About Medical Student Insider

Medical Student Insider (MSI) is a monthly column written by the AMA Government Relations Advocacy Fellow (GRAF). One Fellow is selected each spring to work in Washington, D.C., as a full-time paid member of the AMA's Federal advocacy team for one year. The Fellow is responsible for working with the AMA's federal advocacy team to advance the Association's legislative agenda and policies on behalf of physicians, patients, and medical students.

Medical Student Insider - April 2008

• State Children's Health Insurance Program
• Economic hardship deferment
• Lapse of the Higher Education Act
• Medicaid rules and Graduate Medical Education
• Medicare physician payment

Hello all,

It was great to see nearly 300 of the students and residents of the AMA at this year’s Lobby Day on March 30-31. You successfully reached out to nearly 150 offices of Congressmen and Senators on Capitol Hill, and you advocated for issues including access to care, medical student debt, and health workforce shortages.

This week, many of you will be continuing the advocacy and keeping up the momentum by participating in Cover the Uninsured Week events in your own communities.  The MSS in particular is putting a great deal of energy into these efforts, sponsoring more than 50 registered events to increase awareness and outreach for the uninsured in America.

Since Lobby Day, a lot has been going on regarding some of the policy issues the MSS has worked on this year.  Please read on to find out more, and as always, thanks for reading and send me your feedback on how we can improve the Medical Student Insider for you.

Best,
-Kunal Mitra, your Government Relations Advocacy Fellow

Remember to sign up for the  MSS Health Policy and News listserv to stay up-to-date on important issues affecting medical students.

State Children’s Health Insurance Program
As you may remember, last year the State Children's Health Insurance Program (SCHIP) was extended until March 2009 at a sufficient funding level to maintain its current enrollees.  The program has not been reauthorized, however, and will require reauthorization before March 2009.

Another development that occurred last August was the issuance of enrollment guidelines by the Centers for Medicare and Medicaid Services (CMS), declaring that before expanding SCHIP eligibility to children in families with incomes greater than 250 percent of the poverty level, states must demonstrate that they have enrolled at least 95 percent of children in the state below 200 percent of the federal poverty level who are eligible for Medicaid or SCHIP.  Seventeen states have SCHIP income thresholds above 250 percent of the poverty level, and it has been projected by CMS that at least nine of 17 states will meet these criteria in order to enroll children above 250 percent poverty level.  The Government Accountability Office (GAO) has stated its legal opinion that the guidelines issued by CMS should actually be defined as “rules,” subjecting them to Congressional review before they can take effect.  The GAO’s legal opinion, which is only an opinion and thus has not changed CMS’ stance, states, “The August 17 letter from CMS to state health officials is a statement of general applicability and future effect designed to implement, interpret or prescribe law or policy with regard to [SCHIP]. . . .  Accordingly, it is a rule under the Congressional Review Act. Therefore, before it can take effect, it must be submitted to Congress and the Comptroller General.”

SCHIP continues to be an important program critical to ensuring access to needed health care services for America’s children, and a part of MSS state-level outreach projects to cover the uninsured.

***SCHIP: What You Can Do

• Learn more - Read the COLA SCHIP/Medicaid issue brief (PDF, 259KB).
• Be active - learn about projects that are part of the MSS activities (PDF, 29KB) for Cover the Uninsured Week.

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Economic hardship deferment
In previous e-mails and listserv discussions, you have heard about some of the latest developments with the economic hardship deferment issue and the Higher Education Act (HEA) Reauthorization.  The economic hardship deferment allows residents to postpone repayment of their federal loans for up to 3 years; residents are eligible for deferment typically through the 20/220 pathway, which was eliminated by law in 2007 but temporarily reinstated by the Department of Education.  Since January, the Department of Education (ED) has been participating in a series of negotiated rule-making meetings of its Student Loans Committee, which includes representatives of various stakeholders and is open to the public.  The AMA has been in attendance at these meetings as an observer and has been working closely with the Association of American Medical Colleges (AAMC) representative on the committee.

In the final ED Student Loans committee meeting this month, the ED reiterated its position that it does not intend to maintain the 20/220 pathway on economic hardship deferment past July 1, 2009, although it had expressed a willingness to do so in the past.  The Department cited cost as a reason, stating that the program would cost $1 billion over ten years.  The July 1, 2009, date has been determined to be the cut-off for any new deferments awarded through the 20/220 eligibility criterion, because a new income based repayment program (IBR) will go into effect for which all medical residents will qualify. The IBR will cap a medical resident's monthly loan repayment, based on his or her income, rather than deferring the payment, which for the average resident will result in a monthly $368 payment.

Now that these meetings have been concluded, a proposed rule will be published by the Department, which will allow stakeholder groups to submit comments.  The proposed rule will provide the AMA with another opportunity to advocate for reinstatement of the 20/220 pathway.  However, for a permanent reinstatement, AMA staff and MSS/RFS members have been working tirelessly to advocate for additional cosponsors for and passage of S. 2303 and H.R. 4344, bills that would reinstate the 20/220 pathway through legislative means.

***Economic Hardship Deferment: What You Can Do

• Stay updated: Visit the MSS 20/220 Web page to find all the letters and information on this topic from the very beginning.
• Learn more: Visit the COLA Web page and take a look at the issue briefs and modules regarding 20/220, your finances, and access to care.
• Take action: Use our Action Alert to contact your legislators through e-mail or letters, or call them directly through our hotline.

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Lapse of the Higher Education Act
The Higher Education Act (HEA), which governs federal loan programs and thus affects medical students and residents, has not been reauthorized since 1998 and instead has been maintained by Congress through a series of 11 short-term extensions.  However, as of April 30, 2007, the HEA has not been extended due to the House of Representatives’ inability to pass another extension.  The Senate passed an extension (S. 2929) on April 29 that would extend the HEA through May 31.

It is uncertain at this point what the lapse in the HEA will mean for federally backed student loans offered by private lenders, and it is also unclear when the House will pass its extension and what the consequences of the lapse in the meantime will have been.

The current reauthorization bills in Congress, S. 1642 and H.R. 4137, individually contain or share several provisions for which the AMA has advocated, including lender transparency, disclosure of loan consolidation terms, and a study on medical student indebtedness.

***Higher Education Act: What You Can Do

• Learn more: Visit the updated HEA Web page to learn more about the history of the Higher Education Act and the AMA’s past and current efforts.
• Learn more: Visit the COLA Web page and review the HEA issue brief and module.
• Review the issue: Check out the Lobby Day issue brief (PDF, 27KB) and full presentation (PDF, 188KB) on this topic.

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Medicaid rules and Graduate Medical Education
Last year, the Centers for Medicare and Medicaid Services (CMS) issued seven new Medicaid regulations that would: narrow Medicaid coverage of outpatient hospital, rehabilitation, case management, and school-based administrative and transportation services; and limit taxes that some states charge health providers as a way to increase their draw of Federal Medicaid funds.  In addition, the regulations would reduce Medicaid reimbursements for public and teaching hospitals, which has been estimated by the states affected to reduce GME payments by $9.8 billion over 5 years.  Those regulations were postponed through a Congressional moratorium last year, which prevented the regulations from taking effect until at least May 25, 2008.

On April 23, the House of Representatives approved H.R. 5613, the “Protecting the Medicaid Safety Net Act of 2008,” by a veto-proof majority of 349-62.  This bill would impose another one-year moratorium on the seven Medicaid regulations scheduled to take effect in the coming months, in addition to several other provisions.  The $1.65 billion cost of the bill would be offset by expanding a demonstration project on electronic verification of assets of Medicaid applicants, and by reallocating a portion of the Physician Assistance and Quality Initiative (PAQI) Fund.

The Senate is expected to consider the Medicaid regulations in the coming weeks.  Last year the AMA and several other organizations submitted a letter to CMS urging the rescission of these rules.  The AMA submitted a letter to Congress this past month supporting the policy objectives of H.R. 5613, but opposing the use of the PAQI for any purpose other than preventing Medicare cuts to physicians.

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Medicare physician payment
AMA advocacy efforts for six years have averted total pay cuts of 24 percent, but as you may know, Medicare payment rates for physicians are scheduled to be cut by 10.6 percent on July 1, 2008.  Senator Debbie Stabenow (D-MI) has submitted her bill, S. 2785, known as the “Save Medicare Act of 2008.”

The Save Medicare Act would stop the Medicare physician payment cuts for 18 months and will not increase the cost of permanently fixing the fatally flawed Medicare physician payment system.  The 18-month timeframe will inject some stability into the system for seniors and and for physicians forced to make difficult practice decisions because of planned payment cuts.  The timeframe will also give Congress time to begin working on a long-term solution to the broken payment system without having to take action to stop the cuts twice in one year.

A recent poll revealed that eight out of ten Americans are concerned that Medicare cuts will harm access to care for seniors and baby boomers, with nearly three-quarters of Americans wanting Congress to act on this issue.

***Medicare Payment - What You Can Do:

• Learn more: Visit the AMA Medicare Web page.
• Listen in: Download AMA President-Elect’s, Dr. Nancy Nielsen’s, podcast on Medicare Payment (Audio file)
  Play audio file
• Review the issue: Check out the Lobby Day issue brief (PDF, 46KB) and full presentation (PDF, 154KB) on this topic.
• Act now: Use the American Medical Association Grassroots Hotline at (800) 833-6354 or visit the AMA Advocacy Alert page to e-mail your Senators.

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MSI Archive

Read past issues of MSI (PDF, 41KB)

Medical Student Insider Special Legislative Edition (PDF, 83KB)
Learn more about pressing issues including SCHIP reauthorization, Medicare payment reform, and recent changes to the Higher Education Act.