CMS Administrator Chiquita Brooks-LaSure Breaks Down President Biden’s Health Budget Goals

CMS Administrator Chiquita Brooks - LaSure

[Music]
Marianne O’Hare: Welcome to Conversations on Health Care . This week, we
welcome CMS Administrator Chiquita Brooks - LaSure , on the
President’s proposed expansion of support for mental health
and community health centers in his annual budget.

Chiquita Brooks - LaSure : We have a department - wide focus on mental health, really
looking across all the agencies to really see what we can do.

Marianne O’Hare: Lori Robertson joins us from FactCheck.org . And we end with a
bright idea, improving health and wellbein g in everyday lives.
Now , here are your hosts Mark Masselli and Margaret Flinter .

Mark Masselli: CMS, three letters that make up an important acronym . For
those in our audience who know what CMS stands for and does,
we have the person in charge as our gues t. It makes over 1
trillion in health care expenditures annually, and is the largest
health care payer in the entire country.

Margaret Flinter: And Chiquita Brooks - LaSure is the agency’s administrator.
During the Obama years she played a key role in guidin g the
Affordable Care Act through passage and implementation.
Brooks - LaSure has decades of experience in the Federal
government, on Capitol Hill . She’s also the first Black woman to
lead the agency. Welcome.

Chiquita Brooks - LaSure : Thank you. It’s a pleasu re to be here.

Mark Masselli: Welcome, again, to Conversations on Health Care. You know,
President Biden has just released his proposed budget for the
next fiscal year, and of course now Congress will weigh in. We
know there are some important dollar amoun ts devoted to
community health centers, mental health, HIV prevention, and
other initiatives. I wonder if you could take our listeners through
the budget and the thinking behind it.

Chiquita Brooks - LaSure : So, thank you so much for the question. We are so excited about
this President’s budget. As we all know, starting with mental
health, th at COVID - 19 pandemic has just put such a strain on the
mental health of Americans across the country . And all of us
with children certainly know how much our nation’s chi ldren
have really suffered during this time period , and certainly
children who are in underserved communities are really at a
crisis level. That’s just the tip of the iceberg. And so we have a
department - wide focus on mental health, really looking across
a ll the agencies to really see what we can do. And I would say
about CMS in particular, our focus has been, and it’s going to be,
on the programs we serve.

CMS Administrator Chiquita Brooks - LaSure

So , as you mentioned, I like to say th e three Ms Medicare,
Medicaid and CHIP, Marketplace Coverage . So, we are asking
Congress for additional authority in the Medicare program, and
you will see from us continued emphasis in Medicaid and CHIP
particularly around child health, pediatric care, and certainly in
marketplace , so in commercial insurance, making sure that there
is parity between mental health and physical health. So that’s
one piece that’s a huge priority of the entire department, and
certainly us at CMS.

Another priority is nursing home care . And as part of the State of
the Union, the President released , along with us , a charge to
really look at our care in our nursing homes, and we released
detail on in our budge, asks for additional dollars from Congress
to make sure that we are able to really survey nursing homes
and help them come into compl iance with the rules so that our
nation’s seniors and people who are the most vulnerable are
well taken care of.

Those are two priorities . But health equity is a key priority of this
administration , and we have all been working very hard to
advance health equity across our programs. I think a key part of
our ability to address this is for CMS programs, the financing
side, to really work with the other agencies, whether with CDC,
to partner with NIH, to partner with HRSA, to partner with
CMSA, all the other organizations here to really try to move the
needle on a whole host of issues like maternal health. So that’s
really what this budget is really reflecting, our work of trying to
work together to address some of the most pressing health care
issues facing our nation today.

Margaret Flinter: Well, thank you for sharing those with us. Those are such critical
issues to all of us who are engaged in health care , and in the
communities we are seeing exactly what you are describing. I
wonder if I can just get a qu estion right upfront that’s very much
on people’s minds right now. Health and Human Services
Secretary Becerra has extended the Covid Public Health
Emergency Declaration until April. We are all reading about the
rise of the new Omicron subvariant BA.2 . And I wonder, having
laid out your health worker vaccine mandate for the institutions
and organizations and practices that you certify, or are
responsible for, how long do you think you are going to have to
continue that health worker Covid vaccine mandate? W e know
the Republicans would like those orders to end right now, but
what are your thoughts as you look at what’s coming down the
road for us?

Chiquita Brooks - LaSure : Well, I would say requirements often help people react and

CMS Administrator Chiquita Brooks - LaSure

respond. And I would say what we have seen is that the
response to the requirements has really lifted up institutions
and workers following the requirements. We are seeing booster
rates and vaccination rates really growing, and so I think that
there was such a focus on what are going t o be the hammers
that we are going to use . But really what our approach has been,
has been to work with hospitals and all sorts of facilities to help
them co me into compliance. And I think it’s working very, very
well.

To your larger question about how lo ng are we going to be doing
this, I think that people, be scientists and all of my colleagues
over on the other side of the House, are working really hard to
try to make sure that we are responding to the science from our
perspective. We will be prepared f or the public health
emergency to end at some point. But, as you probably saw, we
put out guidance to the states around when the public health
emergency ends not anticipating that it will end in April or X day
or Y day, but really trying to make sure that everyone is
prepared. And we will do the same for providers and others who
are waiting for our guidance on some of the other emergencies
that expire when the public health emergency ends.

Mark Masselli: You know, Administrator, I want to stay on the topic of the
public health emergency. The CMS is asking states to explain
how they will handle eligibility enrolment when Medicaid
continuous coverage, that began during the pandemic, comes to
an end. And as you know, there are nearly 85 million people
enrolled in Medicaid , all who could suddenly have their eligibility
redetermined. I think it’s fair to say that this could result in
many Americans losing coverage. I wonder if you c an weigh in
here on your thoughts.

Chiquita Brooks - LaSure : Our entire agency is foc used on what we call the great
unwinding, and we are very focused. And when I say ‘the entire
agency’, we are very focused on making sure that we maintain
the gains in coverage. Whether people stay eligible for
Medicaid, or move to marketplace coverage, or Medicare, or
commercial insurance, we are working very hard to make sure
that we don’t lose the gains that we have seen under the public
health emergency. And that absolutely includes working with
states. So our team that focuses on Medicaid, is very clos ely
monitoring and talking to states about how they are preparing,
and really trying to make sure that we keep the gains that we
have experienced. That said, of course states have the ability to
make decisions. It’s a shared responsibility between us, and so
it’s something that we have a close eye on.

CMS Administrator Chiquita Brooks - LaSure

We are also working with state - based marketplaces, so the
other side of the House, to make sure that we keep coverage. A
key part of holding on to the gains is really the subsidies that are
in the American Re scue Plan . Because what we saw during this
open enrolment, were real gains for the people who are right
above that Medicaid level , a nd as we all know that a lot of our
coverage, it’s the leakiest between Medicare and marketplace .
And so I think that’s actu ally a big part of the story about how do
we hold on to these coverage gains, really having those
subsidies makes a huge difference.

Margaret Flinter: Well, Administrator , I wonder if I can get another kind of specific
question in that we are hearing a lot about particularly maybe
from the folks in our audience today in the community health
center space. Who are struggling with the nature of the Good
Faith Estimate that’s part of the No Surprises Act , they already
are managing sliding fee scale requirements , getting those
details to patients, and they are asking if CMS is going to provide
additional guidance to them about how to maybe manage and
simplify all these rules. Anything you would like to say about
that?

Chiquita Brooks - LaSure : So my favorite respon se during the Obama years was it’s coming
soon. So, that’s my answer, it’s coming soon. Now , we definitely
are hearing about the need for more clarification, and the team
is working very hard to get all of the additional guidance that’s
necessary.

Mark Mas selli: Great. You know, each new administration makes changes. And
we know CMS has been adjusting policies enacted by the Trump
administration. You are stopping states from charging monthly
premiums to newly eligible Medicaid enrollees . And I know
Georgia has a lawsuit against CMS saying this change is “an
arbitrary bait and switch of unprecedented magnitude ”. Would
you like to comment on the policy that you are trying to drive
with these important changes?

Chiquita Brooks - LaSure : Yeah. So, broadly I would say that we, the administration, is
firmly committed to making sure that we maintain the coverage
that people depend on. I mean Medicaid is life - changing, life -
saving. I had the privilege of being on a virtual call right when
Missouri had expanded coverage , and got to hear from a woman
who really was talking about her own experience of cancer, and
how this was changing her life, because now she was going to
have coverage. I didn’t go anywhere during my time in the
Obama years without being thanked by someon e saying how it
had affected their lives, changed their lives in many respects.

So, for Medicaid, we want to make sure, particularly during a

CMS Administrator Chiquita Brooks - LaSure

pandemic, that people had access to affordable coverage. And
so that’s what we are doing. We are really encouragi ng states to
expand. We are encouraging states to move in innovative ways.
We need to make sure that people can afford that coverage.

Margaret Flinter: Well, Administrator, through these last couple of very difficult
years, health equity has been very much on the minds of all of
us in health care. CMS Innovation Center , which looks to
enhance health care quality and innovation, as the name
suggests, has included advancing health equity as one of its key
objectives. Tell us about this focus and what is the C MS
Innovation Center looking to do with this focus.

Chiquita Brooks - LaSure : I am so excited about our agenda at CMS. And I would say that
the Innovation Center has a charge, and it’s been focused on
really trying to make sure we are thinking and testing mo dels
that will save costs and hopefully improve quality. The
Innovation Center has had 10 years of experience, and what we
are really trying to do is make sure that the person’s experience
is at the core of what the Innovation Center is doing and how
we’re thinking about it. And there is no more core thing to that
than making sure that we are improving health equity. And not
that it’s an afterthought, as I think it has been for many, many
years.

We are really trying to think about how do we bring in a
stro nger lens of making sure that the innovations are focused on
the underserved, and by underserved, you know, we have
adopted a health equity definition for all of our programs at
CMS, really making sure that every individual has a fair and just
opportunity regardless of the list of things that can keep you
from that, which can include race and sexual orientation, and
socioeconomic and geography. We are really trying to make sure
that our programs are actually working positively to advance
health equity, not that we hope it’s a byproduct.

And so, as part of that, we are including in our models a
requirement on equity, plans, how are you going to try to
address underserved populations in our latest announcement on
ACO REACH where we are actually going to pay a differential
based on the entity’s ability to move the needle on u nderserved
populations. And that includes not just focusing on the people,
but on the organizations like community health centers s erve
the underserved.

So that’s a big piece of making sur e that we achieve health
equity. It’s not just about making sure there are people of color,
etc. included in our data and what have you. It’s making sure
people with cultural competency, organizations that actually are

CMS Administrator Chiquita Brooks - LaSure

in the communities where people need to be served, are
actually included in whatever innovative things we are doing. So
that’s a big part of ACO Reach, as well as our broader strategy of
really making sure we are thinking about the organizations that
serve the people who’re concerned about ac hieving optimal
health outcome.

Mark Masselli: So good to hear that they are using the equity lens as they look
at everything that they are doing. So, we applaud their work. I
want to talk a little bit about the ACO REACH Program. The
Biden Administration has changed the direct contracting model
after pushback from progressive lawmakers, but the House
Progressive Caucus still wants to get rid of it, now known as ACO
REACH . What do you say about their criticism that this
Accountable Care Organization model j ust adds a n un needed
middleman?

Chiquita Brooks - LaSure : Well, pu lling back and really looking at what’s happening in the
Medicare program, is really important that we put all of our
initiatives in context, which we are really trying to do. When you
look at what’s happening in the Medicare Program overall,
Medicare advantage is growing, and it is able to provide some
services that we want to make sure that people who enroll in
traditional Medicare are able to receive. And one big piece of
t hat coordinating c are where we want to see entities having
incentive to make sure that we are looking at the whole person.

And so , as part of some of the changes that we made with ACO
REACH we really wanted to make sure that a provider
perspective was stronger in the ACO R EACH. So, having more
providers as part of the decision - making process was a big part
of some of the things that we wanted to do. But I would say that
we look at models lik e Accountable Care Organizations and we
have learned we have models in different par ts of the program
that when done well can really make a difference in terms of
people’s lives. And so we want to make sure that we are
preserving some of those important elements and really building
on those.

Margaret Flinter: Well, it’s hard to talk about health care without talking about
money of course in our country. But, one of the areas that has
never maybe quite made sense to everybody as anything more
than maybe historical accident, is the difference in the payment
schedules for Medicaid and Medicar e . A physician providing the
exact same service to somebody covered under Medicare or
Medicaid has possibly very significant different payments. The
work of nurse practitioners for the last couple of decades has
been reimbursed to 85% of the physician pay schedule for the

CMS Administrator Chiquita Brooks - LaSure

same service even as we emphasize team - based care and
multidisciplinary teams. What are your thoughts about
approaching some of these longstanding inequities if you will in
the payment system? Is that part of the charge to the
organization at this point ?

Chiquita Brooks - LaSure : Yes. I would say these sometimes -- you know, a lot of the team,
they would say -- they would often hear from me how much of
this is in the [inaudible 00:17:50], how much of this is how we
have done it, and really tr ying to tease out what do we have
authority for, and what can we do under our own authority. I do
think that we as an agency are really focused on making sure
that Medicaid is meaningful coverage. So, whether it’s Medicare
or any of the other Ms, we want i t not to be a card in your
pocket, but really make sure that it is means so you can see your
doctor.

And as part of that, we have a Medicaid Access Request for
Information where we are really looking at making sure that we
are talking and understanding wh at’s happening in the Medicaid
program in terms of people getting adequate access to care,
whether it’s making sure the benefits are there, or making sure
the providers. And certainly in the Medicare program we will
continue to look at what our levers are. We, recently in our
physician fee schedule, included an update that’s going to
integrate more information about a variety of ways that people
get paid. That’s the first update in 20 years of including some of
this additional information. So we are certain ly looking at what
our levers are, and thinking about ways that we can try to
address payment, balancing that with what our statutory
authority is, and being good stewards of the trust funds.

Mark Masselli: Well, I want to pull t he thread on what we can do on our own
authority, particularly on the issue of Graduate Medical
Education Payments, which fall under CMS. The recent National
Academies of Science report on primary care highlighted the
need for the use of interprofessional teams, and I am wondering
c an CMS make changes to those Graduate Medical Payments.
Right now we can only pay for the physicians and the dentists.
How about the rest of the team? Is this an idea that is within
your purview, or does it require legislative action?

Chiquita Brooks - LaSur e : So, the team isn’t sitting with me but they would kick me under
the chair if they were to say don’t you dare commit to anything
in public. So, I will have to say that I will look into it. I will say
that we have, when it comes to GME, a lot of statutory
requirements. We do pay hospitals and that’s usually our lever,
but happy to look at some of these ideas and see if there are

CMS Administrator Chiquita Brooks - LaSure

things that we can do.

Margaret Flinter: Well, perhaps then I am going to rephrase my next question , or
they will be coming and k icking you under the table if I ask you
about reimbursement for community health workers . But I am
really at least as interested in asking you about your thoughts on
this . The community health workers ’ probably a group that
maybe wasn’t so much on the rada r of CMS until we started
moving much more in the direction of moving the needle on
outcomes and value - based plans on the community
engagement. What’s your thought on where community health
workers fit into the kind of Medicare or Medicaid family at this
p oint?

Chiquita Brooks - LaSure : I would say there is sort of new understanding of how important
the community is to delivering health outcomes. I really got
more of a perspective on that right before I ended up being CMS
administrator , really trying to work on some of these issues like
maternal health, like equity, where you really do need the
village to help. And then of course I think we all got an education
when it came to COVID - 19 of just hearing about people need to
hear from trusted partners, and a lot of times those trusted
partners are people in their communities. Or they need the help
from the [inaudible 00:21:43] or the person that connects them
to the other supports , and just how health is one, and probably
one of the biggest determinants of how you are going to be able
to live your best life, and just how integrated all of that is.

So, we are certainly looking at ways that we can integrate
community health workers into our payment processes. So what
works through the Innovation Center of looking in through the
Innovation Center, we have been able to have more flexibility
and we will continue to look at our ability to do that in
Medicare. And certainly in Medicaid states have flexibility to do
those things. We recently approved a waiver in California that
went further in terms of allowing some of those supports, and
certainly we will look at other state initiatives as well.

Mark Masselli: Well, thank you Administrator Brooks - LaSure for these insights .
And thanks to our audience for joining us for this talk about
health care, how it’s paid for, and all the issues wrapped up in
these decisions. You can learn more about Conversations on
Health Care and sign up for our email address at
www.chcradio.com . Again, Admini strator, thank you for all the
work you have done over a lifetime, and we appreciate you taking time with us today.

Chiquita Brooks - LaSure : Have a great day.

CMS Administrator Chiquita Brooks - LaSure

Mark Masselli: Alright. You as well.

Margaret Flinter: Thank you so much.

[Music]

Mark Masselli: A t Conversations on Health Care , we want our audience to be
truly in the know when it comes to the facts about health care
reform and policy. Lori Robertson is an award - winning journalist
and Managing Editor of FactCheck.org, a nonpartisan, nonprofit
consum er advocate for voters that aim to reduce the level of
deception in U.S. Politics. Lori, what have you got for us this
week?

Lori Robertson : The Centers for Disease Control and Prevention recommends
that children get four doses of the polio vaccine, with t he last
dose given between ages four and six. But Representative
Marjorie Taylor Greene , when speaking against a potential
fourth dose of the COVID - 19 vaccines , wrongly suggested that
the CDC doesn’t recommend four shots of the polio vaccine.
Greene, a Rep ublican lawmaker from Georgia, said that Dr.
Anthony Fauci, Director of the National Institute of Allergy and
Infectious Diseases , was “recommending a fourth COVID vaccine
shot.” She then said that many of us were vaccinated against
polio as children, addi ng, “I have never seen the CDC coming out
saying oh, you have got to get your second polio shot, you have
got to get your third, you have got to get your fourth,” saying, “I
think the question we all should ask is when does it stop and
when are enough vacc ines enough.”

The CDC had not yet recommended a fourth COVID - 19 mRNA
vaccine shot to the general public when Greene spoke. It only
had done so for those who are moderately or severely
immunocompromised. On March 29, however, the FDA
authorized a second bo oster, or forth shot, of the Pfizer -
BioNTech and Moderna COVID - 19 vaccines for those age 50 and
older, and for those with immune deficiencies . The CDC’s advice
on the matter was expected to follow shortly.

But as for polio, the CDC does in fact say you sh ould get a
second, third and fourth shot as a child. The CDC says that the
inactivated polio vaccine, the only polio vaccine administered in
the US since the year 2000, is given by shot in the leg or arm.
The CDC recommends four doses, one dose at age two months,
with the subsequent doses at ages four months old, six through
18 months old, and four through six years old. Adult , who have
never been vaccinated against polio, and who are at higher risk
of getting the disease due to their work or travel, should get
three doses, the CDC says. As for Greene’s reference to Fauci, he

CMS Administrator Chiquita Brooks - LaSure

said on March 17 that the vulnerable may need that fourth dose
of the COVID - 19 mRNA vaccines at some point due to waning
vaccine immunity over time.

And t hat's my fact check for this w eek. I'm Lori Robertson ,
M anaging Editor of FactCheck.org.

Margaret Flinter: FactCheck .org is committed to factual accuracy from the
country’s major political players , and is a project of the
Annenberg Public Policy Center at the University of
Pennsylvania . If you have a fact that you woul d like check ed ,
email us at www.chcradio.com . We’ll have FactCheck .org’s Lori
Robertson check it out for you here on Conversations on Health
Care.

[Music]

Mark Masselli : Each week C onversations highlights a bright idea about how to
make wellness a part of our communities and everyday lives.
Asthma is one of the leading causes of trips to the emergency
room for children, and there is often a correlation between high -
density low - income neighborhoods and more trips to the
hospital for treatment and intervention. When officials at
Boston Children’s Hospital noticed a spike in asthma outbreaks
in certain neighborhood clusters, they decided to do something
about it. They launched the Commun ity Asthma Initiative. They
realized that if you could treat the environments in the patient’s
home that might reduce the need to treat the patient in the
emergency room.

Dr. Elizabeth Wood : The home - visiting efforts work with children and families that
ha ve been identified through their hospitalizations and
emergency room visits as an identification of having poorly -
controlled asthma, and also it’s a teachable moment.

Mark Masselli: Dr. Elizabeth Wood heads the program, and says the first step is
to identi fy the frequent flyers, those kids who make repeated
trips to the emergency room. Then they match with the
community health worker who visits their homes several times
and assesses the home for asthma triggers.

Dr. Elizabeth Wood : And they work on three ar eas: understanding asthma itself,
understanding the medication s and the need for control
medications, and then working on the environmental issues.

Mark Masselli: Families were given everything from HEPA filter vacuum
cleaner s to air purifiers, and the hom es are monitored for the
presence of pest or rodents. The result says Dr. Woods has been
pretty dramatic.

CMS Administrator Chiquita Brooks - LaSure

Dr. Elizabeth Wood : What’s remarkable is that there was a 56% reduction in patients
with any emergency department visits, and 80% reduction in
patient s with any hospitalization.

Mark Masselli: The program has been so successful it’s being deployed in other
hospital communities around the country. The Community
Asthma Initiative, a simple reshifting of resources, aimed at
removing the cause of disease ou tbreaks in the community,
leading to healthier patient populations, now that’s a bright
idea.

[Music]

Mark Masselli: You've been listening to Conversations on Health Care. I'm Mark
Masselli.

Margaret Flinter: And I'm Margaret Flinter.

Mark Masselli: Peace and health.

Marianne O’Hare: Conversations on Health Care is recorded at WESU at Wesleyan
University, streaming live at www.chcradio.com , iTunes, or
wherever you listen to podcasts. If you have comments, please
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