info H-1B dependent employers Third party worksites/responsibilities as end client Investigations by DOL, DHS and DOJ Solicitation of Anonymous Tips to DOL, DHS and DOJ Consider Changes to H-1B Program (DOL and DHS) icemiller.com
Other Shifts in Policy Advance parole denials Employment based green card interviews Delays in adjudication Medical examinations Experiences at Ports of Entry – Agent Discretion Termination of H-4 EADs icemiller.com
I-9 Compliance IRCA’s anti -discrimination provisions Pre-offer questioning Effect of travel ban when condition of employment Possible e-verify expansion If DACA ends EAD automatic renewals icemiller.com
What Can You Do? Make thoughtful hiring decisions Confirm passport validity and current I-94 admission record with CBP International and domestic travel Properly maintain immigration status – primary purpose, employment conditions, protect documents Check sources/ watch for rumors Monitor real and perceived changes in law, policy and agency discretion Contact members of Congress icemiller.com
Resources Ice Miller’s Immigration Team (icemiller.com/choosetalent) American Immigration Lawyers Association (www.aila.org) American Immigration Council (www.aic.org) National Immigration Law Center (www.nilc.org) icemiller.com
501(c)(3) and Advance Refunding Bonds under Tax Reform Bills 14 icemiller.com
Future of 501(c)(3) Bonds Uncertain Only in the House version of Tax Cuts and Jobs Act: Repeal of tax- exempt “private activity bonds” after 12/31/17 Private activity bonds are tax-exempt bonds permitted under current law to be issued to finance projects for section 501(c)(3) organizations like hospitals and senior living facilities (in addition to cultural institutions, private colleges and universities and multi-family housing) 15 icemiller.com
Future of 501(c)(3) Bonds Uncertain (cont’d) In the House and Senate versions of the Tax Cuts and Job Acts: Repeal of tax-exempt advance refunding bonds after 12/31/17. An advance refunding is one in which the refunding bonds remain outstanding for a period of more than 90 days after the issuance of the refunding bond issue. 16 icemiller.com
Future of 501(c)(3) Bonds Uncertain (cont’d) Inconsistent treatment of private activity bonds currently being reconciled by a conference committee Advance refunding bonds to be eliminated on 12/31/17 Corporate tax rate adjustment impact on 501(c)(3) bonds 17 icemiller.com
Future of Medicare and Medicaid (View of Recent CMS Officials) 18 icemiller.com
Future of Medicare and Medicaid Presenters: Jonathan Blum – Former Deputy Administrator of CMS Herb Kuhn – Former Deputy Administrator of CMS Mark McClellan – Former Administrator of CMS 19 icemiller.com
Future of Medicare and Medicaid (Cont’d) Common Themes: Lack of clarity, uncertainty, chaos Very high premiums in the individual market as a hedge against the loss of cost-sharing subsidies Individual market continues, but it is not robust End of cost-sharing will lead to increased cost as subsidies increase 20 icemiller.com
Future of Medicare and Medicaid (cont’d) Impact of Repeal of the Individual Mandate: In the Senate version of the tax bill This would eventually have an impact as more healthy people pull out, leading to very selective markets and higher premiums. Low income individuals will get higher subsidies Individual market: Not likely to completely implode – will limp along 21 icemiller.com
Future of Medicare and Medicaid (Cont’d) Personnel Set Policy: Very complimentary of Alex Azar, choice to head HHS Knowledgeable and experienced and respects the agency “Scary smart” Likely to take steps on drug pricing – look more at paying for drugs on a value basis and negotiating drug prices Likely to tackle payment reform and opioids 22 icemiller.com
Future of Medicare and Medicaid (Cont’d) Future of Medicare: Center for Medicare and Medicaid Innovation – Still important More voluntary than mandatory (cancelled mandatory hip fracture and cardiac bundled payment models; reduced mandatory geographic areas participating in comprehensive care for joint replacement from 67 areas to 34 areas) Focus on payment reform ideas 340B – cutting reimbursement 23 icemiller.com
Future of Medicare and Medicaid (Cont’d) Strong emphasis on growing MA program with more flexibility on plan design Focus on DSH and similar payments to the States and how these funds are used Deregulation Preparing for the tsunami – 80 million in Medicare by 2030 24 icemiller.com
Future of Medicare and Medicaid (Cont’d) Future of Medicaid: More State flexibility Transparency More waivers approved quicker – predictability Beneficiary responsibility Continued look at block grants and/or per capita 25 icemiller.com
Mental Health Update 26 icemiller.com
Incidence of Mental Health Disorders (NAMI) 2.4 m (1%): Schizophrenia 6.1 m (2.6%): Bipolar disorder 16 m (6.9%): Depression 42 m (18%): Anxiety 6 m (2.6%): Dementia 2.6 m (1%): Substance Abuse 27 icemiller.com
Unmet Mental Health Needs Incidence: 1 in 2 will develop mental illness in lifetime Relationship to heart disease, obesity, cancer, substance abuse Frequency of suicidal ideation (8.4 m), plans (2.2 m), attempts (1 m) Role of poverty; lack of access to care (1 in 6) Age of onset of symptoms (50% at 14; 75% at 24) Time from symptoms to treatment (8-10 years) Data from Centers for Disease Control & Prevention (CDC), Substance Abuse & Mental Health Services Administration (SAMHSA), National Alliance on Mental Illness (NAMI) 28 icemiller.com
Impact on Workforce, Lost Productivity and Increased Cost of Care Untreated mental illness costs U.S. $100 billion per year in lost productivity Depression can be quadruple cost of care (e.g., diabetes), double sick days (e.g., back pain) Increased/inappropriate use of ER due to decreased or inadequate benefit. 29 icemiller.com
Vulnerabilities: Overmedication; Adverse Drug Reactions (Seniors) Too many doctors; too many specialists Too many prescriptions: 6+ (and possibly 12-20) meds/day Poor medication management: primary care provider unwilling to challenge specialist Overuse of “anti - anxiety” or “sleep” meds causing more agitation, confusion, falls Drug reactions including aggression, anxiety, depression, wandering, not eating 30 icemiller.com
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