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Balderson Legislation Protects Continued Patient Care

Washington, May 12, 2020

WASHINGTON – Congressman Troy Balderson (R-OH) today introduced legislation that could ease the financial burdens caused by the coronavirus (COVID-19) pandemic on certain outpatient care facilities by making these types of facilities eligible to apply for the Paycheck Protection Program (PPP). The Protecting Outpatient Access Act would amend the “Waiver of Affiliation Rules” provision of the CARES Act to adjust PPP eligibility standards for certain small businesses, including facilities providing critical patient care such as mental health and substance abuse centers, dialysis centers, health maintenance organization (HMO) medical centers, freestanding ambulatory surgical and emergency centers, and other outpatient care centers.

“The Paycheck Protection Program is serving as a lifeline to thousands of Ohio businesses through this pandemic,” said Balderson. “Facilities that provide essential care like freestanding ambulatory surgery centers, dialysis clinics, and mental health and substance abuse treatment centers are hurting right now and should be able to access critical relief funds so patient care can continue seamlessly after the pandemic.”

“Ohio hospitals experienced significant financial hardship during this pandemic while providing emergency care and COVID-19 treatment for patients,” said the Ohio Hospital Association. “The Ohio Hospital Association thanks Congressman Balderson, leaders in Congress, and the Administration for their support of the Paycheck Protection Program. The PPP can be a lifeline for small businesses and other organizations that are suffering significant economic loss as a result of the COVID-19 public health emergency. We welcome efforts to include outpatient nonprofit hospitals services and centers with this important program to support health care in our communities.”

“Patients across Ohio and the country rely on ambulatory surgery centers to have their health care needs met,” said Bill Prentice, CEO of Ambulatory Surgery Center Association. “The Ambulatory Surgery Center Association supports Representative Balderson’s legislation, which would give facilities access to a financial lifeline and ensure that patients’ access to care is not unduly interrupted.”

“We are delighted that this bill recognizes the crisis currently being confronted by our mental health and substance use providers, while offering a very practical solution already available to others,” said Ron Manderscheid, PhD, Executive Director of the National Association for Rural Mental Health. “Congratulations to Representative Balderson!”

“May is Mental Health Month, and it has never been more important than this year,” said Tonya Fulwider, Associate Director of Mental Health America of Ohio. “MHAOhio is grateful for Representative Balderson’s support of the mental health needs of our community and state. We’re all experiencing this collective trauma to varying degrees, but it's understandable for people who live with depression, anxiety, OCD, and other mental health issues to have increased symptoms right now. It's also understandable for people who've never experienced mental health issues to have feelings of anxiety and depression that are new and uncomfortable. We can all work together to support our mental health in the face of uncertainty.

“I am humbled and heartened every day by the extraordinary measures our staff has implemented to keep patients and our colleagues safe…” said Shawn Holt, President and CEO of Maryhaven. “Maryhaven is fighting two major battles. In the midst of a global pandemic, we also still struggle with an opioid epidemic that continues claiming tragically high numbers of overdose deaths every day. Our doors remain open because we must be there for those with addictions or severe mental health challenges. And, we willingly accept and care for patients who are at the highest risk of contracting COVID-19 because that is our mission… I deeply appreciate Congressman Balderson’s advocacy efforts to make our community a safer place to live.”

The Protecting Outpatient Access Act is also endorsed by the National Association of Addiction Treatment Providers, American Association of Orthopedic Surgeons, National Association of County Behavioral Health and Developmental Disability Directors, and Mental Health America.


As written, the CARES Act—which created the Paycheck Protection Program—disadvantages outpatient health care centers, which frequently maintain an affiliation with a local nonprofit hospital. Under the PPP, small businesses are subject to current SBA affiliation rules, meaning the employees of all affiliated entities are counted in determining the number of workers employed by the business. If this number totals over 500, the applying small business is deemed ineligible for PPP.

Affiliations within the medical sector inherently differ from those in other business sectors; they arise from patient treatment continuity plans and community access to care relationships, unlike the primarily financial affiliations common in other business sectors. Many ambulatory surgery centers and other outpatient care facilities are unable to apply for PPP because of these patient-centered affiliations with nonprofit hospitals. These outpatient care centers are typically required to remain open and provide services during the pandemic, while operating with little staff and limited resources. This has been financially burdensome, particularly when combined with the inability to perform elective procedures (their primary revenue driver) under many states’ emergency orders.

Many outpatient care centers face the imminent possibility of closure without relief. Once exempted from the affiliation rule, these centers would be able to apply for and receive PPP loans and forgiveness.


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