AOTA Statement on Better Care Reconciliation Act of 2017 (BCRA)

The Arizona Occupational Therapy Association would like to share with its members an update from AOTA regarding federal legislation that has potential negative impact for occupational therapy services in Arizona. "AOTA believes that certain provisions of the BCRA would jeopardize sources of funding and guarantees of coverage for occupational therapy services that help people across the lifespan achieve health, functioning, and independence. The plan to restructure the Medicaid program goes much farther than repealing and replacing the health care reform law enacted in 2010. By changing Medicaid from an open-ended guarantee to a capped or block granted program, the BCRA has the potential to affect millions of children, adults with serious disabilities, people receiving home and community based services, seniors in nursing homes, and kids getting therapy services in schools.

Like the House-passed American Health Care Act (AHCA), the BCRA imposes a per capita cap which is designed to grow slower than the projected growth rate for Medicaid per-beneficiary costs. Under a per capita cap, federal funding would not increase for emergencies or other developments that increase average cost per enrollee, like a new disease outbreak or the opioid epidemic. As the difference between what states are entitled to under current law and what they get under a cap grows over time, states will consider cutting eligibility, covered benefits, and provider payments. Optional Medicaid services like occupational therapy for adults will likely be among the first to be cut and home and community based services may be diminished as states adjust to the caps. The BCRA’s caps grow significantly more slowly than those proposed in the AHCA.

Pediatric occupational therapy services are mandatory services under Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. EPSDT is designed to ensure that children get the services they need for maximum health, education, and independence by mandating a comprehensive set of benefits that includes therapy services. AOTA is concerned that a loss of hundreds of millions of dollars of federal funding will force states to curtail Medicaid’s child health benefit.  

A per capita cap would also jeopardize a source of funding that helps schools pay for occupational therapy and other Medicaid-covered services required under the Individuals with Disabilities Education Act (IDEA). Currently, Medicaid pays $4 billion a year for occupational therapy and other services for children with disabilities that support their right to a free appropriate public education.

Medicaid expansion has connected individuals with disabilities and chronic conditions, including mental health and substance use disorders, to occupational therapy and other health care services. It has also allowed individuals caring for people with serious disabilities to access health insurance to maintain their own health and wellbeing.

The Senate bill makes changes to individual and small group market rules that would undercut nationwide coverage standards by broadening an existing waiver authority and making it easier for states to obtain. “Rehabilitative and habilitative services and devices” is one of the 10 categories of essential health benefits (EHBs) that individual and small group plans have to cover, but that the BCRA would allow states to waive. Habilitative services help people keep, learn, or improve skills and functioning for daily living that they never had, while rehabilitative services help people keep, get back, or improve skills and functioning for daily living that have been lost or diminished because of injury, illness, or disability.

For occupational therapy practitioners and the people they serve, encouraging states to waive the EHB standards through 1332 waivers could be as consequential and disruptive as allowing states to opt out of pre-existing condition protections. The Congressional Budget Office projects that rehabilitative and habilitative services are among the categories of services most likely to be eliminated if states are given the chance to redefine the EHBs. Waiving the EHBs will weaken protections for people with pre-existing conditions because without minimum benefit standards there is no guarantee that health plans will cover the services that people with serious illnesses, disabilities, or chronic conditions need. Health plans may be designed to exclude enrollees with high-cost conditions by excluding the services they need, and health plans that choose to cover an expensive condition will soon attract a sicker risk pool, raise premiums, and become unaffordable.

The AHCA’s EHB waivers could also undermine the economic security of Americans with employer-sponsored insurance. The ban on annual and lifetime limits and the cap on yearly out-of-pocket costs in current law only apply to services that are defined as EHBs. A state that chooses to waive the rehabilitative and habilitative services EHB will be exposing people who get their coverage on the job to higher out-of-pocket costs and new limits on therapy services."