Rural Access to Home Health Services, PACE Among Lawmakers’ Future Spending Priorities

U.S. lawmakers have repeatedly highlighted a need to rethink the nation’s long-term care landscape in recent months, partly in response to the COVID-19 pandemic but also because of the country’s rapidly changing demographics.

A recently published budget report from the House Appropriations Committee obtained by Home Health Care News offers further insight into that call to action.

Each year, Congress publishes reports with its enacted federal budget outlining how and where federal dollars should be spent. This year’s budget report related to the U.S. Department of Health and Human Services (HHS) is noteworthy for its several passages with language strongly supporting home-based care and a shift away from institutional settings.


“I’ve never seen so many references to home-based care before and keeping people in their own homes,” one longtime industry advocate told HHCN.

For starters, the Appropriations Committee budget report urges the U.S. Centers for Medicare & Medicaid Services (CMS) to avoid any payment policies that could “risk patient access to home health providers” in rural areas. That could potentially include the agency’s ongoing adjustments to the home health rural add-on, which is currently being phased out despite its history of bipartisan support.

Broadly, rural add-on payments have given certain home health providers a small reimbursement boost to continue delivering services while dealing with costly travel demands and often smaller patient populations.


“Aging in place is beneficial to the patients that we serve, as well as appropriate utilization of Medicare resources,” Tonya Hopper, vice president of home health operations at Interim HealthCare of Texas & New Mexico, told HHCN in 2018. “Without the rural add-on, there would not be any ability to care for rural Americans in their homes, which would force patients into an institutional setting.”

The House budget report — a roadmap to future spending — also generally urges Congress to allocate more money to home- and community-based supportive services at large. Specifically, it calls for an additional $10 million above the 2021 budget request to further fund “a wide range of social services that enable seniors to remain independent in their homes for as long as possible.”

“This language is important because it shows what [lawmakers] are concerned about,” the advocate said. “It’s instructional to the enacted budget.”

The spending roadmap additionally includes language urging Congress to “maximize access to health care through technology with equitable payment and reimbursement policies.” That message comes during a time when the HHS Office of Inspector General is actively auditing telehealth utilization by Medicare-certified home health agencies.

Outside of the home health field but related to aging in place, the House budget report similarly encourages Congress to beef up its support of Programs of All-Inclusive Care for the Elderly (PACE). As of November, there were at least 272 PACE centers in 31 states, according to the National PACE Association.

PACE organizations offer comprehensive medical and social services to certain frail, community-dwelling elderly individuals to keep them out of long-term care facilities.

“The Committee acknowledges the important role of [PACE] in the lives of over 52,000 participants, by allowing these highly medically complex Medicare or Medicaid beneficiaries to live at home, instead of in a nursing facility,” the report states. “The Committee urges CMS to move forward expeditiously on PACE-specific pilots, authorized by the PACE Innovation Act of 2015, specifically testing the innovative, comprehensive, integrated and fully risk-bearing PACE model of care with new Medicare or Medicaid beneficiaries.”

Rebalancing Medicare

Beyond keeping seniors healthy and happy at home, the House Appropriations Committee budget report also hints at lawmakers’ views toward the rebalancing of Medicare.

Health care policymakers accelerated the development of Medicare Advantage (MA) and did everything possible to encourage beneficiary enrollment under the Trump administration. That mission is perhaps best illustrated by the MA hospice carve-in and CMS’s multiple moves to expand what supplemental benefits MA plans can offer.

There were nearly 25.4 million MA beneficiaries nationwide for the month of October, with an overall Medicare-eligible population of about 62.5 million individuals, according to statistics from the Better Medicare Alliance. That comes out to an MA penetration rate of roughly 40% — an all-time.

The future of MA has been murky after the election of President Joe Biden and key Democrat victories in the Senate, however. Republicans have naturally been more supportive of the MA program.

The budget report directs CMS to “avoid taking any action that actively promotes one form of Medicare coverage over another, particularly with respect to the choice between traditional Medicare and Medicare Advantage.”

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