Trump's 2019 budget blueprint: 15 healthcare takeaways

President Donald Trump on Monday released his $4.4 trillion budget for fiscal 2019 with an addendum to partially account for the two-year bipartisan budget deal reached in Congress last week.

Released under the title "Efficient, Effective, Accountable: An American Budget," the proposal emphasizes austerity in nondefense programs while increasing funds to the Pentagon. President Trump's proposal would add $984 billion to the deficit in 2019 and more than $7 trillion over the next decade, which would bring the projected deficit down by $3.6 trillion, according to Politico.

The addendum calls for $540 billion in nondefense discretionary spending next year, up $75 billion from the original budget to account for the two-year Bipartisan Budget Act enacted last week. However, this is still $57 billion below the cap of $680 billion set by Congress in their budget agreement.

Here are 15 proposals related to healthcare in the president's budget. 

1. President Trump's budget requests $68.4 billion in discretionary spending for HHS, which is a 21 percent decrease from 2017 funding levels. It includes funds for the 21st Century CURES Act and continues to invest in the administration's health priorities, including efforts to combat the opioid epidemic and repeal and replace the ACA.

2. The budget accounts for $675 billion in net mandatory savings to repeal and replace the ACA. It includes policy proposals to enact legislation similar to the Graham-Cassidy bill, promote block grants, repeal Medicaid expansion and install a Medicaid per-capita cap program.

3. Funding to combat the opioid epidemic is a major focus of the budget. President Trump allots $5 billion in new resources for HHS over the next five years — including $1 billion in 2019 — to address opioid abuse, treatment and prevention. These funds would be used for a media campaign, improved access to opioid overdose reversal drugs, surveillance and prevention efforts, drug courts, services for pregnant women addicted to opioids, and supplemental funds for Native Americans and Alaska Natives, among other initiatives. The budget approves an additional $100 million for the National Institutes of Health to work with pharmaceutical companies to develop better methods of prevention, treatments for addiction, overdose reversal drugs and nonaddictive pain therapies. It also includes $123 million for the Substance Abuse and Mental Health Services Administration and $126 million for the Centers for Disease Control and Prevention.

The addendum allots an additional $10 billion in discretionary funding for the opioid epidemic and mental health services.

4. A second major aim of the budget is to address high drug prices through Medicare Part D and B reforms and a Medicaid demonstration. Specifically, the new demonstration program would test Medicaid coverage and financing strategies in up to five states. To address drug spending in Medicare Part D, the budget proposes giving Part D plans greater negotiating power with drug companies, modifying rebate strategies and capping out-of-pocket spending for enrollees. Under Part B, the proposal includes policies intended to discourage pharmaceutical companies from increasing prices faster than inflation, and it also calls for continued reform to the Medicare 340B Drug Pricing Program to ensure hospitals use those savings to directly improve care for low-income populations.

5. The budget expands Medicaid coverage related to opioid addiction treatment and proposes a Medicare bundled payment for medication-assisted treatment, as well as reimbursement for such treatment. The budget would expand Medicaid to comprehensively cover medication-assisted treatment options for opioid addiction and create ways to monitor providers who do not follow best practices for prescribing. It proposes a bundled payment demonstration for community-based medication-assisted treatment as well as authorizes Medicare reimbursement for methadone, the drug used to taper patients off opioids, for the first time.

6. The budget calls for $70.7 billion for the Veterans Health Administration, up 9.6 percent from 2017 levels. This includes $11.9 billion for a newly consolidated veteran community care program, $381 million to address the opioid epidemic and $8.6 billion for veteran-focused mental health services. The budget also calls for Congress to set aside $75.6 billion in advance appropriations for VA care in 2020.

7. The budget would extend Medicare solvency by eight more years and increase flexibility in the Medicaid program, according to the White House. It would do this by restructuring payments unrelated to health insurance in the Medicare program and financing these payments outside of the Health Insurance Trust Fund. Other Medicare reforms include paying offsite hospital-owned physician practices the same rate as independent practices and reducing hospital payments when patients are discharged to hospice quickly. For Medicaid, the budget includes policy proposals to add work requirements and to allow additional assets, such as lottery winnings, to count toward income in determining eligibility for the program.

8. Health Care Fraud and Abuse Control would receive discretionary funds of $770 million, up $45 million from 2017 levels. This additional allotment is intended to improve integrity and transparency of the Medicare and Medicaid programs.

9. The budget cuts $451 million in health professional training and consolidates graduate medical education spending into a capped grant program. The 14 training programs on the chopping block were identified as low value and ineffective in building a stronger medical workforce in the communities that needed it most. The budget does continue to fund scholarships and loan repayment programs.

10. The budget would eliminate the Agency for Healthcare Research and Quality. It consolidates the functions of this agency into NIH to reduce duplication. This move saves $324 million, partially offset by a request of $256 million for NIH to consolidate its health services research with that of AHRQ's.

11. The addendum includes $9.2 billion more in funds for NIH. This would return NIH funds to fiscal 2017 funding levels of $33 billion.

12. The budget cuts spending for the Office of National Coordinator for Health IT by 36 percent. This brings it down to $38 million in 2019. The reasoning behind this cut is that the ONC's original mission to spur EHR adoption has largely been accomplished, and now the agency can focus on "core health IT functions."

13. Federal public health officials could face job cuts. The budget calls for a review of the U.S. Public Health Service Commissioned Corps, which employs 6,500 professionals who receive military benefits. The result of the review "could range from phasing out unnecessary Corps functions to reinventing the Corps into a smaller, more targeted cadre," the report reads.

14. The budget includes a proposal to shift CDC funds for emergency preparedness and health security to HHS. This means the HHS assistant secretary for preparedness and response would oversee the Strategic National Stockpile. The aim here is to consolidate strategic decision-making for nimble responses during public health emergencies.

15. Infectious disease programs would receive a boost of $40 million through the CDC. This would be funneled into a demonstration initiative targeting various infectious diseases. It would be implemented in up to five states, with preference going to those where infectious disease rates are increasing due to opioid abuse. The budget also calls for reauthorization of the Ryan White HIV/AIDS Program, which provides care for about half of Americans with HIV, particularly those who are uninsured or underinsured.

Many provisions of this budget are likely to change, as the final plan will ultimately be decided by Congress. Office of Management and Budget Director Mick Mulvaney will present the president's budget and provide more details to the Senate Budget Committee Tuesday and the House Budget Committee Wednesday, Politico reported. 


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