Although characterized by supporters as an approach that "embodies fiscal responsibility," the 2020 federal budget proposal from the Trump administration is facing criticism that the $4.1 trillion plan cuts too deeply into health care and education. Many of the proposed changes run counter to current APTA public policy priorities by reducing access to care and sacrificing important investments in research and education.

The proposed budget, released by the White House last week, was touted by acting Office of Management and Budget Director Russ Vought as a plan that "takes aim at Washington's fraud, waste, and abuse," and will lead to a balanced budget in 15 years.

Others see things differently. The approach is accompanied by significant cuts to a range of issues important to APTA, including funding decreases for the National Institutes of Health, the Centers for Disease Control and Prevention, the Administration for Community Living, the National Health Services Corps, and the Maternal and Child Health Block Grant program. The budget also includes policy recommendations that alter Medicaid and Medicare.

The budget proposal is just that—a proposal. Congress must act on the plan in order for it to become law. APTA Executive Vice President of Public Affairs Katy Neas says that while the budget itself isn't likely to survive, there's a danger that some of the more damaging concepts could live on.

"It's unlikely that Congress will embrace the changes to Medicare, Medicaid, and funding for important work at the National Institutes of Health," Neas said. "However, the challenge for APTA, the physical therapy profession, and patients will be to keep up the pressure against some of the budget's more damaging ideas that may resurface from time to time in policy debates."

Among those more damaging ideas, according to APTA: the administration's proposal to move Medicaid away from its current funding system to a per-capita block grant program. The administration estimates the change could result in a $160 billion savings, but critics say the shift would reduce access to care, as would another provision in the plan that would mandate work or community volunteer requirements for "able-bodied, working-age individuals."

The plan also calls for cuts to Medicare, primarily through a combination of payment decreases, more stringent oversight of individual provider reimbursement patterns, and more extensive prior authorization requirements for physicians.

Among the provisions of particular interest to physical therapists (PTs) and their patients and clients:

• Durable medical equipment, prosthetics, and orthotics (DMEPOs). Under the Trump budget, the US Centers for Medicare and Medicaid Services (CMS) competitive bidding program would be extended to apply to ventilators and orthotics, which could interfere with patient access to these devices as well as the ability for patient-specific adjustments to be made by providers. Additionally, the proposal would expand CMS prior authorization authority to additional DMEPOs—another provision that APTA believes could delay or prevent patient access.


• Postacute care payment. The proposed budget steadily lowers annual Medicare payment updates for skilled nursing facilities, home health agencies, and inpatient rehabilitation facilities beginning in the 2020 fiscal year, leading up to the adoption of a unified postacute payment system for all settings in the 2025 fiscal year.


• Prior authorization authority. The budget extends CMS authority to require prior authorization for all Medicare fee-for-service items and services, specifically those that CMS claims are at high risk for fraud and abuse.


• Oversight of "excessive" physician orders for certain services—including therapy. The administration budget seeks to establish a prior authorization program for high-utilization practitioners of radiation therapy, therapy services, advanced imaging, and anatomic pathology services beginning in 2021. CMS would conduct annual reevaluations to identify the physicians who would be subject to prior authorization in the next calendar year.


• National Institutes of Health (NIH) funding. The proposal would lower NIH funding by $4.5 billion to $6 billion compared with 2018, including a $900 million reduction in funding for the National Cancer Institute.


• Education. In addition to reducing funding for college work-study programs and ending loan forgiveness for public-sector workers, the administration's plan would cancel a $1.4 billion surplus in the federal Pell grant program.

"APTA's advocacy focus is on increasing patient access to effective care, eliminating inefficiencies and reducing administrative burden on providers, and supporting research and innovation," Neas said. "The administration's 2020 budget in many ways stands in contrast to those priorities, and we will continue to help legislators and policymakers understand the important differences."