/ en Tue, 29 Jul 2025 22:52:11 -0500 Wed, 16 Jul 25 11:45:00 -0500 /advisory/2025-07-03-key-highlights-final-one-big-beautiful-bill-act <div class="container"><div class="row"><div class="col-md-8"><p>The Senate July 1, and the House July 3, passed a budget reconciliation bill, the <a href="https://sponsors.aha.org/rs/710-ZLL-651/images/07032025-Legis-language-h1_eas.pdf" target="_blank" title="Full text of the One Big Beautiful Bill Act (OBBBA) PDF.">One Big Beautiful Bill Act (OBBBA)</a>, H.R. 1, a sweeping package that enacts many of President Trump’s legislative priorities on taxes, border security, energy and deficit reduction. The bill includes significant policy changes to Medicaid and the Health Insurance Marketplaces.</p><p>The Medicaid program provides health insurance coverage for 72 million Americans, including children, pregnant women, the elderly, the disabled and millions of working Americans. According to the <a href="https://www.cbo.gov/publication/61534" target="_blank" title="Congressional Budget Office: Estimated Budgetary Effects of an Amendment in the Nature of a Substitute to H.R. 1, the One Big Beautiful Bill Act, Relative to CBO's January 2025 Baseline">Congressional Budget Office</a> (CBO) score of a draft version of the Senate bill, the OBBBA will lead to nearly $1 trillion in Medicaid cuts and result in more than 11.8 million people losing Medicaid and health insurance marketplace coverage.</p><p>Historically, provider taxes and state-directed payments (SDPs) allow hospitals to bridge the chronic and historic underpayment by Medicaid for the care they deliver. The legislation includes limitations on the use of provider taxes and SDPs. The CBO score for the policy changes related to SDPs and provider taxes is $340 billion and will result in direct decreases in hospital payments. The AHA estimates that the provider tax changes alone will result in a loss of federal payments to hospitals of $232 billion over 10 years.</p><h2>AHA Statement</h2><p>In a <a href="/press-releases/2025-07-03-aha-statement-house-passage-one-big-beautiful-bill-act" target="_blank" title="AHA Statement on House Passage of One Big Beautiful Bill Act">statement</a> shared with the media following passage in the House July 3, AHA President and CEO Rick Pollack said, “Today is an extremely disappointing and very difficult day for health care in America. Despite months of clearly demonstrating the implications that these Medicaid proposals will have on the patients and communities we serve, especially the most vulnerable populations, Congress has enacted cuts of nearly a trillion dollars to the Medicaid program. No matter how often repeated, the magnitude of these reductions — and the number of individuals who will lose health coverage — cannot be simply dismissed as waste, fraud, and abuse. The faces of Medicaid include our children, our disabled, our seniors, our veterans, our neighbors, and friends. The real-life consequences of these reductions will negatively impact access to care for all Americans.</p><p>“The AHA remains committed to working with all stakeholders to mitigate the impact of these cuts wherever possible. Our goal is to help ensure hospitals can remain open for their communities, and people can get the care they need when they need it. Our nation’s health and economic future depend on it.”</p><h2>AHA Summary of OBBBA Provisions Impacting Hospitals and Health Systems</h2><h3>SUBTITLE B — HEALTH</h3><h3>Chapter 1 — Medicaid</h3><h3><em>Subchapter A — Reducing Fraud and Improving Enrollment Processes</em></h3><h4>Section 71101: Moratorium on Implementation of Medicaid Savings Program Eligibility and Enrollment Rule (Effective from enactment through Sept. 30, 2034)</h4><p>Prohibits the Department of Health and Human Services (HHS) Secretary from implementing, administering or enforcing the amendments made by the Medicare Savings Program (MSP) rule for 10 years. This would rollback requirements that states 1) automatically enroll certain Supplemental Security Income recipients in the qualified Medicare beneficiary eligibility group of the MSP program, 2) use data from the low-income subsidy program as an application for MSPs and align the family size definitions between the MSP and Low Income Subsidy programs, and 3) accept self-attestation for certain types of income and resources. CBO estimates that this provision will result in a $85.3 billion reduction in federal spending over 10 years.</p><h4>Section 71102: Moratorium on Implementation of Medicaid, CHIP and Basic Health Program Eligibility and Enrollment Rule (Effective from enactment through Sept. 30, 2034)</h4><p>Prohibits the HHS secretary from implementing, administering or enforcing the amendments made by the provisions of the eligibility and enrollment rule for 10 years. This would limit states’ ability to use other data sources (such as payroll or state vital statistics data) to determine an individual’s eligibility for Medicaid and limit states’ use of prepopulated renewal forms. It also would allow states to impose annual and/or lifetime limits on Children’s Health Insurance Program (CHIP) benefits and to disenroll CHIP beneficiaries for failure to pay premiums or enrollment fees. CBO estimates that this provision will result in a $81.6 billion reduction in federal spending over 10 years.</p><h4>Section 71107: Eligibility Redeterminations (Effective Jan. 1, 2027)</h4><p>Requires states to redetermine eligibility once every six months for beneficiaries enrolled through the Medicaid expansion eligibility pathway, beginning in calendar year (CY) 2027. The HHS secretary must issue guidance related to implementing the rule no later than 180 days after enactment. The bill appropriates $75 million to the Centers for Medicare & Medicaid Services (CMS) administrator for fiscal year (FY) 2026 for implementation of the provisions. CBO estimates that this provision will result in a $62.6 billion reduction in federal spending over 10 years.</p><h4>Section 77109: Alien Medicaid Eligibility (Effective Oct. 1, 2026)</h4><p>Restricts eligibility for Medicaid to the following groups: legal permanent residents, certain Cuban immigrants and Compact of Free Association migrants lawfully residing in the United States. The bill appropriates $15 million to the CMS administrator for FY 2026 for implementation of the provisions. CBO estimates that this provision will result in a $6.2 billion reduction in federal spending over 10 years.</p><h4>Section 7110: Expansion FMAP for Emergency Medicaid (Effective Oct. 1, 2026)</h4><p>Beginning Oct. 1, 2026, the bill limits the Federal Medical Assistance Percentage (FMAP) to the state’s traditional FMAP for emergency Medicaid services provided to unlawfully present aliens who, except for their immigration status, would qualify for Medicaid expansion. The bill appropriates $1 million for FY 2026 to the CMS administrator for implementation of the provision. CBO estimates that this provision will result in a $28.2 billion reduction in federal spending over 10 years.</p><h3><em>Subchapter B — Preventing Wasteful Spending</em></h3><h4>Section 71111: Moratorium on Implementation of Rule Relating to Staffing Standards for Long-term Care Facilities Under the Medicare and Medicaid Programs (Effective from enactment through Sept. 30, 2024)</h4><p>Prohibits HHS from implementing the Minimum Staffing Standards for long-term care facilities and the Medicaid Institutional Payment Transparency Reporting regulation for 10 years. CBO estimates that this provision will result in a $23.1 billion reduction in federal spending over 10 years.</p><h4>Section 71112: Reducing State Medicaid Costs (Effective Jan. 1, 2027)</h4><p>Limits the timeframe for retroactive Medicaid and CHIP eligibility to 30 days prior to the application date for expansion enrollees, and 60 days prior to the application date for traditional enrollees, as opposed to the current 90-day period. CBO estimates that this provision will result in a $4.2 billion reduction in federal spending over 10 years.</p><h4>Section 71113: Federal Payments to Prohibited Entities (Effective on enactment into 2026)</h4><p>Prohibits states from receiving federal matching funds for services rendered by providers who provide abortions (other than Hyde Amendment exceptions) and receive more than $800,000 in Medicaid payments in 2023. This applies to not-for-profit, essential community providers primarily engaged in family planning services, reproductive health and related medical care. This provision applies for one year, beginning on the date of enactment. The bill appropriates $1 million for FY 2026 to the CMS administrator for implementation of the provisions. CBO estimates that this provision will result in a $52 million increase in federal spending over 10 years.</p><h3><em>Subchapter C — Stopping Abusive Financing Practices</em></h3><h4>Section 71114: Sunsetting Increased FMAP Incentive. (Effective Jan. 1, 2026)</h4><p>Repeals the ability for states that have not yet expanded Medicaid to receive 5% enhanced FMAP funds should they later choose to expand. CBO estimates that this provision will result in a $13.6 billion reduction in federal spending over 10 years.</p><h4>Section 71115: Provider Taxes (Freeze effective upon enactment; reduction begins Oct. 1, 2027)</h4><p>Freezes existing provider taxes imposed by a state or local unit of government as of the date of enactment. Removes the ability of a state or local unit of government to impose a new provider tax after enactment by setting the “hold harmless threshold” at 0%. Beginning in FY 2028, the hold harmless threshold for <strong>expansion states</strong> with an existing tax will be reduced by 0.5% annually until the threshold reaches 3.5% in 2032. Provider taxes in non-expansion states and provider taxes imposed on nursing homes and intermediate care facilities will remain frozen at their rates as of enactment. The bill appropriates $20 million for FY 2026 to the CMS administrator for implementation of the provisions. CBO estimates that this provision will result in a $191.1 billion reduction in federal spending over 10 years.</p><h4>Section 71116: State-directed Payments (SDP cap effective on enactment; reduction effective by the rating period on or after Jan. 1, 2028)</h4><p>Caps SDPs at 100% of the total published Medicare rate in expansion states and 110% of the total published Medicare rate in non-expansion states. SDPs approved (or where there was a good faith effort to be approved) by May 1, 2025, and SDP payments for rural hospitals approved (or where there was a good faith effort to be approved) by enactment will be grandfathered in at a higher rate. Completed preprints for SDPs can be submitted until enactment and may be grandfathered in at a higher rate. Beginning with the rating period on or after Jan. 1, 2028, all grandfathered SDPs would be reduced by 10 percentage points annually until the specified Medicare payment rate limit is achieved. The total published Medicare rate is defined as provided in 438.6(a) of title 42 of the Code of Federal Regulations or any future regulation that replaces it. Rural hospitals are defined as those located in a rural area, treated as being in a rural area, or located in a rural census tract, as well as critical access hospitals, sole community hospitals, Medicare-dependent hospitals, low-volume hospitals and rural emergency hospitals. The bill appropriates $7 million for each FY between 2026 and 2033 for the implementation of the provision. CBO estimates that this provision will result in a $149.4 billion reduction in federal spending over 10 years.</p><h4>Section 71117: Requirements Regarding Waiver of Uniform Tax Requirement for Medicaid Provider Tax (Effective upon enactment)</h4><p>Modifies the requirements regarding the uniformity of provider taxes and, specifically, whether a state’s tax is considered “generally redistributive.” A tax will not be considered generally redistributive if:</p><ol type="a"><li>Lower-volume Medicaid health care entities are taxed at a lower rate than higher-volume Medicaid health care entities.</li><li>High Medicaid volume health care entities are taxed more heavily than non-Medicaid health care entities.</li><li>The tax establishes any target or exclusion related to a health care entity’s Medicaid participation status.</li></ol><p>The HHS secretary will determine an applicable transition period (up to three years) for taxes considered not generally redistributive. CBO estimates that this provision will result in a $34.6 billion reduction in federal spending over 10 years.</p><h3><em>Subchapter D — Increasing Personal Accountability</em></h3><h4>Section 71119: Requirement for States to Establish Medicaid Community Engagement Requirements for Certain Individuals (Effective Dec. 31, 2026)</h4><p>Requires certain nonpregnant, nondisabled adult Medicaid beneficiaries to meet certain community engagement requirements (work requirements) beginning Dec. 31, 2026. Individuals must work or engage in qualifying activities (e.g., community service, educational programs, job training) for no less than 80 hours per month. The legislation exempts, among other groups, parents, guardians and caretaker relatives of children aged 14 or under, or disabled individuals. States are permitted to receive temporary exemptions with HHS approval. The legislation limits the types of entities that can contract with states to help implement this provision, effectively barring Medicaid managed care plans from assisting. The bill provides $200 million in FY 2026 for state implementation and $50 million for federal administration. CBO estimates that this provision will result in a $325.8 billion reduction in federal spending over 10 years.</p><h4>Section 71120: Modifying Cost-sharing Requirements for Certain Expansion Individuals Under the Medicaid Program (Effective Oct. 1, 2028)</h4><p>Requires Medicaid expansion enrollees with incomes above 100% of the federal poverty level to pay up to $35 in cost sharing per service. Cost sharing for non-emergency services provided in a hospital emergency department may exceed $35. The provision will exclude certain services, including primary care, pregnancy-related services, mental health or substance use disorder services. Total cost sharing may not exceed 5% of family income. CBO estimates that this provision will result in a $7.5 billion reduction in federal spending over 10 years.</p><h3><em>Subchapter E — Expanding Access to Care</em></h3><h4>Section 71121: Making Certain Adjustments to Coverage of Home or Community-based Services Under Medicaid (Effective July 1, 2028)</h4><p>Provides states with the option to pursue a standalone waiver under section 1915(c) and expand access to home and community-based services. The bill appropriates $50 million for FY 2026 to the HHS secretary for implementation of the provisions. Further, the bill appropriates $100 million for FY 2027 for making payments to states delivering home or community-based services. CBO estimates that this provision will result in a $6.6 billion increase in federal spending over 10 years.</p><h3>Chapter 2 — Medicare</h3><h3><em>Subchapter A — Strengthening Eligibility Requirements</em></h3><h4>Section 71201: Limiting Medicare Coverage of Certain Individuals (Effective 18 months from enactment)</h4><p>Restricts eligibility for Medicare for non-citizens to the following groups: legal permanent residents, certain Cuban immigrants and Compact of Free Association migrants lawfully residing in the United States. CBO estimates that this provision will result in a $5.1 billion reduction in federal spending over 10 years.</p><h3><em>Subchapter B — Improving Services for Seniors</em></h3><h4>Section 71202: Temporary Payment Increase Under the Medicare Physician Fee Schedule to Account for Exceptional Circumstances (Effective Jan. 1, 2026)</h4><p>Provides a rate update to the Physician Fee Schedule of 2.5% for calendar year (CY) 2026 only. There is no adjustment for CY 2025. CBO estimates that this provision will result in a $1.9 billion increase in federal spending over 10 years.</p><h4>Section 71203: Expanding and Clarifying the Exclusion for Orphan Drugs Under the Drug Price Negotiation Program (Effective Jan. 1, 2028)</h4><p>Modifies the Inflation Reduction Act to exclude orphan drugs under the Drug Price Negotiation Program. CBO estimates that this provision will result in a $4.9 billion increase in federal spending over 10 years.</p><h3>Chapter 3 — Health Tax</h3><h3><em>Subchapter A — Improving Eligibility Criteria</em></h3><h4>Section 71301: Permitting Premium Tax Credit Only for Certain Individuals (Effective Jan. 1, 2027)</h4><p>Restricts eligibility premium tax credits for marketplace coverage for non-citizens to the following groups: legal permanent residents, certain Cuban immigrants and Compact of Free Association migrants lawfully residing in the United States. CBO estimates that this provision will result in a $69.8 billion reduction in federal spending over 10 years.</p><h4>Section 71302: Disallowing Premium Tax Credits During Periods of Medicaid Ineligibility Due to Alien Status (Effective Jan. 1, 2026)</h4><p>Disallows undocumented immigrants who report income below 100% of the federal poverty level and are in their five-year Medicaid waiting period (due to immigration status) from receiving premium tax credits to purchase health insurance on the marketplaces. CBO estimates that this provision will result in a $49.5 billion reduction in federal spending over 10 years.</p><h3><em>Subchapter B — Preventing Waste, Fraud and Abuse</em></h3><h4>Section 71303: Requiring Verification of Eligibility for the Premium Tax Credit (Effective Jan. 1, 2028)</h4><p>Prohibits an individual from claiming the premium tax credit if the individual’s eligibility related to income, enrollment and other requirements is not actively verified annually. This will prohibit automatic reenrollment for enrollees receiving premium tax credits by requiring them to actively prove tax credit eligibility each year. CBO estimates that this provision will result in a $36.9 billion reduction in federal spending over 10 years.</p><h4>Section 71304: Disallowing Premium Tax Credit in Case of Certain Coverage Enrolled in During the Special Enrollment Period (Effective Jan. 1, 2026)</h4><p>Prohibits individuals from receiving premium tax credits if they enroll in health coverage on the marketplace through a special enrollment period associated with their income. CBO estimates that this provision will result in a $39.5 billion reduction in federal spending over 10 years.</p><h4>Section 71305: Eliminating Limitation on Recapture of Advance Payment of Premium Tax Credit (Effective Jan. 1, 2026)</h4><p>Removes the repayment limits and requires affected individuals to reimburse the Internal Revenue Service for the full amount of excess tax credit received. CBO estimates that this provision will result in a $17.3 billion reduction in federal spending over 10 years.</p><h3><em>Subchapter C — Enhancing Choice For Patients</em></h3><h4>Section 71306: Permanent Extension of Safe Harbor for Absence of Deductible for Telehealth Services (Effective Jan. 1, 2025)</h4><p>Provides a safe harbor to allow telehealth services to be provided pre-deductible for patients with high-deductible health plans. CBO estimates that this provision will result in a $4.3 billion reduction in federal revenue over 10 years.</p><h4>Section 71307: Allowance of Bronze and Catastrophic Plans in Connection with Health Savings Accounts (Effective Jan. 1, 2026)</h4><p>Allows bronze and catastrophic plans to contribute to health savings accounts. CBO estimates that this provision will result in a $3.6 billion reduction in federal revenue over 10 years.</p><h4>Section 71308: Treatment of Direct Primary Care Service Arrangements (Effective Jan. 1, 2026)</h4><p>Allows individuals in high-deductible health plans to enroll in direct primary care service arrangements and to use their health savings accounts for payment. CBO estimates that this provision will result in a $2.8 billion reduction in federal revenue over 10 years.</p><h3>Chapter 4 — Protecting Rural Hospitals and Providers</h3><h4>Section 71401: Rural Health Transformation Program (Effective upon enactment)</h4><p>Creates a rural stabilization fund with $50 billion, to be paid out as $10 billion annually across FYs 2026 through 2030. States will need to submit a one-time application to CMS to be eligible for an allotment of these funds during a submission period specified by CMS (with an application and decision date no later than Dec. 31, 2025). Of the $50 billion in funding, 50% of the funds for each fiscal year will be equally distributed among all the states with an approved application. Forty percent of the funds for each fiscal year will be distributed in a method determined by CMS. CMS will consider the following as its distribution method: the percentage of the state population located in rural geographies, the proportion of rural health facilities in the state relative to the nation, and any other factors deemed appropriate by CMS. Not more than 10% of the amount allocated to the states can be used for administrative expenses. Separately, the legislation appropriates $200 million to the CMS administrator for FY 2025 to implement the provision.</p><h3>SUBTITLE A — TAX</h3><h3>Chapter 4 — Investing In American Families, Communities and Small Businesses</h3><h3><em>Subchapter B — Permanent Investments in Students and Reforms to Tax-Exempt Institutions</em></h3><h4>Section 70415: Endowment Tax for Universities (Effective Jan. 1, 2026)</h4><p>Amends the excise tax rate for universities based on student endowments. The rates are as follows: 1.4% for student endowments ranging from $500,000-$750,000 , 4% for student endowments ranging from $750,000-$2 million, and 8% for all student endowments above $2 million. CBO estimates that this provision will result in a $761 million increase in federal revenue over 10 years.</p><h4>Section 70416: Executive Compensation (Effective Jan. 1, 2026)</h4><p>Limits tax-exempt organizations’ ability to deduct compensation over $1 million, including for former employees, dating back to tax year 2017. CBO estimates that this provision will result in a $3.8 billion increase in federal revenue over 10 years.</p><h3><em>Subchapter C — Permanent Investments in Community Development</em></h3><h4>Section 70426: One Percent Floor on Deduction of Charitable Contributions Made by Corporations (Effective Jan. 1, 2026)</h4><p>Allows a deduction for corporate charitable contributions only to the extent that the aggregate of corporate charitable contributions exceeds 1% of a taxpayer’s taxable income and does not exceed 10% of the taxpayer’s taxable income. CBO estimates that this provision will result in a $16.6 billion increase in federal revenue over 10 years.</p><h3>Chapter 5 — Ending Green New Deal Spending, Promoting America-First Energy and Other Reforms</h3><h3><em>Subchapter A — Termination of Green New Deal Subsidies</em></h3><h4>Section 70503: Termination of Qualified Commercial Clean Vehicles Credit (Credit terminates Sept. 30, 2025)</h4><p>Eliminates the tax credit that allowed for tax-exempt entities to receive a direct payment for the lesser of 1) 15% of the vehicle’s cost (30% for vehicles not powered by gas or diesel) or 2) the incremental cost of the vehicle relative to a comparable vehicle. CBO estimates that this provision will result in a $104.5 billion increase in federal revenue over 10 years.</p><h4>Section 70504: Termination of Alternative Fuel Vehicle Refueling Property Credit (Credit terminates June 30, 2026)</h4><p>Eliminates the tax credit that allowed for a tax-exempt owner of property to receive direct payment for the cost of installing a qualified alternative fuel vehicle refueling station on property, such as electric charging stations CBO estimates that this provision will result in a $1.96 billion increase in federal revenue over 10 years.</p><h4>Section 70507: Termination of Energy Efficient Commercial Buildings Deduction (Deduction terminates June 30, 2026)</h4><p>Eliminates a tax deduction for tax-exempt organizations for energy-saving commercial building property. The deduction will terminate for any property with construction beginning after June 30, 2026. CBO estimates that this provision will result in a $134 million increase in federal revenue over 10 years.</p><h4>Section 70513: Termination and Restrictions on Clean Electricity Investment Credit (Credit terminates Dec. 31, 2027)</h4><p>Eliminates a tax credit for investing in qualifying zero-emission electricity generation facilities or energy storage technology. Under the previous law, the credit was phased out in 2032. Specifically, this provision:</p><ul><li>Terminates eligibility for covered wind and solar facilities placed into service after Dec. 31, 2027.</li><li>Increases the domestic content requirement for projects to be eligible for the domestic content bonus. The current law requires that 40% of the manufactured products in a facility be from a domestic source. The act will increase the required threshold to 45% (or 27.5% for offshore wind) from June 16, 2025, until Dec. 31, 2025; 50% (or 35% for offshore wind) for CY 2026; and 55% after Dec. 31, 2026.</li><li>Prevents access to credits for wind and solar if the taxpayer rents or leases the property to a third party.</li><li>Prohibits credits that include any material assistance from a prohibited foreign entity.</li></ul><p>Additionally, the bill eliminates the investment tax credit for certain energy properties for qualified projects. Specifically, the provision eliminates the 2% base credit for projects not meeting prevailing wage and apprenticeship requirements, applies to construction beginning on or after June 16, 2025.CBO estimates that this provision will result in a $177.9 billion increase in federal revenue over 10 years.</p><h2>Further Questions</h2><p>If you have further questions, please contact AHA at <a href="tel:1-800-424-4301">800-424-4301</a>.</p></div><div class="col-md-4"><div class="sticky"><a href="/system/files/media/file/2025/07/Legislative-Advisory-Key-Highlights-of-the-Final-One-Big-Beautiful-Bill-Act.pdf" target="_blank" title="Click here to download the Legislative Advisory: Key Highlights of the Final One Big Beautiful Bill Act PDF."><img src="/sites/default/files/inline-images/Page-1-Legislative-Advisory-Key-Highlights-of-the-Final-One-Big-Beautiful-Bill-Act.png" data-entity-uuid="6a061d3b-a8fa-410e-baa3-17eaad87d657" data-entity-type="file" alt="Legislative Advisory: Key Highlights of the Final One Big Beautiful Bill Act page 1." width="696" height="900"></a></div></div></div></div> div.sticky { position: sticky; top: 0; } Thu, 03 Jul 2025 00:00:01 -0500 Advocacy & Public Policy /leadership-dialogue <div class="container"><div class="row"><div class="col-md-8"><img src="/sites/default/files/inline-images/leadership-dialogue-freese-decker-pollack-0725-900x400.jpg" data-entity-uuid="170fb397-8bd2-4b79-8863-d07fac49492d" data-entity-type="file" alt="Leadership Dialogue. A Conversation with AHA Chair Tina Freese Decker and AHA President and CEO Rick Pollack." width="900" height="400"><p>In early July, Congress enacted the One Big Beautiful Bill Act — a sweeping package that contained many of President Trump’s legislative priorities on taxes, border security, energy and deficit reduction, as well as significant policy changes to Medicaid and the Health Insurance Marketplaces. This legislation will have a significant impact on hospitals and health systems as the changes are enacted.</p><p>In this episode, 2025 AHA Board Chair Tina Freese Decker talks with AHA President and CEO Rick Pollack about the legislation’s key provisions that apply to health care. Freese Decker and Pollack discuss how the AHA is helping the field prepare for some of the law’s changes, as well as ongoing efforts to mitigate some of the policies.</p><p>During the conversation, Freese Decker and Pollack also look ahead to the many key advocacy priorities that are still on the table for the remainder of the year, including several provisions that the AHA hopes to get enacted as part of a government funding bill at the end of September.</p><p>Grassroots advocacy and sharing stories with legislators about the real-world impact the policies they enact will have on patients and communities remain vital, and the conversation closes by exploring what this looks like for hospitals and health systems.</p><p>* <em>Note that this conversation was recorded on July 11, 2025.</em></p><hr><p></p><hr><div></div> <details class="transcript"> <summary> <h2 title="Click here to open/close the transcript."> <span>View Transcript</span><br>   </h2> </summary> <p> 00:00:01:04 - 00:00:32:24<br> Tom Haederle<br> Welcome to Advancing Health. Most experts agree that less reliance on foreign made medical and pharmaceutical products would be a good thing for U.S. health care. But experts also agree it's going to take some time to increase control over our supply chain. In today's podcast hosted by Tina Freese Decker, president and CEO of Corewell Health and the 2025 Board Chair of the ���������� Association, we hear from two experts about the potential impact of the Trump administration's trade tariffs on our supply chain and what they could mean for patients and providers. </p> <p> 00:00:32:27 - 00:00:39:28<br> Tom Haederle<br> This podcast was recorded on May 15th. </p> <p> 00:00:40:00 - 00:01:04:17<br> Tina Freese Decker<br> Hello, and thank you so much for joining us today. I'm Tina Freese Decker, president and CEO of Corewell Health and board chair for the ���������� Association. This month, we are diving into a topic that is top of mind for all of our leaders, not just in health care. It's tariffs. As our nation watches the changing tariff policy play out for those in the hospital field, there are serious considerations as it relates to our supply chain. </p> <p> 00:01:04:19 - 00:01:31:00<br> Tina Freese Decker<br> Every day at Corewell Health and I'm sure at every hospital health system across our country, we use a wide array of products, devices and pharmaceuticals to deliver safe and effective care to our communities. The lives of the people we serve often depend on these items being readily available, making a robust health care supply chain critical. While the field shares the administration's long term goal of strengthening the domestic supply chain for essential medical and pharmaceutical products, </p> <p> 00:01:31:03 - 00:01:57:00<br> Tina Freese Decker<br> we know that achieving this goal will require significant time. In the short term, there is concern that tariffs could inadvertently disrupt that availability of these essential care delivery products, increase the complexity of delivering patient care, and significantly raise hospital costs. So today, I'm joined by two guests who will help us better understand the current environment as it relates to tariffs and the potential implications to health care supply chain. </p> <p> 00:01:57:02 - 00:02:06:12<br> Tina Freese Decker<br> Brian Pomper is a partner at Akin Gump Strauss Hauer and Feld, a D.C. based law firm, and he specializes in international trade policy. Welcome, Brian. </p> <p> 00:02:06:19 - 00:02:07:05<br> Brian Pomper, JD<br> Thanks for having me. </p> <p> 00:02:07:20 - 00:02:24:28<br> Tina Freese Decker<br> Before joining Akin Gump, Brian formerly served as the chief international trade counsel to the Senate Finance Committee, where he advised of all aspects of the committee's international trade and economic agenda. So we'll get into some of your expertise today. And we are also joined by Akin Demehin. Welcome, Akin. </p> <p> 00:02:25:05 - 00:02:26:03<br> Akin Demehin<br> Thank you Tina. </p> <p> 00:02:26:05 - 00:02:54:05<br> Tina Freese Decker<br> Akin is AHA's vice president for quality and safety policy. He leads public policy analysis, development and advocacy efforts related to quality, patient safety and workforce on behalf of the ���������� Association. He also leads a regulatory policy development efforts related to the health care workforce. So thank you so much for joining us today. There's so many ups and downs, so many negotiations about what's happening with tariffs. </p> <p> 00:02:54:08 - 00:03:00:20<br> Tina Freese Decker<br> So Brian, I'm going to start with you. Can you tell us where we are today about what's happening for tariffs. </p> <p> 00:03:00:22 - 00:03:29:23<br> Brian Pomper, JD<br> Sure thing. Well there's a couple different avenues that the administration has taken on its trade and tariff plan, I'd say. The first I'd just talk about the giant reciprocal tariff regime that the president announced on Liberation Day, as he calls it, on April 2nd. On April 2nd, he announced that he would be imposing 10% tariffs on every country in the world and higher tariffs on 57 of those countries on April 9th. </p> <p> 00:03:29:23 - 00:03:53:27<br> Brian Pomper, JD<br> And so the 10% tariffs went into effect April 5th and then April 9th - for about a few hours - you had much higher tariffs on those 57 countries. The bond market and the stock market reacted quite negatively at the time. And so he decided he would pause those higher tariffs on the 57 countries for 90 days to allow for negotiations. </p> <p> 00:03:53:27 - 00:04:18:21<br> Brian Pomper, JD<br> He said at the time it was because the bond market had gotten, in his words, yippy. So they were watching what was happening in the broader market. Concerned about where the market was trending, decided to pause this enterprise to allow for these kind of bilateral negotiations over the course of 90 days. And so that's where we are now. Where there are, really, one hears 18 to 20 countries that are in active negotiations with the administration. </p> <p> 00:04:18:21 - 00:04:38:22<br> Brian Pomper, JD<br> There are many more that have proposed some degree of, measures they could take for their own economy. So there are really are dozens of countries that are engaged in negotiations with the United States during this 90 day period. There's been one announced agreement with the United Kingdom that was late last week or earlier this week. </p> <p> 00:04:38:24 - 00:04:58:07<br> Brian Pomper, JD<br> I would just note that that agreement with the U.K., it's much less of an operational agreement and much more really of a kind of a scoping exercise in agreement to agree sometime in the future on certain matters. And so it's really just a little bit of an appetizer for what maybe these agreements might look like in the future. </p> <p> 00:04:58:07 - 00:05:22:03<br> Brian Pomper, JD<br> And the hard part in even negotiating with the U.K. has yet to be done. There's a rumor that there's another agreement that should be announced here fairly soon, but I expect there will be a whole series of these kinds of announcements over the course of the next 90 days, until July 9th. I wouldn't expect the very high reciprocal tariffs on those 57 countries to snap back immediately into place on July 9th. </p> <p> 00:05:22:06 - 00:05:39:01<br> Brian Pomper, JD<br> My expectation is that countries that are able to negotiate, as the U.K. did, will end up with a 10% tariff. They won't get their higher tariff. But even for those countries that have expressed a willingness to negotiate with the United States, I don't think that the higher tariffs will go into place. I think the president will extend the pause there. </p> <p> 00:05:39:08 - 00:06:05:14<br> Brian Pomper, JD<br> So that's reciprocal tariffs. And then there are section 232 investigations. This is a mechanism whereby the president can ask the Department of Commerce to do an investigation into the national security impact of certain imports. And there has been, a variety of investigations that this president has, has undertaken and actually imposed tariffs on steel and aluminum and autos. All those tariffs are in place under the section 232 authority. </p> <p> 00:06:05:16 - 00:06:30:16<br> Brian Pomper, JD<br> But there's also investigations into pharmaceuticals, into semiconductors, trucks, timber, lumber, copper, aerospace, potentially more coming down the pike. And so we're expecting those investigations to be announced here in the coming months. But we don't know exactly where the president will land yet. The premise of those investigations is supposed to be the national security impacts of those imports. </p> <p> 00:06:30:18 - 00:06:52:20<br> Brian Pomper, JD<br> But really, the president seems to be using them as a cudgel to try to force companies to restore their manufacturing from overseas to the United States by tariffing the imports. He seems to like a tariff of 25%. That's the tariff that applies on steel, aluminum and autos. I think that's where we see him landing on some of these others. </p> <p> 00:06:52:23 - 00:07:26:13<br> Brian Pomper, JD<br> And unlike the reciprocal tariffs where there's a lot of negotiation that's ongoing, the section 232 tariffs feel a lot stickier. They'll be a lot harder to get out from underneath them. And then of course there are the China tariffs. When the president announced the 34% reciprocal tariff for China. China retaliated and we ended up in a tit for tat retaliation that ended up really with, 145% base tariff on imports into the United States from China and 125% tariff from US exports to China. </p> <p> 00:07:26:15 - 00:07:46:12<br> Brian Pomper, JD<br> That really was like an economic blockade. And both economies really needed to lower those and in fact, they did agree. The United States and China agreed to lower those tariffs. And so now the tariffs on products coming into China, the base tariff is 30% plus whatever additional tariffs might apply. And from the US side into China, it's 10%. </p> <p> 00:07:46:15 - 00:08:02:28<br> Tina Freese Decker<br> I was just recently reading a book, history book and talked about tariffs. So can you share how tariffs have been handled differently compared in the past, how they are different today than they were used in past administrations or past years and strategies? </p> <p> 00:08:03:00 - 00:08:26:03<br> Brian Pomper, JD<br> Yeah. Thank you. I love this question. Allows me to bring out my inner professor. So I would say for the first 150 years of American history, there was no topic that was more often and more frequently debated in Congress than what should be the level of the tariff. You had the incipient industrial industries in the North that wanted higher tariffs to protect their growing power up there. </p> <p> 0:08:26:05 - 00:08:49:15<br> Brian Pomper, JD<br> And then you had growers in the South who wanted open export markets, and so they wanted low tariffs so that other countries don't go there. So there was this just constant negotiation. We ended in 1930 with something called the Smoot-Hawley tariff, which people may remember from their high school history class, as blamed for having deepened the Great Depression, I think widely perceived as a negative economic outcome. </p> <p> 00:08:49:17 - 00:09:10:10<br> Brian Pomper, JD<br> And since 1930, what the Congress has really done is to delegate to the president quite a bit of authority over trade policy. This is why we have things like the section 232 investigation, where Congress has understood that well, you know, maybe it's not the best use of congressional time to negotiate on what the tariff on salmon imports should be. </p> <p> 00:09:10:13 - 00:09:33:18<br> Brian Pomper, JD<br> You know, we're going to let the president kind of deal with that stuff. So we have for the last almost 100 years, had this kind of joint authority between Congress and the president where they would share this, this sort of responsibility. And I think there are those who will argue that that President Trump is using this authority in ways that hadn't been contemplated. </p> <p> 00:09:33:20 - 00:09:56:17<br> Brian Pomper, JD<br> In particular, I would say, with a line of tariffs that I didn't talk about, which are these tariffs under the International Emergency Economic Powers Act that were imposed on Canada and Mexico, also on China. And actually, I should say IEEPA is the underlying authority the president used for this entire reciprocal tariff regime. It is a very aggressive use of this authority. </p> <p> 00:09:56:20 - 00:10:17:18<br> Brian Pomper, JD<br> That that's unusual. The president is much more willing to push legal boundaries, of course, not just in tariffs, but we certainly see it in tariffs here. So much so it is currently being challenged in the courts. And it's really anybody's guess whether the courts are going to decide that he may have exceeded his authority under the IEEPA statute to him to impose these tariffs. </p> <p> 00:10:17:21 - 00:10:19:28<br> Tina Freese Decker<br> And can you explain the IEEPA statute? </p> <p> 00:10:20:01 - 00:10:43:18<br> Brian Pomper, JD<br> Sure. I'm happy to. So IEEPA stands for the International Emergency Economic Powers Act. It was passed in 1977 to allow the president to act quickly in cases of some sort of economic emergency. It's actually the basis for our entire export controls regime. It has never been used before to impose tariffs. President Trump is the first president to use it to impose tariffs. </p> <p> 00:10:43:21 - 00:11:08:13<br> Brian Pomper, JD<br> There was a predecessor statute called the Trading With the Enemy Act, that President Nixon used to impose tariffs when we were in the process of going off of the gold standard, because there was a balance of payments crisis at the time. That was challenged in the courts, and the court at the time decided that was okay because the court decided, well, those tariffs that the president imposed were really in response to a true economic crisis. </p> <p> 00:11:08:13 - 00:11:32:19<br> Brian Pomper, JD<br> There wasn't enough gold in Fort Knox to cover the number of dollars that were in circulation at the time. And those tariffs were imposed for a relatively short period. It was only four months. And it wasn't every country and every product. If you fast forward now to the successor statute, the IEEPA statute, which was written largely because the Trading With the Enemy Act...it was an awkward fit for some of these actions that President Nixon took. </p> <p> 0:11:32:21 - 00:11:59:07<br> Brian Pomper, JD<br> Here you now have a president who has used IEEPA to impose tariffs on every country, every product, effectively forever. And so the question that the court in Yoshida, which is the case I'm talking about, the court in Yoshida decided the president in that case was not seeking to usurp the role of Congress, which is clearly given to Congress in the Constitution to control international economic relations, trade with foreign nations. </p> <p> 00:11:59:10 - 00:12:30:11<br> Brian Pomper, JD<br> The president wasn't seeking to stand in the role of Congress in resetting tariffs, because it was only time limited and, you know, limited in coverage. Here it's a much different circumstance where you really do have the entirety of the harmonized tariff code that covers all of our trade with every country being reset through executive order. I do think that there are very strong legal arguments that will be made and are being made in court, literally right now as we speak, that the president exceeded his authority under </p> <p> 00:12:30:14 - 00:12:40:06<br> Brian Pomper, JD<br> IEEPA. So it's not inconceivable in the next few weeks, you could see a court order that would invalidate the president's actions and really get rid of this entire reciprocal tariff regime. </p> <p> 00:12:40:08 - 00:13:04:03<br> Tina Freese Decker<br> Thank you very much. That was an excellent summary, we really appreciate that. I'm going to switch to Akin. Akin, can you share an overview of concerns specific to hospitals as how it relates to the tariffs may impact access to pharmaceuticals, medical supplies, other needed devices, and do you think that there is going to be a concern about exasperate some of the shortages that we have experienced to date? </p> <p> 00:13:04:06 - 00:13:27:02<br> Akin Demehin<br> Absolutely. I think the complexity that Brian was talking about in terms of how these tariffs are being rolled out is really needing the complexity of the health care supply chain. And the concern that we hear from members and that we really put front and center in our own advocacy efforts is what does this mean for the delivery of patient care? </p> <p> 00:13:27:04 - 00:13:54:21<br> Akin Demehin<br> What does it mean for our caregivers in health care facilities? Hospitals and health systems are constantly weaving together both domestic and international sources for their drugs, for their medical devices, and for other critical supplies. And we know that even temporary disruptions to the flows of those goods can have significant impacts to how hospitals deliver care. Great example are cancer drugs. 00:13:54:24 - 00:14:20:02<br> Akin Demehin<br> Many of those are manufactured in China or rely on a significant number of key starting materials that are manufactured in China or in other locations across the globe. The disruption from tariffs could potentially lead to disruptions in those carefully planned cancer treatments that really rely on careful scheduling. The same thing is true of things like cardiovascular medicines. </p> <p> 00:14:20:04 - 00:14:57:21<br> Akin Demehin<br> As you raised at the outset, Tina, we certainly support ongoing efforts to onshore production and really strengthen the domestic supply chain. At the same time, even those medical goods and devices that are manufactured here in the U.S. often draw in content from abroad. Great example is an infusion pump, where even those infusion pumps are manufactured here in the US might have parts from 20 or more different countries, ranging from the aluminum that goes into manufacturing the pole to the computer chips to the plastics. </p> <p> 00:14:57:24 - 00:15:12:17<br> Akin Demehin<br> All of that involves a considerable amount of complexity. And switching sourcing and offshoring production really is a long term effort. So we've really tried to elevate those concerns in our work around tariffs. </p> <p> 00:15:12:19 - 00:15:19:09<br> Tina Freese Decker<br> So can you tell us what the ���������� Association is doing to secure exemptions for medical devices and pharmaceuticals? </p> <p> 00:15:19:11 - 00:15:56:23<br> Akin Demehin<br> Sure. So early in the rollout of the tariffs from the administration - going back to early February - we actually sent a letter to the president outlining our concerns about the potential impacts of tariffs to the delivery of patient care, to our ability to provide things like personal protective equipment to frontline providers. And we've continued to follow that up with ongoing proactive dialogue with the administration to really focus on advocating for exemptions for pharmaceutical products and for medical devices. </p> <p> 00:15:56:25 - 00:16:27:12<br> Akin Demehin<br> Bryan talked about the section 232 investigations. The administration has one ongoing for pharmaceutical products, and had an opportunity for the field to share feedback. And we share our concerns with the administration and continue to ask for exemptions. The other thing that we are trying to do is to really provide the hospital and health system perspective to policymakers, to the media, to the administration. </p> <p> 00:16:27:14 - 00:16:51:22<br> Akin Demehin<br> We're in a bit of a unique position versus other kinds of fields where we are large consumers of the goods within the supply chain. Our ability to stockpile any of these supplies is often constrained by just the sheer availability of the supplies. The shelf life for things like pharmaceuticals is finite, so it's not necessarily something that you can just have hanging out on a shelf. </p> <p> 00:16:51:25 - 00:17:20:12<br> Akin Demehin<br> There's space that you have to have in order to warehouse some of these materials. And the way that hospitals and health systems are reimbursed means that it's really our members that bear the costs of tariffs. Because our rates are set by government and by contracts in the private sector, the potential cost impacts of tariffs are ones that we really feel quite directly for our members. </p> <p> 00:17:20:14 - 00:17:33:17<br> Tina Freese Decker<br> Akin, you answered all of my questions coming through there. That was fantastic, because those are all of the concerns that we have as members and what's going on. Brian, do you think that exemptions are likely knowing this administration? </p> <p> 00:17:33:19 - 00:17:54:18<br> Brian Pomper, JD<br> An excellent question I get from many, many clients. And I would go back to what I mentioned earlier. My expectation is that the American economy is going to struggle a bit under the weight of all of the tariffs that the president has imposed in all these ways. And there are more tariffs coming under these section 232 investigations that are currently ongoing. </p> <p> 00:17:54:20 - 00:18:27:09<br> Brian Pomper, JD<br> I think that many in Congress, especially on the Republican side, have expressed privately but not publicly concern about the president's strategy with respect to tariffs and how it might impact their constituents. But I think over time, the political and economic pressure is going to force some kind of adjustment in the administration. And I think the most logical pressure valve to be released for the administration is for them to reimpose some type of exclusion process, as we did have in the first administration. </p> <p> 00:18:27:09 - 00:18:33:15<br> Brian Pomper, JD<br> So if I'm a betting person, yes, I think we will have some kind of exclusion process. </p> <p> 00:18:33:18 - 00:18:54:27<br> Tina Freese Decker<br> We'll come back to see if you're right. And so to close out our conversation today, this has been really helpful, a great history lesson and understanding of what's going on. Brian and Akin, can you share with us what your advice would be for our members? What should we be thinking about doing, planning for, as we think about these tariffs and the impact that they have? </p> <p> 00:18:54:29 - 00:19:13:08<br> Brian Pomper, JD<br> Yeah, I always tell clients if something is important to you, important to your bottom line, you need to be vocal about it, and you need to be telling people how these measures are going to impact you. It's hard to argue with the goal, or at least one of the goals the president has of increasing manufacturing employment in the United States. </p> <p> 00:19:13:08 - 00:19:34:21<br> Brian Pomper, JD<br> Who doesn't want that? I think where there's debate is how best to achieve that. But I do think it's important for organizations like AHA to go talk to your members, talk to the people who focus on the policy issues, the policy areas that you deal with. Let them know how these tariffs are going to impact you, and ask them to weigh in on your behalf. </p> <p> 00:19:34:21 - 00:19:46:01<br> Brian Pomper, JD<br> And just make sure that whatever the administration does, they try to maximize benefit while minimizing harm. So I would just say where there's an opportunity to engage, I encourage the AHA to do so. </p> <p> 00:19:46:04 - 00:19:50:13<br> Tina Freese Decker<br> Maximize benefit and minimize harm. Great statement. Akin? </p> <p> 00:19:50:15 - 00:20:20:02<br> Akin Demehin<br> You know, Brian's counsel here is extremely wise. I'll just build on it in a couple of ways. One of the things that I know hospitals and health systems are so good at doing is bridging that gap between data and story. And often it is those stories of what's happening on the ground, how the steps that you go through to access supplies to deliver care, how those are affected, and playing that out for what it means for patients. </p> <p> 00:20:20:04 - 00:20:49:15<br> Akin Demehin<br> Those are the kinds of stories that I know policymakers respond to. It really makes the issue even more real for them. And as Brian alluded to, raising some of those concerns with policymakers and certainly reaching out to us here at AHA, we can always be strong advocates on your behalf when we have intel and stories, and other information from all of you to help make the case as best we can. </p> <p> 00:20:49:16 - 00:20:58:17<br> Akin Demehin<br> So we want to stay connected as we possibly can with all of you going forward so that we can push for those exemptions for pharmaceuticals and medical devices. </p> <p> 00:20:58:19 - 00:21:23:02<br> Tina Freese Decker<br> That's wonderful. And your example about the cancer drugs or the smart pump or MRI and how all of those pieces come together is one of those stories that we can talk about and how it impacts us. So Brian and Akin, thank you so much for your time today and sharing in your expertise. I know this is an evolving issue and the AHA will continue to monitor closely and advocate on behalf of our field. </p> <p> 00:21:23:04 - 00:21:29:13<br> Tina Freese Decker<br> And thank you to everyone tuning in today. We'll be back next month for another Leadership Dialogue conversation. </p> <p> 00:21:29:15 - 00:21:37:26<br> Tom Haederle<br> Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts. </p> </details> </div> --></div><div class="col-md-4"><div class="views-element-container"> <section class="top-level-view js-view-dom-id-cd923855505c6034c9894f80664f911676051a017a59e030d37e40ec5a9df24c resource-block"> <h2>Previous Leadership Dialogues and Rounds</h2> <div class="resource-wrapper"> <div class="resource-view"> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/news/chairpersons-file/2025-06-30-chair-file-leadership-dialogue-legal-advocacy-protect-hospitals-aha-general-counsel-chad" hreflang="en">Chair File: Leadership Dialogue — Legal Advocacy to Protect Hospitals With AHA General Counsel Chad Golder</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2025-06-30T09:55:49-05:00">Jun 30, 2025</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/news/chairpersons-file/2025-05-27-chair-file-leadership-dialogue-tariffs-and-health-care-brian-pomper-and-akin-demehin" hreflang="en">Chair File: Leadership Dialogue — Tariffs and Health Care with Brian Pomper and Akin Demehin</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2025-05-27T10:11:08-05:00">May 27, 2025</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/news/chairpersons-file/2025-04-28-chair-file-leadership-dialogue-cybersecurity-health-care-john-riggi-ahas-national-advisor" hreflang="en">Chair File: Leadership Dialogue — Cybersecurity in Health Care with John Riggi, AHA’s National Advisor for Cybersecurity and Risk</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2025-04-28T11:46:47-05:00">Apr 28, 2025</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/news/chairpersons-file/2025-03-31-chair-file-leadership-dialogue-importance-advocacy-and-storytelling-rural-health-lori" hreflang="en">Chair File: Leadership Dialogue — Importance of Advocacy and Storytelling in Rural Health with Lori Wightman, R.N., CEO of Bothwell Regional Health Center</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2025-03-31T10:49:30-05:00">Mar 31, 2025</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/news/chairpersons-file/2025-02-24-chair-file-leadership-dialogue-advancing-health-and-building-trust-lynn-hanessian-and-robert" hreflang="en">Chair File: Leadership Dialogue — Advancing Health and Building Trust with Lynn Hanessian and Robert Trestman, M.D.</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2025-02-24T08:21:34-06:00">Feb 24, 2025</time> </span> </div></div> </div> </div> <div class="more-link"><a href="/topics/leadership-dialogue">Watch More Leadership Dialogues and Rounds Videos</a></div> </section> </div> </div></div></div> Wed, 16 Jul 2025 11:45:00 -0500 Advocacy & Public Policy /advancing-health-podcast/2025-07-16-behind-bill-what-one-big-beautiful-bill-act-means-hospitals-and-health-systems <p>The passage of the One Big Beautiful Bill Act will present many policy changes and challenges for America's hospitals and health systems. In this Leadership Dialogue conversation, Tina Freese Decker, president and CEO of Corewell Health and 2025 AHA board chair, talks with Rick Pollack, president and CEO of the ���������� Association, about the sweeping impacts this legislation will have in the health care field. They break down the $900 billion in Medicaid and ACA marketplace cuts, the real-world effects on communities, and the behind-the-scenes advocacy that helped blunt even deeper damage.</p><p>This podcast was recorded on July 11, 2025</p><hr><div></div><p> </p> Tue, 15 Jul 2025 23:50:34 -0500 Advocacy & Public Policy /advancing-health-podcast/2025-07-02-when-medicaid-disappears-how-cuts-could-devastate-behavioral-health-care-rural-america <p>Potential Medicaid cuts could have devastating impacts on rural communities, particularly for behavioral health care access. In this conversation, Jon Ulven, Ph.D., behavioral health psychologist and chair of adult psychology at Sanford Health, details the fragile behavioral health landscape in rural America and how Medicaid cuts could deepen gaps in health care access and resources. Dr. Ulven also shares powerful patient stories and a compelling call to action — reminding us what’s truly at stake when access to care disappears.</p><hr><div></div><div class="raw-html-embed"><details class="transcript"> <summary> <h2 title="Click here to open/close the transcript."> <span>View Transcript</span><br>   </h2> </summary> <p> 00:00:01:04 - 00:00:25:09<br> Tom Haederle<br> Welcome to Advancing Health. South Dakota-based Sanford Health is the largest rural health system in the United States. Yet even with its size and resources, there are many challenges to delivering the care that patients need, especially regarding behavioral health services and the threats to care posed by cutbacks to Medicaid. </p> <p> 00:00:25:12 - 00:00:51:27<br> Rebecca Chickey<br> Hello, I'm Rebecca Chickey. I'm the senior director of behavioral health at the ���������� Association. And is my great honor to be here today with Dr. Jon Ulven, who is chair of psychology of Sanford Health, which is the largest rural health system in the country and covers North Dakota, South Dakota, Minnesota, and probably parts of the country that are very small and rural surrounding those states. </p> <p> 00:00:51:29 - 00:01:20:25<br> Rebecca Chickey<br> So, Dr. Ulven, thank you so much for joining us today for this very important topic: serving and meeting the mental health needs of rural Americans. And particularly the intersection of that with patients who are covered by Medicaid. So to set the stage, I'd love to have you share a little bit about Sanford Health, what it's like to really - I say rural - but you're in frontier states for the most part. </p> <p> 00:01:20:28 - 00:01:35:05<br> Rebecca Chickey<br> So the vastness of North and South Dakota and what that does to create challenges in terms of access and, the solutions that you've had to come up with but help the listeners understand the barriers. </p> <p> 00:01:35:07 - 00:02:01:07<br> Jon Ulven, Ph.D.<br> Yeah. So first of all, just thanks for having me. And I really appreciate the attention to this really important topic. You mentioned a few states, but  I'm just going to mention a few more states that we cover, Rebecca, because we're also in Wyoming, Iowa, Wisconsin and then the Upper Peninsula of Michigan. We have a very, very large footprint for our organization, and we serve about 2 million patients in that area. </p> <p> 00:02:01:09 - 00:02:26:05<br> Jon Ulven, Ph.D.<br> We do a lot of work with very rural areas, as you were mentioning, frontier type states. And North Dakota and South Dakota, most of those counties are known as behavioral health shortage areas. I practice primarily in Moorhead, Minnesota. And in the state of Minnesota about 80% - 80 to 85% - of our counties are known as a behavioral health shortage areas. </p> <p> 00:02:26:07 - 00:02:49:24<br> Jon Ulven, Ph.D.<br> So we have, just a very unique set of challenges when it comes to the trying to provide world class health care and behavioral health care to a footprint that size. And when we look at the rurality of the folks we serve. And so things that we often encounter, we counter pretty much persistent challenges with provider shortages. </p> <p> 00:02:50:01 - 00:03:14:10<br> Jon Ulven, Ph.D.<br> It's hard to recruit to this part of the country. We're in a perpetual state of recruitment. And we also know that a couple of unique things that happen with rural areas. We have people who can travel for literally some of...I've seen patients who travel across the state of North Dakota to come to an appointment on the eastern side of the state. </p> <p> 00:03:14:15 - 00:03:31:21<br> Jon Ulven, Ph.D.<br> So there are sometimes some very legitimate transportation challenges. And then, and then also, I think one of the things that is - when you are in a small rural community, and I know because I grew up in one, I actually grew up about 25 miles from where I am right here in Moorhead. I grew up on a farm. </p> <p> 00:03:31:24 - 00:03:50:22<br> Jon Ulven, Ph.D.<br> There's some nice opportunities for connectivity in a rural setting, but there's also you lose anonymity. So you have you have challenges with people who, might need behavioral health services. But, everybody knows everybody's business. So it makes it really hard to reach out and seek care. </p> <p> 00:03:50:24 - 00:04:10:09<br> Rebecca Chickey<br> I hear you, I grew up in rural Alabama. And it took 20 minutes to get to the closest gas station, and 20 more minutes from that to get to the closest hospital. So, perhaps not quite as rural as yours, but you got the fact and everyone in the little community I grew up in knew everyone else's business. </p> <p> 00:04:10:09 - 00:04:21:00<br> Rebecca Chickey<br> And with that comes the stigma of seeking care. It's incredible. That's one of the things we've been working on. So glad you're working on it, too. What about broadband? Can you speak to that for just a minute? </p> <p> 00:04:21:02 - 00:04:45:23<br> Jon Ulven, Ph.D.<br> Yeah. So to try to meet this behavioral health need, Sanford has invested a tremendous amount of infrastructure and time into a virtual care platform that we offer for this footprint, an area that I described a little bit earlier, where currently we have about 1 in 5 of our behavioral health visits are virtual at this time. </p> <p> 00:04:45:26 - 00:05:08:16<br> Jon Ulven, Ph.D.<br> So people can access this through their phones, through their computers at home. And we offer a confidential service where we are able to with the technology throughout that footprint, be able to deliver that type of care. And it's something that we are training our clinicians on a regular basis about, the effective ways to provide this modality of care. </p> <p> 00:05:08:21 - 00:05:17:06<br> Jon Ulven, Ph.D.<br> I think in all of our areas, this has just become a pretty common way of life for us to do care that we have a certain portion of it that's virtual. </p> <p> 00:05:17:08 - 00:05:20:23<br> Rebecca Chickey<br> And so you complement that with in-person visits, I assume. </p> <p> 00:05:21:00 - 00:05:46:17<br> Jon Ulven, Ph.D.<br> We do. Like I said, about 1 in 5 of our visits are virtual. I really have appreciated, some of the innovative minds that we've had here at Sanford to do some unique things. Like, for example, we have a very small community. The name of the town is Lidgerwood , North Dakota. And in Lidgerwood, North Dakota, which is like I said, I grew up around here, so I remember playing basketball in Lidgerwood, just a very, very small community. </p> <p> 00:05:46:19 - 00:06:08:06<br> Jon Ulven, Ph.D.<br> And if you head to that town, what they have is they had a clinic setting there, but it was nearly impossible to keep that staffed. So now what we've done is we have some bare bones medical staff in that area. We have some imaging capabilities and we have people to check patients in as they come in, and then they can do virtual care from there. </p> <p> 00:06:08:08 - 00:06:31:16<br> Jon Ulven, Ph.D.<br> And so they can do all different types of virtual care. They could be there for a checkup with their primary care physician. They can be there for a specialty visit for one of our other departments, and they can do behavioral health care from there as well. So we're trying to have both kind of this, this nice opportunity for people to have where they can go to a location if they need, if they have some difficulties with their technology </p> <p> 00:06:31:16 - 00:06:56:19<br> Jon Ulven, Ph.D.<br> and so they can't do the virtual care themselves, that we offer that up to people. And in this building that I'm in right here in Moorhead, we have 17 psychologists and master's level therapists. We have psychiatry here, social workers, nursing staff. And then within our building we have family medicine, internal medicine, women's health, pediatrics. We have a lab here. </p> <p> 00:06:56:19 - 00:07:20:28<br> Jon Ulven, Ph.D.<br> We have a pharmacy here. So we have this nice opportunity to provide just a really well-rounded, amount of health care. To tie back into the, connecting with what we're all here for, it's talking about the, you know, our ability to do that type of care, to think that way and to provide this platform of care. </p> <p> 00:07:21:00 - 00:07:37:26<br> Jon Ulven, Ph.D.<br> A lot of it has to do with in our country the ways that we pay for health care. And that's where we get into what has been a mainstay for health systems, and especially when we think about rural health systems is the services that are allowable by Medicaid. </p> <p> 00:07:37:28 - 00:08:04:18<br> Rebecca Chickey<br> I want to get back to that point. But before we go further about the devastating cuts that are being discussed right now, help the listeners with a couple of stories, if you can. What has been - so your ability to provide these services, your ability to provide access to care virtually or in person by being creative around that clinic that was probably on the verge of maybe closing and not being there in that community. </p> <p> 00:08:04:20 - 00:08:09:18<br> Rebecca Chickey<br> What are some of the personal stories you've seen that have impacted the lives and how? </p> <p> 00:08:09:20 - 00:08:30:08<br> Jon Ulven, Ph.D.<br> Many stories that that I could share around this. I've been here with, Sanford for 21 years. I'm a licensed psychologist, and as you were saying, I'm the department chair of our adult psychology group. So I often feel like, jack of all trades and a master of none. But what I do is I do some hospital based coverage from time to time. </p> <p> 00:08:30:08 - 00:08:56:24<br> Jon Ulven, Ph.D.<br> And so we have an inpatient psychiatric unit that I will occasionally provide care for. So a very common course that we would see would be somebody who is uninsured or underinsured. And they end up coming through our emergency department for a mental health crisis. And while they're there, the team, with our emergency department determines that the patient needs hospitalization in our inpatient psychiatric unit. </p> <p> 00:08:56:26 - 00:09:23:18<br> Jon Ulven, Ph.D.<br> Patient is admitted there. While they're there, we might uncover, for example, a first episode psychosis. So if you take someone who is a young individual in one of our communities who is having an onset that might lead to schizophrenia diagnosis, they're having a first episode of psychosis. And so we have the opportunity to assess the person there, start the person on anti-psychotic medications. </p> <p> 00:09:23:18 - 00:09:42:21<br> Jon Ulven, Ph.D.<br> And then let's say that we also uncover that this person has a substance use disorder. Well, we have had the opportunity to enroll this person in Medicaid. Perhaps this person is unemployed, underemployed, has a position where they just don't have the benefits to have, that standard type of health care that a lot of us are able to have. </p> <p> 00:09:42:23 - 00:10:07:29<br> Jon Ulven, Ph.D.<br> And so we get this person on Medicaid, and what we're able to do from our inpatient unit is set this person up with a primary care provider, a psychiatrist, a therapist, and we're able to do things like get this person started on some medication that might help with cravings for substance use. And we can we can also work with some of our community partners to try to get this person engaged in that care. </p> <p> 00:10:08:02 - 00:10:27:16<br> Jon Ulven, Ph.D.<br> What I often think about is just that if that early intervention that we know that if we can help this person out at that point on an early basis, we are really and in some ways, we're bending the trajectory for their health throughout the course of that person's life. And it is such an important time. </p> <p> 00:10:27:18 - 00:10:50:10<br> Rebecca Chickey<br> That's phenomenal. For the listeners: Statistically, by the age of 14, probably about 50% of the population if you're going to show or have a psychiatric or substance use disorder, those symptoms are showing by the age of 14. And correct me if I'm wrong here, keep me honest. But then by the time you're 21 to 24, we're up to 75%. </p> <p> 00:10:50:12 - 00:11:13:05<br> Rebecca Chickey<br> So that early identification and intervention and treatment, there's so many opportunities to improve the long term health of the individual, the ability to have a joyful life, to engage and be productive and make the most of the resources around them. It's just critically important. And you're being there, is equally so. </p> <p> 00:11:13:07 - 00:11:33:12<br> Jon Ulven, Ph.D.<br> Thank you for that. You know, as we're having this conversation that when we hear stories like this, sometimes the tendency as humans to just say, oh, that's nice. And it's important to hear about that. But we, it's a bit abstracted from us. If we don't have the ability to treat that type of individual, we see, as we see, diminishing services across the board. </p> <p> 00:11:33:14 - 00:12:02:13<br> Rebecca Chickey<br> Research shows that 50% of children and 18% of adults in rural communities are covered by Medicaid. Let that sink in, listeners. 50% of the kids in rural communities are covered by Medicaid and 18% of adults. Medicaid is also the largest payer for behavioral health. So speak a little bit more about the impact of these Medicaid cuts that are, currently being discussed in Congress and what that would mean for your community. </p> <p> 00:12:02:15 - 00:12:22:02<br> Jon Ulven, Ph.D.<br> Yeah, thank you for that. And just as you were saying that, just another I think another example just comes to mind for me, and that's the that's the example of that, something that I think a lot of people don't think about. And that's health care coverage for foster kids, for foster children. So, if you think about that for a moment, you're a family who's taking on a foster child. </p> <p> 00:12:22:05 - 00:12:46:25<br> Jon Ulven, Ph.D.<br> We  don't allow that those folks to go under the foster parents' insurance. There's a gap. There's a gap in care that is consistently filled by Medicaid. And if we think about some of the folks and even if our, you know, listeners can think about some situations where they think a foster child would come from a situation if they're obviously coming from a situation that is a distressing and challenging situation. </p> <p> 00:12:46:27 - 00:13:13:13<br> Jon Ulven, Ph.D.<br> Often there are there are lots of different health related issues, including mental health issues. Essentially, these folks would possibly be in a situation where they would have no care, no, no access to care. And we know some things about, looking at places, for example, where, Medicaid expansion has hit a certain area and we can we can take a look at some big numbers about like what's the impact of that? </p> <p> 00:13:13:13 - 00:13:39:27<br> Jon Ulven, Ph.D.<br> And we know, for example, that in one study they, looked at suicide rates, of the rate of suicide. And it was over the course of many years and found that folks who had access to Medicaid expansion that suicide rates go down. In the study that they looked at over a series of years, literally thousands of lives, they can see a reduction in completed suicides, which would suggest that there were thousands of lives saved. </p> <p> 00:13:40:04 - 00:14:08:14<br> Jon Ulven, Ph.D.<br> I'll also offer just a more pragmatic one. There was a study that was out of Montana that looked at a group of people who were participating in a tele-psychiatry practice. A large number of these folks were Medicaid recipients. And what they found was that, participating in this psychiatry practice, they had a 38% reduction in inpatient hospitalizations, 18% reduction in emergency department visits. </p> <p> 00:14:08:16 - 00:14:45:00<br> Jon Ulven, Ph.D.<br> So if you think about the higher cost elements of health care, when we can invest in ways that we know have evidence support, are effective, get the job done, we're actually preventing some of that higher cost care that that truly is. But I would much rather work on preventing something from getting worse than what ends up happening when people are at that level of distress, when they make it to our emergency department, or when I'm covering on our inpatient unit and I can see that I'm working with someone who has gone without care for a significant amount of time. </p> <p> 00:14:45:02 - 00:15:09:13<br> Rebecca Chickey<br> Again, going upstream, early intervention prevention, treatment, rather than waiting for the crisis, which might not only just impact the individual, but others as well, depending upon what the crisis is and how many people show up to the emergency room. So, as we draw this podcast to a close, is there a call to action that you would share with the listeners? </p> <p> 00:15:09:13 - 00:15:19:23<br> Rebecca Chickey<br> If there's something you would like to encourage them to do? Or, the last thing that you want to make sure that they that resonates as they click off to this podcast. </p> <p> 00:15:19:25 - 00:15:48:29<br> Jon Ulven, Ph.D.<br> My heart often goes to children. I only work with adults in my practice, but I but I mean, I'm a father myself. I think about that. Just that point you just made that earlier, we can intervene the better. And I think it's important that one study found that there children who have Medicaid coverage, they're four times more likely to have a regular visits with like, a pediatrician or get some of their health care needs met. </p> <p> 00:15:49:01 - 00:16:08:28<br> Jon Ulven, Ph.D.<br> And that that includes behavioral health and that they're 2 to 3 times more likely to receive preventative care. And then we think about when it comes to, adults who are enrolled in Medicaid, that they're five times more likely to have a regular source of health care and also receive preventative care. From the listening perspective </p> <p> 00:16:08:28 - 00:16:34:28<br> Jon Ulven, Ph.D.<br> I hope that what this has done is just increased an awareness to truly wide reaching effects that a change in Medicaid is going to it's going to have for the way that we deliver health. And I would say especially in rural health care. Rural health care systems are routinely much more impacted by non reimbursable care. And so you add to that, we're going to see some pretty significant reduction in services </p> <p> 00:16:34:28 - 00:16:51:12<br> Jon Ulven, Ph.D.<br> would be I think a reasonable guess. The thing that like call to action? I think one of the things I'm so I feel so privileged about in, in that, in North Dakota. I'm a citizen of North Dakota, I practice in Minnesota, I'm right on the border. Because we're in a small state of North Dakota, </p> <p> 00:16:51:15 - 00:17:30:05<br> Jon Ulven, Ph.D.<br> I have been able to work with our government support people and been able to testify. The last two legislative sessions, we have had laws changed in the state of North Dakota. That's been a great opportunity through connections of - here's me as a psychologist, working with our legislators. We all are responsible in a health care setting or our elected officials to improve the lives of the patients and the citizens of our states. And in a bipartisan way, when we can find some nice opportunities to get some things done that are truly meaningful for people in the states we serve, it's a win for everybody. </p> <p> 00:17:30:08 - 00:17:49:16<br> Rebecca Chickey<br> That's phenomenal. Thank you. Your passion for this work, both for the patients that you serve, for the organization that you work for and with, and for having an impact work globally. It resonates throughout this entire podcast. So thank you for that passion, for bringing it to the work that you do. And thank you for sharing it with the rest of the field. </p> <p> 00:17:49:18 - 00:17:51:13<br> Jon Ulven, Ph.D.<br> Well, thank you very much. </p> <p> 00:17:51:16 - 00:17:59:27<br> Tom Haederle<br> Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify or wherever you get your podcasts. </p> </details></div> Tue, 01 Jul 2025 23:54:19 -0500 Advocacy & Public Policy /news/headline/2025-07-01-senate-passes-one-big-beautiful-bill-act <p>The Senate narrowly <a href="https://www.senate.gov/legislative/LIS/roll_call_votes/vote1191/vote_119_1_00372.htm">passed</a> the <a href="https://www.congress.gov/bill/119th-congress/house-bill/1">One Big Beautiful Bill Act (H.R. 1)</a> on July 1 by a 50-50 tally, with Vice President J.D. Vance casting the tie-breaking vote. The Senate version of the bill now goes back to the House for consideration as Congress attempts to meet President Trump’s July 4 deadline. <br><br>The July 1 Senate vote followed a lengthy “vote-a-rama" on proposed amendments that lasted more than 24 hours. An amendment from Sen. Rick Scott, R-Fla., was withdrawn during the process that would have required, in expansion states, that any Medicaid beneficiary who temporarily lost coverage and reapplied to be enrolled at the traditional Medicaid Federal Medical Assistance Percentage.<br><br>Despite the withdrawn amendment, the Senate bill still contained provisions that would make greater cuts to Medicaid than the initial bill passed by the House.<br><br>In a <a href="/press-releases/2025-07-01-aha-statement-senate-passage-one-big-beautiful-bill-act">statement</a> shared with media, AHA President and CEO Rick Pollack said, “We are deeply disappointed by today’s vote in the United States Senate to advance the One Big Beautiful Bill Act (H.R. 1). The real-life consequences of these nearly $1 trillion in Medicaid cuts – the largest ever proposed by Congress – will result in irreparable harm to our health care system, reducing access to care for all Americans and severely undermining the ability of hospitals and health systems to care for our most vulnerable patients. <br><br>“This legislation will cause 11.8 million Americans to be displaced from their health care coverage as they move from insured to uninsured status. It also will drive up uncompensated care for hospitals and health systems, which will affect their ability to serve all patients. It will force hospitals to make service line reductions and staff reductions, resulting in longer waiting times in emergency departments and for other essential services, and could ultimately lead to facility closures, especially in rural and underserved areas.</p><p>We urge the House to mitigate this legislation and protect access to health care for patients and communities.” <br><br>The House Rules Committee is <a href="https://rules.house.gov/media/videos/rules-committee-hearing-senate-amendment-hr-1-0">meeting</a> July 1 to begin preparing the bill for floor consideration. </p> Tue, 01 Jul 2025 15:41:50 -0500 Advocacy & Public Policy /action-alert/2025-07-01-senate-passes-budget-reconciliation-bill-house-expected-vote-week <div class="container"><div class="row"><div class="col-md-8"><p>The Senate today voted 51 to 50, with a deciding vote by Vice President J.D. Vance, to pass its version of the <a href="https://sponsors.aha.org/rs/710-ZLL-651/images/Alert-07012025_FILE_0958.pdf?version=0">budget reconciliation bill</a>. Republican Sens. Susan Collins, R-Maine, Rand Paul, R-Ky., and Thom Tillis, R-N.C., voted against the final passage. The One Big Beautiful Bill Act (OBBBA) contains drastic cuts to the Medicaid program, among other provisions that impact the health care field. The AHA continues to make the case to lawmakers for mitigation as the bill moves through the budget reconciliation process and will provide members with critical updates.</p><p>AHA President and CEO Rick Pollack said in a statement sent to the media, “We are deeply disappointed by today’s vote in the United States Senate to advance the One Big Beautiful Bill Act (H.R. 1). The real-life consequences of these nearly $1 trillion in Medicaid cuts — the largest ever proposed by Congress — will result in irreparable harm to our health care system, reducing access to care for all Americans and severely undermining the ability of hospitals and health systems to care for our most vulnerable patients.</p><p>“This legislation will cause 11.8 million Americans to be displaced from their health care coverage as they move from insured to uninsured status. It also will drive up uncompensated care for hospitals and health systems, which will affect their ability to serve all patients. It will force hospitals to make service line reductions and staff reductions, resulting in longer waiting times in emergency departments and for other essential services, and could ultimately lead to facility closures, especially in rural and underserved areas.</p><p>“We urge the House to mitigate this legislation and protect access to health care for patients and communities.”</p><p>The AHA successfully advocated against an amendment from Sen. Rick Scott, R-Fla. Sen. Scott last night withdrew his amendment, which, starting in 2031, would have reduced the Federal Medical Assistance Percentage (FMAP) paid to states that have expanded their Medicaid programs and would have led to a reduction of Medicaid payments to hospitals by $99.2 billion over five years.</p><p>It is anticipated that the House and Senate will not elect to pursue a conference on the bill; therefore, the House is poised to take up the Senate version of the OBBBA. The House Committee on Rules is meeting today to establish the terms and conditions of debate for the vote. House leadership plans to move the bill to the floor tomorrow and hold a vote this week to send the bill to the president for signature by the July 4 holiday.</p><p>The following are highlights of key changes from the <a href="/advisory/2025-06-28-senate-releases-legislative-text-substitute-hr1-one-big-beautiful-bill-act">original text</a> to the OBBBA as passed by the Senate. The AHA will provide a full summary of key provisions impacting the hospital field once the bill is enacted.</p><h2>Key Changes in the OBBBA</h2><ul><li><strong>Provider taxes (Section 71115). </strong>Amends language to include provider taxes levied by units of local government, in addition to states. Additionally, the legislation increases the amount of implementation funding available to the Centers for Medicare & Medicaid Services (CMS) administrator to $20 million for fiscal year (FY) 2026.</li><li><strong>State-directed payments (Section 71116). </strong>Adds language clarifying that completed preprints for payments can be submitted until enactment and may be grandfathered in at a temporarily higher rate, in addition to those already approved by the Health and Human Services Secretary. Amends the definition<strong> </strong>of the total published Medicare payment rate to the definition provided in section 438.6(a) of title 42 of the Code of Federal Regulations or any future regulation that replaces it.</li><li><strong>Rural health transformation program (Section 71401). </strong>Increases the funds available in the rural stabilization fund to $50 billion, to be paid out as $10 billion annually across FYs 2026 through 2030 (two years earlier).</li><li><strong>Modifying cost-sharing requirements for Medicaid expansion enrollees (Section 71120). </strong>Appropriates $15 million to the CMS administrator for FY 2026 to implement the provision.</li><li><strong>Expansion FMAP for emergency Medicaid (Section 71110). </strong>Appropriates $1 million to the CMS administrator for FY 2026 to implement the provision.</li></ul><h2>Provisions No Longer Included in the OBBBA</h2><ul><li><strong>Expansion of FMAP for certain states providing payments for health care services furnished to certain individuals (formerly Section 71111).</strong> Would have lowered the Medicaid expansion FMAP from 90% to 80% for states that choose to provide coverage using the state’s funds to people who are undocumented.</li><li><strong>Prohibiting federal Medicaid and CHIP funding for certain items and services (formerly Section 71114).</strong> Would have prohibited federal Medicaid or CHIP funds from being spent on specified items and services for gender transition purposes.</li><li><strong>Determination of FMAP for high-poverty states (formerly Section 71124).</strong> Would have provided an enhanced FMAP match for certain “high-poverty states” determined annually.</li><li><strong>Application of cost-of-living adjustment to the non-labor-related portion for hospital outpatient department services furnished in Alaska and Hawaii (formerly Section 71204). </strong>Would have provided a cost-of-living adjustment to the non-labor-related portion of hospital outpatient payments in Alaska and Hawaii.</li></ul><h2>Resources</h2><p>The AHA has developed myriad resources for member use. Visit the <a href="/advocacy/advocacy-issues/medicaid">Medicaid Issues page</a> and the <a href="/advocacy/action-center">AHA Action Center</a> for the latest tools and resources.</p><h2>Further Questions</h2><p>If you have further questions, please contact AHA at 800-424-4301.</p></div><div class="col-md-4"><a href="/system/files/media/file/2025/07/senate-passes-budget-reconciliation-bill-house-expected-to-vote-this-week-alert-7-1-2025-f.pdf"><img src="/sites/default/files/2025-07/cover-senate-passes-budget-reconciliation-bill-house-expected-to-vote-this-week-alert-7-1-2025.png" data-entity-uuid data-entity-type="file" alt="Action Alert: Senate Passes Budget Reconciliation Bill; House Expected to Vote This Wee" width="NaN" height="NaN"></a></div></div></div> Tue, 01 Jul 2025 13:17:55 -0500 Advocacy & Public Policy /news/chairpersons-file/2025-06-30-chair-file-leadership-dialogue-legal-advocacy-protect-hospitals-aha-general-counsel-chad <p>Advocacy is a core part of the work of the AHA, protecting and sustaining what hospitals and health systems need to truly care for our communities. We often hear about legislative and regulatory advocacy, but legal advocacy is another important part of these efforts, both in and outside the courts.</p><p>Chad Golder, general counsel at the AHA, recently joined me on the Leadership Dialogue for a conversation on our current legal environment, what the AHA is doing on behalf of members, and what hospital and health system leaders can do to help. </p><p>We discuss a number of issues, including:</p><ul><li>The 340B Drug Pricing Program, a crucial lifeline for eligible hospitals to manage rising prescription drug costs and ensure our patients and communities have access to the health care services they need.</li><li>Regulatory relief to address regulations that foster anticompetitive conduct by insurers and limit the ability of hospitals and health systems to thrive in a competitive free market.</li><li>The many legal challenges to actions the Trump administration has undertaken.</li><li>Potential implications of a Supreme Court decision last year overturning the Chevron doctrine, which required courts to defer to federal agencies to interpret ambiguous laws. </li></ul><p>I hope you find our conversation insightful and strategic. Look for future conversations with health care, business and community leaders on making health better as part of the Chair File in 2025.</p><p><em>* Note that this conversation was recorded on June 10, 2025.</em><br> </p><p></p><p> </p><div></div><p> </p> Mon, 30 Jun 2025 09:55:49 -0500 Advocacy & Public Policy /action-alert/2025-06-28-time-act-now-contact-senate-and-house-lawmakers-today <div class="container"><div class="row"><div class="col-md-8"><p>The Senate version of the budget reconciliation bill proposes even GREATER CUTS to the Medicaid program than the House bill. See the AHA’s <a href="/system/files/media/file/2025/06/senate-releases-legislative-text-for-substitute-to-hr-1-the-one-big-beautiful-bill-act-advisory-6-28-2025.pdf">Legislative Advisory</a> with key highlights from the Senate version and the AHA’s <a href="/press-releases/2025-06-28-aha-statement-senate-reconciliation-package">statement</a>.</p><p><strong><u>The reconciliation process is not over yet.</u> </strong>There is still time to contact your lawmakers. Under the rules, the reconciliation bill is limited to 20 hours of debate followed by unlimited amendments prior to the final vote. There will also be a process for a final amendment that could provide the opportunity for additional changes. The Senate bill will be sent back to the House for their final vote. This could provide another opportunity for changes.</p><p class="text-align-center"><span><strong>Don’t wait!</strong></span></p><p>Ask your senators and representatives to <strong>protect Medicaid and access to health care and services</strong> in your community.</p><p>Advocate to your Republican senators to<strong> reject the additional cuts in the Senate reconciliation bill, </strong>especially as related to provider taxes and state-directed payments.</p><p>Equally important, <strong>tell your Republican House members, who could still have significant influence over the final product, to oppose the current Senate changes to provider taxes and state-directed payments.</strong></p><ul><li><strong>Share with your lawmakers the impact of these proposals on your hospital’s ability to care for patients.</strong></li><li><strong>Urge the Senate and House to reject the harmful Senate changes to provider tax rates and state-directed payments</strong>.</li></ul><h2>Medicaid Resources</h2><p><strong>Explain that Medicaid is vital to your communities.</strong> Use the following AHA resources in your advocacy efforts and find more tools and resources on the <a href="/advocacy/advocacy-issues/medicaid">Medicaid Issues page</a>.</p><ul><li><a href="/fact-sheets/2025-06-05-medicaid-spending-reductions-would-lead-losses-jobs-economic-activity-and-tax-revenue-states">Medicaid Spending Reductions Would Lead to Losses in Jobs, Economic Activity and Tax Revenue for States</a>.</li><li><a href="/fact-sheets/2025-06-05-medicaid-spending-reductions-would-lead-losses-jobs-economic-activity-and-tax-revenue-states">Medicaid Coverage Supports Rural Patients, Hospitals and Communities</a>.</li><li><a href="/fact-sheets/2025-06-13-rural-hospitals-risk-cuts-medicaid-would-further-threaten-access">Rural Hospitals at Risk: Cuts to Medicaid Would Further Threaten Access</a>.</li><li><a href="/fact-sheets/2025-04-14-whats-stake-medicaid-covers-people-you-know">What’s at Stake: Medicaid Covers the People You Know</a>.</li><li><a href="/infographics/2025-05-07-infographic-4-things-you-should-know-about-medicaid-provider-taxes-and-payments">4 Things You Should Know About the Medicaid Provider Taxes and Payments</a>.</li><li><a href="/fact-sheets/2025-04-14-protect-access-care-reject-cuts-medicaid-program-and-premium-hikes-working-families">Protect Access to Care: Reject Cuts to the Medicaid Program and Premium Hikes on Working Families</a>.</li><li><a href="/issue-brief/2025-05-01-state-infographics-whats-stake-medicaid-covers-people-you-know">State Infographics: What’s at Stake</a>.</li></ul><h2>Further Questions</h2><p>Visit the <a href="/advocacy/action-center">AHA Action Center</a> for more resources on these issues and other priorities important to hospitals and health systems. If you have further questions, please contact the AHA at 800-424-4301.</p></div><div class="col-md-4"><a href="/system/files/media/file/2025/06/time-to-act-is-now-contact-senate-and-house-lawmakers-today-alert-6-28-2025.pdf"><img src="/sites/default/files/2025-06/cover-time-to-act-is-now-contact-senate-and-house-lawmakers-today-alert-6-28-2025.png" data-entity-uuid data-entity-type="file" alt="Action Alert: TIME TO ACT IS NOW: Contact Senate and House Lawmakers Today" width="NaN" height="NaN"></a></div></div></div> Sat, 28 Jun 2025 10:32:01 -0500 Advocacy & Public Policy /advisory/2025-06-28-senate-releases-legislative-text-substitute-hr1-one-big-beautiful-bill-act <div class="container"><div class="row"><div class="col-md-8"><p>The Senate has released its <a href="https://www.budget.senate.gov/imo/media/doc/the_one_big_beautiful_bill_act.pdf">legislative text</a> for the substitute to H.R. 1, One Big Beautiful Bill Act (OBBBA), a sweeping package that would enact many of President Trump’s legislative priorities on taxes, border security, energy and deficit reduction. The bill, which Republicans are attempting to pass through the reconciliation — a budget tool that gives Congress a fast-track mechanism to avoid the Senate filibuster and pass legislation with a simple majority — includes significant policy changes to Medicaid and the Health Insurance Marketplaces.</p><p>While the AHA continues to review the bill's text, below are some key provisions of importance to hospitals and health systems, as well as a statement AHA shared with the media.</p><p>While many of the provisions are the same or similar to the Senate Finance Committee (SFC) language released <a href="https://www.finance.senate.gov/chairmans-news/chairman-crapo-releases-finance-committee-reconciliation-text">June 16</a> and delineated in the <a href="/advisory/2025-06-16-senate-finance-committee-releases-legislative-text-reconciliation-bill">AHA Legislative Advisory</a>, there are some additions, including a rural hospital fund and a physician-payment fix for 2026, and modifications, including new start dates for Medicaid provider taxes and state-directed payments. Note that several provisions in the full Senate bill differ from those in the <a href="/advisory/2025-05-22-aha-summary-one-big-beautiful-bill-acts-provisions-impacting-hospitals-and-health-systems">House bill passed</a> on May 22.</p><p>The <a href="/issue-landing-page/2025-02-07-budget-reconciliation-process-resource-page">reconciliation process</a> is not over with the Senate vote. Under the rules, the reconciliation bill is limited to 20 hours of debate followed by unlimited amendments prior to the final vote. Both chambers must pass an identical bill to complete the reconciliation process and send the bill to the president for signature or veto. The AHA today will send members details on next steps and resources to engage lawmakers.</p><h2>AHA Statement</h2><p>In a statement shared with the media this morning, AHA President and CEO Rick Pollack said, “On behalf of the patients and communities we serve, America’s hospitals oppose the Senate substitute to the One Big Beautiful Bill Act<strong>.</strong></p><p>“This legislation will put at risk the 72 million Americans who rely on Medicaid for their health care and jeopardize the hospitals that serve them. It will adversely impact critical care for children, pregnant women, the elderly, disabled and millions of working Americans. The sheer magnitude of these cuts, the largest ever proposed by Congress, will dramatically increase the number of uninsured and undermine the ability of hospitals across America to provide critical services to everyone.</p><p>“We are disappointed that the Senate bill goes in the wrong direction and is substantially worse than its House counterpart.</p><p>“By making severe limitations to provider taxes and state directed payments, two lifelines for hospitals, the bill will result in the curtailing of essential services and the closure of hospitals, particularly in rural areas.</p><p>“Without modifications during the consideration of the legislation, we urge the Senate to reject this bill. As written, it will negatively impact not only Medicaid beneficiaries but also the health care of all Americans.”</p><h2>Key Provisions of Interest to Hospitals and Health Systems</h2><p><strong>Medicaid provider taxes (Section 71117).</strong> The legislation would freeze provider taxes as of the <strong>date of enactment</strong>. For new taxes, the “hold harmless threshold” is set at 0%.</p><ul><li>For expansion states, beginning in fiscal year (FY) 2028 — <em><strong>one year later than the SFC proposal</strong></em> — and continuing through 2032, their threshold will be reduced by 0.5% annually until the threshold reaches 3.5% (excluding nursing homes and intermediate care facilities).</li><li>Non-expansion states will remain frozen at their provider tax rate <strong>as of enactment.</strong></li></ul><p><strong>Medicaid state-directed payments (71118). </strong>The legislation would cap state-directed payments (SDPs) at 100% of Medicare in expansion states and 110% of Medicare in non-expansion states. The legislation would temporarily grandfather those SDPs approved (or where there was a good faith effort to be approved) by May 1, 2025. The updated language includes the following changes:</p><ul><li>Removes language that would have allowed preprints to be submitted to the secretary prior to enactment.</li><li>For payments for <strong>rural hospitals</strong>, if a state has obtained approval or good faith effort <em>before enactment</em> of the legislation,<strong> </strong>the SDP may temporarily exceed Medicare payment limits.  Rural hospitals include those located in a rural area, treated as being in a rural area, or located in a rural census tract, as well as critical access hospitals, sole community hospitals, Medicare dependent hospitals, low volume hospitals and rural emergency hospitals. Payments for non-rural hospitals are subject to the May 1, 2025, deadline for approval (or good faith effort to be approved).</li><li>The total SDP amount for all hospitals in all states would be reduced by 10 percentage points annually until the specified Medicare payment rate limit is achieved, beginning with the rating period on or after Jan. 1, 2028 — <em><strong>one year later than the SFC proposal</strong></em>.</li></ul><p><strong>Rural health transformation program (71401) — New. </strong>The legislation would create a $25 billion rural stabilization fund, to be paid out as follows: $10 billion in FYs 2028 and 2029, $2 billion in FYs 2030 and 2031, and $1 billion in FY 2032. Of that total amount, half is distributed equally among all states, and half is distributed based on CMS’ discretion, with it targeted at states with more rural areas.  </p><p><strong>Temporary payment increase under the Medicare physician fee schedule to account for exceptional circumstances (71202) — New.</strong> The legislation would provide a set update to the Physician Fee Schedule of 2.5% for calendar year (CY) 2026 only. There is no adjustment for CY 2025.</p><h2>Other Additions in the Senate Bill</h2><ul><li>The bill makes certain adjustments to coverage of home and community-based services under Medicaid (Sec. 71123).</li><li>The bill provides an enhanced Federal Medical Assistance Percentage (FMAP) match for certain “high poverty states” determined annually (Sec. 71124).</li><li>The bill modifies the Inflation Reduction Act to exclude orphan drugs under the Drug Price Negotiation Program (Sec. 71203).</li><li>The bill includes a cost-of-living adjustment to the non-labor-related portion of hospital outpatient payments in Alaska and Hawaii (Sec. 71204).</li><li>The bill provides a safe harbor to allow telehealth services to be provided pre-deductible for patients with high-deductible health plans (Sec. 71306).</li><li>The bill allows bronze and catastrophic plans to contribute to health savings accounts (Sec. 7130).</li><li>The bill allows individuals in high-deductible health plans to enroll in direct primary care service arrangements and to use their health savings accounts for payment (Sec. 71308).</li></ul><h2>The Senate Bill No Longer Includes</h2><ul><li>A provision that would have reinstated direct cost-sharing reduction payments to insurers starting in 2026.</li><li>A provision that made changes to the public service loan forgiveness program that would limit eligibility for medical residents.</li><li>A provision that prohibited federal financial participation under Medicaid and CHIP for individuals without verified citizenship, nationality or satisfactory immigration status.</li></ul><h2>The Following Provisions in the Senate Bill Have No Material Changes from the Senate Finance Committee's July 16 Draft Legislation</h2><ul><li><strong>Medicaid community engagement requirements (Section 71121). </strong>The legislation would require certain nonpregnant, nondisabled adult Medicaid beneficiaries to meet certain community engagement requirements (“work requirements”) beginning Dec. 31, 2026. Individuals must work or engage in qualifying activities (e.g., community service, educational programs, job training) for no less than 80 hours/month. The legislation would exempt, among other groups, parents, guardians and caretaker relatives of children aged 14 or under, or a disabled individual. States would be permitted to receive temporary exemptions with Department of Health and Human Services (HHS) approval. The legislation would limit the types of entities that can contract with states to help implement this provision, effectively barring Medicaid managed care plans from assisting. The bill provides $200 million in FY 2026 grants for state implementation and $50 million for federal administration. In contrast, H.R. 1 exempted parents and caretakers of a disabled individual or dependent child (18 or under), did not explicitly prohibit contractors with financial interests, and provided $100 million for state implementation of the provisions.</li><li><strong>Eligibility redeterminations (Section 71107).  </strong>Consistent with H.R. 1, the legislation would require states to redetermine eligibility once every six months for beneficiaries enrolled through the Medicaid expansion eligibility pathway, beginning in calendar year 2027.</li><li><strong>Modifying retroactive eligibility under the Medicaid and CHIP programs (Section 71113). </strong>The legislation would limit the timeframe for retroactive Medicaid and CHIP eligibility to 30 days prior to the application date for expansion enrollees, and 60 days prior to the application date for traditional enrollees, as opposed to the current 90-day period.</li><li><strong>Medicaid cost-sharing requirements for certain expansion individuals (Section 71122). </strong>Consistent with H.R. 1, the legislation would require Medicaid expansion enrollees with incomes above 100% of the federal poverty level (FPL) to pay up to $35 in cost sharing per service. Cost sharing for non-emergency services provided in a hospital emergency department may exceed $35. The provision would exclude certain services, including primary care, pregnancy-related services, mental health or substance use disorder services. Total cost sharing may not exceed 5% of family income.</li><li><strong>Prohibition on implementation of certain regulations (Sections 71101, 71102, and 71112).</strong> Consistent with H.R. 1, the legislation prohibits the HHS secretary from implementing, administering or enforcing the eligibility and enrollment rules (including the final nursing home staffing rule, final Medicaid eligibility and enrollment rule, and final Medicare savings program eligibility and enrollment rule) for 10 years (ending Sept. 30, 2034).</li><li><strong>Public program eligibility for certain non-citizens (Sections 71109, 71201 and 71301). </strong>The legislation would restrict eligibility for Medicare, Medicaid and premium tax credits for marketplace coverage for non-citizens to the following groups: legal permanent residents, certain Cuban immigrants, and Compact of Free Association migrants lawfully residing in the United States. This expands on provisions included in H.R. 1.</li><li><strong>Expansion FMAP for emergency Medicaid (Section 71110).</strong> Beginning Oct. 1, 2026, the legislation would limit the Federal Medical Assistance Percentage (FMAP) for emergency Medicaid services provided to unlawfully present aliens who, except for their immigration status, would qualify for expansion to the state’s traditional FMAP. In contrast, H.R. 1 did not include provisions limiting the FMAP for emergency Medicaid.</li><li><strong>Disallowing premium tax credits during periods of Medicaid ineligibility due to alien status (Section 71302). </strong>Consistent with H.R. 1, the legislation would disallow undocumented immigrants who report income below 100% of the federal poverty level and are in their five-year Medicaid waiting period (due to immigration status) to receive premium tax credits to purchase health insurance on the marketplaces.</li><li><strong>Requiring verification of eligibility for the premium tax credit (Section 71303). </strong>Consistent with H.R. 1, the legislation would prohibit an individual from claiming the premium tax credit if the individual’s eligibility related to income, enrollment and other requirements is not actively verified annually. This would prohibit automatic reenrollment for enrollees receiving premium tax credits by requiring them to actively prove tax credit eligibility each year. Over half of all returning enrollees in 2025 enrolled through automatic reenrollment.</li><li><strong>Disallowing premium tax credit in case of certain coverage enrolled in during the special enrollment period (Section 71304).</strong> Consistent with H.R. 1, the legislation would prohibit individuals from receiving premium tax credits if they enroll in health coverage on the marketplace through a special enrollment period associated with their income.</li><li><strong>Eliminating limitation on recapture of advance payment of premium tax credit (Section 71305). </strong>Mostly consistent with H.R. 1, the legislation would remove the repayment limits and require affected individuals to reimburse the Internal Revenue Service for the full amount of excess tax credit received. The Senate language includes a special rule for those with incomes that unexpectedly fall below 100% of the federal poverty level so that they do not need to repay the full amount of their premium tax credits.</li><li><strong>Endowment tax for universities (Section 70415)</strong>: The legislation would amend the excise tax rate for universities based on student endowments. The rates are as follows: 1.4% for student endowments ranging from $500,000-$750,000 (current law), 4% for student endowments ranging from $750,000-$2 million, and 8% for all student endowments above $2 million. In contrast, H.R. 1 had a maximum excise tax rate of 21% for student endowments above $2 million.</li><li><strong>Executive compensation (Section 70416)</strong>: The legislation would limit tax-exempt organizations’ ability to deduct compensation over $1 million.</li><li><strong>Charitable contributions for non-itemizers (Section 70424)</strong>: The legislation would create a permanent deduction on charitable contributions for taxpayers who do not elect to itemize.</li><li><strong>Floor on charitable contributions (Section 70425)</strong>: The legislation would impose a 0.5% floor on charitable contributions for taxpayers who elect to itemize for taxable years after Dec. 31, 2025.</li><li><strong>1% floor on deduction of charitable contributions made by corporations (Section 70426)</strong>: The legislation would allow a deduction for corporate charitable contributions only to the extent that the aggregate of corporate charitable contributions exceeds 1% of a taxpayer’s taxable income and does not exceed 10% of the taxpayer’s taxable income.</li></ul><h2>Further Questions</h2><p>If you have further questions, please contact AHA at 800-424-4301.</p></div><div class="col-md-4"><a href="/system/files/media/file/2025/06/senate-releases-legislative-text-for-substitute-to-hr-1-the-one-big-beautiful-bill-act-advisory-6-28-2025.pdf" target="_blank" title="Click here to download the Legislative Advisory: Senate Releases Legislative Text for the Substitute to H.R.1, the One Big Beautiful Bill Act PDF."><img src="/sites/default/files/2025-06/cover-senate-releases-legislative-text-for-substitute-to-hr-1-the-one-big-beautiful-bill-act-advisory-6-28-2025-r.png" data-entity-uuid data-entity-type="file" alt="Legislative Advisory: Senate Releases Legislative Text for the Substitute to H.R.1, the One Big Beautiful Bill Act cover." width="640" height="834"></a></div></div></div> Sat, 28 Jun 2025 08:24:25 -0500 Advocacy & Public Policy /news/headline/2025-06-27-cms-announces-new-prior-authorization-program-pilot <p>The Centers for Medicare & Medicaid Services June 27 <a href="https://www.cms.gov/newsroom/press-releases/cms-launches-new-model-target-wasteful-inappropriate-services-original-medicare" title="rollout">announced</a> the rollout of a 6-year technology-enabled prior authorization program pilot. Through the Wasteful and Inappropriate Service Reduction Model pilot, CMS will partner with third-party entities to implement a technology-based prior authorization program for a specified list of services delivered to patients with traditional fee-for-service Medicare. Under the regionally based model, participating providers will have the choice of submitting prior authorization requests for selected items and services or subjecting their post-service claim to pre-payment medical review. </p> Fri, 27 Jun 2025 16:28:14 -0500 Advocacy & Public Policy