Comment on CMS-2026-2609-0001

I. Executive Summary I am writing to express my strong opposition to the proposed Medicare payment policies under Docket CMS-2026-2609-0001. While program updates aim to streamline administration, the proposed payment cuts, site-neutral rate expansions, and efficiency recalibrations pose a direct threat to healthcare delivery. These changes disproportionately harm patients and imperil the survival of rural hospitals and safety-net health systems operating under severe financial constraints. CMS must withdraw these reductions to safeguard patient access and healthcare infrastructure. II. Harm to Patients and Rural Healthcare Access 1. Destabilization of Rural Hospitals: Rural healthcare facilities rely heavily on Medicare reimbursement to sustain baseline operations. Facing low patient volumes, high fixed operating costs, and high uncompensated care, rural hospitals cannot absorb expanding site-neutral cuts or efficiency reductions. Applying non-facility fee rates to hospital outpatient settings fails to account for the costs of maintaining 24/7 emergency response, specialized equipment, and standby capacity. 2. Loss of Essential Patient Services: Reduced reimbursement forces rural providers to eliminate vital service lines, including outpatient surgery, maternal care, and specialized diagnostics. For rural residents, losing local access creates significant travel barriers, delays necessary treatments, and worsens health outcomes. 3. Accelerated Market Consolidation: Payment cuts drive independent rural practices and community hospitals into financial distress. This accelerates healthcare consolidation, forcing facilities to merge into large health systems or shut down, reducing competition and limiting patient choice. III. Administrative and Legal Limitations 1. Exceeding Statutory Authority (Loper Bright): Following Loper Bright Enterprises v. Raimondo, 144 S. Ct. 2244 (2024), courts no longer grant Chevron deference to agency interpretations of ambiguous statutes. Broad rate-setting provisions under Title XVIII of the Social Security Act do not grant CMS unlimited authority to restructure hospital reimbursement mechanics or impose widespread site-neutral cuts that disregard statutory provider classifications. 2. Major Questions Doctrine: Under West Virginia v. EPA, 597 U.S. 697 (2022), agency actions involving issues of "vast economic and political significance" require explicit Congressional authorization. Reallocating billions in outpatient reimbursement and risking rural healthcare system closures represents a major policy decision lacking explicit statutory authorization. 3. Arbitrary and Capricious Standard (5 U.S.C. § 706): Under the Administrative Procedure Act (APA), agency action is unlawful if it fails to consider critical aspects of a rule (Motor Vehicle Mfrs. Ass'n v. State Farm, 463 U.S. 29 (1983)). CMS failed to adequately evaluate: Unique overhead costs of rural facilities compared to urban physician offices. Inflationary pressures and workforce cost increases on safety-net providers. Direct spillover impacts where outpatient reimbursement cuts force total facility insolvencies. IV. Requested Action CMS should withdraw the proposed payment reductions under Docket CMS-2026-2609-0001. CMS must exempt rural hospitals and safety-net providers from site-neutral payment reductions and perform comprehensive baseline cost assessments before altering reimbursement frameworks.