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Healthcare Today

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Jacob Beaver

December 8, 2017

The tax bills that have passed the House and Senate are getting most of the attention in Washington these days. The expectation is that the leadership of the House and Senate will work for a close resolution of the differences in order to send a bill to the President before Christmas. We expect the final version of the bill to look a lot more like the Senate-passed version as many provisions were added to secure the necessary Republican votes for initial passage. Dropping or changing those provisions could spell problems for Leader McConnell as he seeks to round up 50 votes again.

There are a few significant provisions in the tax bills affecting healthcare. Repeal of the individual mandate of the Affordable Care Act is likely to remain in the bill given the over $300 billion in savings it generates. The Senate bill actually makes the deduction for medical expenses more generous than current law while the House bill repeals the deduction entirely. Preserving the deduction at least will be critical for getting the necessary votes in the Senate. Finally, the House bill eliminates the tax preference for private activity bonds which many hospitals use for construction projects. A number of House Republicans have urged their leadership to maintain the tax preference in the conference report.

The Centers for Medicare and Medicaid Services released numbers for enrollment in insurance plans on the federal exchange found at HealthCare.gov. The numbers were 20 percent higher for a similar period last year, but expectations are that overall enrollment is going to be down from last year with the Trump Administration cutting the enrollment period in half and significantly reduced the advertisement budget. The final date for enrollment this year is December 15, 2017.

  • Collins considers changing vote on tax bill over amendments – The Hill (Dec 7)
    “Sen. Susan Collins(R-Maine) said Thursday that she may change her vote on the final version of the GOP tax reform bill if her proposed amendments are not included in its final version. “I would. I’m going to look at what comes out of the conference committee meeting to reconcile the differences between the Senate and House Bill. So I won’t make a final decision until I see what that package is,” Collins told CBS WABI 5 when asked if she would consider changing her vote.”
  • Study: ObamaCare bills backed by Collins would lower premiums – The Hill (Dec 6)
    “Two bipartisan ObamaCare fixes being pushed by GOP Sen. Susan Collins (Maine) would reduce premiums by 18 percent in 2019, according to a new study. The study fromAvalere, a consulting firm, finds that the two bills would more than cancel out the projected premium increase from repealing ObamaCare’s mandate that most individuals purchase health insurance. Collins secured a commitment from Senate Majority Leader Mitch McConnell (R-Ky.) to support passage of the two bills before the end of the year in exchange for her vote for tax reform, which includes repeal of the ObamaCare mandate.
  • Health law sign-ups seen as falling short though more enroll – Associated Press (Dec 6)
    “Americans are signing up in growing numbers for the Affordable Care Act’s subsidized health insurance, the government said Wednesday. But with enrollment season cut in half and just over a week to go, experts say the final tally will likely fall short. About 3.6 million people signed up through Dec. 2 in states served by the federal HealthCare.gov website, according to the Centers for Medicare and Medicaid Services. That’s about 20 percent higher than the comparable period last year.”
  • Justice Dept. investigating use of fetal tissue – CNN (Dec 8)
    “The Justice Department is looking into Planned Parenthood’s practices related to human fetal tissue, according to a letter obtained by CNN. The letter— from the Justice Department’s head of its Office of Legislative Affairs — does not mention Planned Parenthood by name but asks the Senate Judiciary Committee to turn over unredacted documentation supporting a December 2016 report titled “Human Fetal Tissue Research,” which purports to describe the organization’s practices.”
  • Nothing Protects Black Women From Dying in Pregnancy and Childbirth – ProPublica (Dec 7)
    “In recent years, as high rates of maternal mortalityin the U.S. have alarmed researchers, one statistic has been especially concerning. According to the CDC, black mothers in the U.S. die at three to four times the rate of white mothers, one of the widest of all racial disparities in women’s health. Put another way, a black woman is 22 percent more likely to die from heart disease than a white woman, 71 percent more likely to perish from cervical cancer, but 300 percent more likely to die from pregnancy- or childbirth-related causes. In a national study of five medical complications that are common causes of maternal death and injury, black women were two to three times more likely to die than white women who had the same condition.”

December 1, 2017

As we write this, the Senate is trying to wrap up consideration of the tax bill that includes the repeal of the individual mandate in it.  The expectation is the Republican Leadership will make changes to the bill via a yet-to-be seen amendment from Senator McConnell that addresses the remaining concerns with the bill and pass the bill tonight.  Republican Leadership in both the House and Senate are planning to race to a compromise between the House and Senate passed tax bills to get a final vote in December.  There is a strong likelihood the individual mandate repeal will remain in the bill.

With the individual mandate repeal moving forward it is also much more likely that the Alexander-Murray bill to stabilize the individual insurance market will move forward as well.  There are no predictions yet on the exact timing of its consideration.

The Trump Administration took some additional steps in its efforts to address the opioid crisis in the country.  Attorney General Jeff Sessions announced $12 million in grant funding to fight the illegal manufacturing of methamphetamine, heroin and prescription opioids.  The Justice Department also announced opening a new Drug Enforcement Administration office in Kentucky to improve enforcement in the Appalachian mountain region.  President Trump also asked his Counselor Kellyanne Conway to lead and coordinate efforts from the White House in the Administration’s fight against the opioid epidemic.


  • Alex Azar, Trump’s HHS nominee, says addressing drug prices would be his top priority – Stat News (Nov 29)
    “Alex Azar, President Trump’s pick to lead the Health and Human Services Department, didn’t mince words when he described his top priority for the agency, telling lawmakers Wednesday that drug prices are too high and must be lowered. “The president has made this clear, so have I,” Azar said.”
  • Enrollment in ACA health-care plans is still running ahead of last year – Washington Post (Nov 22)
    “The number of Americans signing up for health-care plans under the Affordable Care Act continues to run ahead of last year in states relying on the federal insurance exchange, according to federal figures released Wednesday that span nearly half of an abbreviated enrollment season. Between the start of the current sign-up period on Nov. 1 and Saturday, nearly 2.28 million people chose health-care plans for the coming year — slightly more than during the first four weeks of the ACA enrollment period a year ago, reports from the Centers for Medicare and Medicaid Services show.”
  • Stabilization Bill Couldn’t Fix the Damage of Repealing Obamacare’s Mandate – Bloomberg (Nov 29)
    “The CBO has estimated that scrapping the mandate would result in 4 million people losing health coverage in 2019 and premiums in the individual market to increase by 10 percent. On Wednesday, the nonpartisan Congressional agency said a stabilization proposal backed by some Republican Senators would have no impact on its calculations.”
  • McConnell promises Collins tax bill won’t lead to Medicare cut – The Hill (Nov 30)
    “Senate Majority Leader Mitch McConnell (R-Ky.) is promising the GOP tax bill, which is projected to add $1.4 trillion to the deficit over the next decade, will not result in cuts to Medicare next year. McConnell offered the vow to Sen. Susan Collins (R-Maine), a key swing vote, during a Wednesday meeting in his office. He said that he would stop an automatic spending cut to Medicare next year that is required by the “pay-as-you-go” or “pay-go” budgetary rule.”

November 17, 2017

The big news in healthcare is the revivification of Obamacare repeal efforts in the form of the individual mandate’s repeal being included in Senate tax reform plan. That plan passed the Senate Finance Committee yesterday on a party line vote, though with the Thanksgiving district work period next week, it isn’t likely to see the Senate floor until November 27th at the earliest. Sen. Murkowski (R-AK), one of the three Republican senators to sink the earlier GOP repeal bill, has suggested her vote for the tax legislation is contingent on passage of the Murray-Alexander bill that would appropriate funds for cost-sharing reduction payments beforehand. It’s reasonable to assume that this applies to other moderate Senate Republicans, such as Sen. Collins (R-ME). The Murray-Alexander bill has 12 Republican cosponsors, which means if it came to vote on the Senate floor it would pass under the 60-vote threshold required in the chamber.

In nomination news, the President has sent up his replacement pick for former HHS Sec. Tom Price, choosing former Eli Lilly and Co. senior executive Alex Azar. Azar worked in the George W. Bush administration for six years, both as HHS general counsel and deputy secretary of the department. He has begun meetings with senators who will vote on his nomination in committee, meeting with HELP Committee Chairman Lamar Alexander (R-TN) Thursday. His confirmation hearing before HELP is set for November 29th, though Senate Finance is ultimately the committee of jurisdiction over the vote to send his nomination to the Senate floor. Senate Finance has not yet set a date for their nomination hearing.

On the regulatory side, CMS proposed a rule yesterday that included a request for comments on how to cut the costs of Medicare Part D drugs. They acknowledged in the rule that the true price of the drug is hidden from those purchasing them, and specifically asked how the rebates and discounts negotiated by manufacturers and providers could be better shared so consumers could reap some of the benefit. The other parts of the rule that will likely go into effect sooner than anything gleaned from the public comment period would: reduce costs of biosimilar drugs for low-income and high-needs patients; require plans for patients receiving low-income subsidies and those who exceed the threshold for catastrophic coverage to have lower Part D maximum co-payments for biosimilars; allow Part D plans to immediately substitute generics for brand-name drugs at the same cost or lower should they come to market during the plan year; and allow patients to access drugs at their preferred pharmacy, excepting those at risk of opioid abuse who would be required to obtain opioids from select providers.

  • Defying gloomy predictions, Obamacare enrollment surges – Politico (Nov 15)
    “Doomsday headlines about Obamacare enrollment may be having an unforeseen consequence: booming sign-ups in the troubled insurance marketplaces. Obamacare’s fifth open enrollment season, the first under President Donald Trump, is off to a surprisingly robust start despite the brutal developments of the past year — skyrocketing premiums, dwindling competition, unremitting Republican efforts to eradicate it.”
  • Bipartisan bill would halt cuts to hospitals’ drug subsidies – Axios (Nov 15)
    “Two House members, Republican David McKinley of West Virginia and Democrat Mike Thompson of California, have proposed a billthat would stop pending drug payment cuts to hospitals. Three major hospital lobbying groups and three health systems also sued the feds this week to prevent the cuts to those drug subsidies, which are part of the federal 340B drug discount program.”
  • How Cotton brought Obamacare repeal back from the dead – Politico (Nov 15)
    “Sen. Tom Cotton was about to enter the White House early this month to discuss immigration policy when he got an unexpected call from President Donald Trump to talk about a different topic. For days, the Arkansas senator had been working behind the scenes to convince Republicans that reigniting a battle over repealing Obamacare in the tax fight wasn’t as crazy as it seemed. But Trump, still smarting from GOP’s failures to dismantle the law whom Cotton had first pitched on the idea four days prior, needed little persuading.”
  • Why repealing Obamacare’s individual mandate is so crucial for tax reform – Washington Post (Nov 14)
    “Senate Republicans slipped the repeal of a key Affordable Care Act provision into their tax bill Tuesday, adding a provision that would allow them to declare a victory on health care while gaining more than $300 billion to offset the cost of tax reform. The individual mandate is one of the most unpopularparts of the ACA — a requirement that people either buy health insurance or pay a penalty. About5 million taxpayers paid a fine in 2016, according to a January letter sent by IRS Commissioner John Koskinen.”
  • CBO: Tax Plan Could Cut Medicare By $25 Billion – Roll Call (Nov 14)
    “Medicare, the largest nonexempt mandatory program, would be cut $25 billion since cuts to the seniors’ health insurance program are limited to 4 percent in any fiscal year under the law. That would leave $111 billion in other nonexempt cuts, affecting programs such as agricultural subsidies, state workforce development grants for individuals with disabilities, and even some mandatory funding streams for the immigration enforcement and border protection agencies.”

November 10, 2017

This was a big week for tax reform with the Ways and Means Committee marking up their bill and the Senate Finance Committee releasing their own, different version of comprehensive tax reform. As a result, there was not as much activity with healthcare in Washington this week. Although there was speculation that a repeal of the Affordable Care Act’s (ACA) individual mandate might make it in to the tax reform bill as way to bring in more revenue into the bill, ultimately, Chairman Brady decided against adding the individual repeal to his bill.

The Trump Administration did issue new regulations that will allow employers to not cover birth control in their health insurance plans. Previously, the ACA included birth control as part of the essential health benefits with an exception for religious organizations, who the Obama Administration had exempted. Critics wanted the waiver for religious organizations to go further and late last week, the Departments of Health and Human Services, Treasury, and Labor issued interim final rules that will allow businesses that have moral objections to offering birth control coverage to avoid doing so. Because these are interim final rules, they policy change will take effect immediately.

Outside of Washington, the voters in Maine approved a ballot initiative to expand Medicaid under the ACA. The ballot measure passed with nearly 60% of the vote. The governor and legislature will now grapple with funding Maine’s share of the expansion. Republican Governor LePage has strenuously objected to expanding Medicaid and has vetoed 5 different attempts from the legislature to expand Medicaid.

  • Despite Trump’s scorn, early ‘Obamacare’ sign-ups top 600k- WaPo (Nov 9)
    “Despite President Donald Trump’s efforts to take down “Obamacare,” more than 600,000 people signed up for coverage the first week of open enrollment, the government said Thursday. With only four days of data, experts said it’s hard to discern a trend. But definitely the Affordable Care Act doesn’t seem to be collapsing. If anything, sign-ups for 2018 are on track with previous years. Figures from the Centers for Medicare and Medicaid Services showed that 601,462 people signed up Nov. 1-4 in the 39 states served by the federal HealthCare.gov website. Of those consumers, about 77 percent were renewing their coverage, and about 23 percent were new customers, a split that mirrors previous years. Because sign-ups for states running their own health insurance markets are not included in the early data, overall national enrollment is guaranteed to be higher.”
  • States will be allowed to impose Medicaid work requirements, top federal official says- WaPo (Nov 7)
    The government will give states broader leeway in running their Medicaid programs and allow them to impose work requirements on enrollees, a top federal health official said Tuesday in outlining how the Trump administration plans to put its mark on the insurance program for low-income Americans. Seema Verma, who heads the Health and Human Services Department’s Centers for Medicare and Medicaid Services, did not spare criticisms of the Obama administration and called its opposition to work requirements “soft bigotry.”
  • Maine Voters Approve Medicaid Expansion, a Rebuke of Gov. LePage- NYT (Nov 7)
    “Voters in Maine approved a ballot measure on Tuesday to allow many more low-income residents to qualify for Medicaid coverage under the Affordable Care Act, The Associated Press said. The vote was a rebuke of Gov. Paul LePage, a Republican who has repeatedly vetoed legislation to expand Medicaid. At least 80,000 additional Maine residents will become eligible for Medicaid as a result of the referendum. Maine will be the 32nd state to expand the program under the health law, but the first where voters, not governors or legislators, decided the issue. Other states whose leaders have resisted expanding the program were closely watching the campaign, particularly Utah and Idaho, where newly formed committees are working to get Medicaid expansion on next year’s ballots.”


November 3, 2017

Release of the comprehensive tax reform proposal from the House Ways and Means Committee took most of the oxygen out of the room this week. However, there still were some developments in the healthcare world. The House Ways and Means and Senate Finance Committees introduced their Affordable Care Act (ACA) stabilization bills this week. Action on these bills is not likely until tax reform is behind us, which will almost certainly push this issue into 2018.

The House passed a 5-year extension of the Children’s Health Insurance Program (CHIP) this week. The bill passed largely on a party line vote with only 15 Democratic members voting in favor. The bill also includes some additional Medicaid funding for Puerto Rico and the Virgin Islands for two years. Also included is $5 billion for the Disproportionate Share Hospital (DSH) program. The bill extends a number of other expiring health programs, including Health Centers and the National Health Service Corps, but it does not carry any of the Medicare extenders. The bill uses increases in Medicare premiums for high income earners and taps the ACA’s Prevention and Public Health Fund as pay-fors, both of which are objectionable to Democratic members of Congress. We expect the Senate to pass a bipartisan CHIP extension in the coming weeks, as opposed to taking up this House bill.

The Centers for Medicare and Medicaid Services (CMS) issued a final rule for the hospital outpatient prospective payment system that made dramatic changes to the reimbursement under the 340B program. The rule cuts payments for separately payable non pass-through drugs to average sales price (ASP) minus 22.5% from ASP plus 6%. Hospitals are reacting strongly to this rule and may need to fight this in the courts.

The President’s Commission on Combatting Drug Addiction and the Opioid Crisis issued their final report this week. The report contains over 50 specific recommendations for combatting this opioid epidemic. Of note, the report calls on the expanded use of drug courts to channel substance abusers into treatment. The report attempts to tackle prevention, prescribing practices, supply reduction and better enforcement practices, improvements in treatment, and further research and development.

  • House passes bill to fund children’s insurance program – The Hill (Nov 3)
    “Legislation to fund the Children’s Health Insurance Program for five years passed the House on Friday over the objections of Democrats, who oppose how the legislation is paid for. The bill passed 242-174. It now heads to the Senate, where it is unlikely to get a floor vote, leaving lawmakers at an impasse.”
  • Hospitals sue CMS over 340B drug changes – Axios (Nov 1)
    “Three hospital lobbying groups — the American Hospital Association, America’s Essential Hospitals and the Association of American Medical Colleges — are suingthe Centers for Medicare & Medicaid Services after the agency finalized a rule Wednesday that would drastically cut outpatient drug payments under the federal 340B drug discount program.”
  • The bicoastal bid to shore up Obamacare – Politico (Nov 1)
    “Two big blue states on opposite sides of the country have a mission: Save Obamacare. California and New York, which run their own health insurance exchanges and will spend tens of millions this year on marketing and outreach, don’t expect to have a stellar year in the sign-up season that starts Wednesday.”
  • Trump throws curveball in tax talks, says bill should include Obamacare changes – Washington Post (Nov 1)
    “President Trump on Wednesday said congressional Republicans should make a major change to their upcoming tax cut bill by including changes to the Affordable Care Act, an idea that has divided the GOP for months. The idea had already been rejected one day earlier by House Ways and Means Committee Chairman Kevin Brady (R-Tex.), who had said it risked bogging down the process. But Trump, in two Twitter posts Wednesday, pushed the idea, which has gained currency with some Senate Republicans.”
  • Conservatives push to repeal Obamacare mandate in tax package – Politico (Nov 3)
    “Conservatives are attempting to revive efforts to gut Obamacare’s individual mandate as part of the Republican overhaul of the tax code. Despite a public push last week by Sens. Tom Cotton (R-Ark.) and Ron Johnson (R-Wisc.) to include repeal of the mandate in the tax package, tax bill writers didn’t include that in the measure released Thursday. But POLITICO Playbook reports there may be new momentum for adding the repeal into the bill.”
  • House votes to repeal ObamaCare’s Medicare cost-cutting board – The Hill (Nov 2)
    “The House on Thursday voted to repeal a controversial Medicare cost-cutting board that has drawn the ire of both parties. Lawmakers voted 307-111 to abolish what is known as the Independent Payment Advisory Board (IPAB). The board is tasked with coming up with Medicare cuts if spending rises above a certain threshold but has been criticized as outsourcing the work of Congress.”

October 27, 2017

There were a number of moving parts with healthcare this week in Washington.

The President gave a major speech on the opioid crisis this week. In the speech, the President announced that he is directing the Department of Health and Human Services (HHS) to declare a public health emergency that will allow HHS to direct grant money to the states for treating patients in their states. It will also allow HHS to waive the restriction in the Medicaid program for treating addiction in facilities with more than 16 beds. The emergency is a 90-day designation that can be renewed for as long as the crisis persists. This designation is short of a national emergency designation that could have freed up funds from the FEMA to combat the epidemic.

The Congressional Budget Office (CBO) released a score this week of the Alexander-Murray bill to stabilize the Affordable Care Act (ACA). CBO score indicates that enactment of the bill will reduce the deficit by $3.8 billion over ten years. The estimate also indicates that the bill will not change health insurance coverage relative to the projections in their policy baseline. Supporters of the bill have been pointing to this score as reason for the Senate to take quick action on the bill.

Ways and Means and Senate Finance Republicans announced an agreement on a bill to “repair” the ACA. The legislation would fund the Cost-Sharing Reduction (CSR) program for two years. The bill also suspends the individual and employer mandates for four years and two years respectively. It also includes an expansion of Health Saving Accounts (HSAs) by increasing the contribution limit.

The House is poised to vote on a 5-year extension of the Children’s Health Insurance Program (CHIP). We are hearing there is bicameral and bipartisan agreement on the policy but there is not yet consensus on how to pay for the bill. It is possible the House could vote on a bill with the pay-fors the Democratic Members object to, but that bill would not be able to get through the Senate. We are hoping the bipartisan agreement can be found sooner rather than later.

  • Trump Declares Opioid Crisis a ‘Health Emergency’ but Requests No Funds- NYT(Oct 26)
    “President Trump on Thursday directed the Department of Health and Human Services to declare the opioid crisis a public health emergency, taking long-anticipated action to address a rapidly escalating epidemic of drug use. But even as he vowed to alleviate the scourge of drug addiction and abuse that has swept the country – a priority that resonated strongly with the working-class voters who supported his presidential campaign – Mr. Trump fell short of fulfilling his promise in August to declare “a national emergency” on opioids, which would have prompted the rapid allocation of federal funding to address the issue.”
  • Study: Premiums for popular ACA plan up by 34 percent- Washington Post (Oct 26)
    “Premiums for the most popular “Obamacare” plans are going up an average of 34 percent, according to a study that confirms dire predictions about the impact of political turmoil on consumers. Window-shopping on HealthCare.gov went live Wednesday, so across the country consumers going online can see the consequences themselves ahead of the Nov. 1 start of sign-up season for 2018. The consulting firm Avalere Health crunched newly released government data and found that the Trump administration’s actions are contributing to the price hikes by adding instability to the underlying problems of the health law’s marketplaces.”
  • Democrats pitch Medicaid ‘public option’ for states- Washington Post (Oct 25)
    “Progressive Democrats, more confident that the legislative threat to the Affordable Care Act has passed, are adding a new bill to their stack of health-care legislation – one that would allow people to buy into a Medicaid “public option” in their states. The State Public Option Act, sponsored by Sen. Brian Schatz (D-Hawaii) in the Senate and Rep. Ben Ray Luján (D-N.M.) in the House, would expand Medicaid from a program available only to Americans at or slightly above the poverty level, to a universal program anyone could buy into. Already, 18 Democrats in the Senate have co-sponsored the bill, including Sen. Bernie Sanders (I-Vt.) and most of the party’s potential 2020 presidential candidates.”

October 20, 2017

This week we saw Senators Alexander (R-TN) and Murray (D-WA) release the legislative text of a bill to stabilize the individual insurance market and offer states more flexibility. The key provisions are as follows:

  • Grants governors more flexibility in applying for State Innovation Waivers under Section 1332 of the Affordable Care Act (ACA).
  • Cuts the approval process of State Innovation Waivers in half and allows for approvals in urgent situations.
  • Allows State Innovation Waivers to remain in effect for six years to give more stability to the markets.
  • Authorizes the cost-sharing reduction (CSR) payments.
  • Allows more individuals to qualify for catastrophic coverage – the so-called Copper Plans under the ACA.
  • Directs the Secretary to do more outreach and education about enrollment in the ACA plans.
  • Directs the Secretary of Health and Human Services in consultation with the state insurance commissioners to issue a regulation to allow for the sale of insurance products across state lines. While these plans will still must comply with the ACA, it could allow for the formation of the association health plans.

A bipartisan group of 24 senators (12 Republicans and 12 Democrats) came out in support of the measure at its introduction. The bill was hailed by a coalition of health care providers (physician and hospital trade associations), health insurers, and the US Chamber of Commerce.

It has drawn mixed reviews from the President – he has both panned it as an insurance company bailout and praised the deal. It has also met stiff opposition from key groups in the House such as the Republican Study Committee. We believe if the bill were put on the House and Senate floors it would likely pass both chambers, but it is not clear whether or when there will be such an opportunity.

  • GOP to Trump: Stop flip-flopping on Obamacare deal – Politico (Oct 19)
    “Key Senate Republicans are urgently trying to get President Donald Trump to reconsider his apparent opposition to a bipartisan deal shoring up health insurance markets, several senators said Thursday morning. Sens. Lindsey Graham of South Carolina and Lamar Alexander of Tennessee, who negotiated the deal with Democratic Sen. Patty Murray of Washington, both spoke to the president about it on Wednesday evening. Trump has variously praised the deal and trashed it as a “bailout” of insurance companies, and both Graham and Alexander are trying to pull him back from the brink.”
  • Here’s the Alexander-Murray bill – Axios (Oct 17)
    “Here’s the draft text of the deal struck by Sens. Lamar Alexander and Patty Murray, obtained from a senior GOP aide. The plan can now be seriously evaluated, especially regarding changes made to Affordable Care Act state innovation waivers.”
  • Trump leaning toward former pharma exec for health secretary – Politico (Oct 17)
    “President Donald Trump is leaning toward nominating Alex Azar, a former pharmaceutical industry executive and George W. Bush administration official, to serve as Health and Human Services secretary, according to two White House officials. If chosen, Azar would replace Georgia Republican Tom Price, who resigned in September after POLITICO reported that he spent more than $1 million in taxpayer money on private and government planes for travel.”
  • Why doctor and hospital groups are fighting a measure to rein in drug costs – Stat (Oct 19)
    “In recent years, doctors nationwide have lamented ever-rising drug prices that are limiting patient access to crucial medicines and undermining hospital finances. But a ballot initiative in Ohio is flipping that script. Several prominent physician and hospital groups are joining pharmaceutical companies to oppose a proposal to rein in drug costs paid by state agencies. Their reasoning? Drug makers, wholesalers, and pharmacies will actually raise prices on most Ohioans if the state takes a mandatory discount.”
  • Trump would have to broker Obamacare truce – Politico (Oct 17)
    “A bipartisan deal in Congress offers a glimmer of stability for the Obamacare insurance markets. But for it to become law, each party will need to declare a victory — and President Donald Trump will have to agree to prop up a law he just spent months trying to repeal. For Democrats, the deal negotiated by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) would restore key subsidies that Trump cut off just days ago. For Republicans, it would offer states flexibility to approve health insurance plans that would have the lower premiums they’ve promised voters.”

October 13, 2017

It was another big week for healthcare in Washington this week. President Trump signed his much-anticipated executive order in his attempt to make health coverage more accessible and affordable. Our summary of the executive order can be found here. It is yet to be seen how far the federal agencies will go in proposing policies to implement the broad direction they were given, as well as how those policies will impact the individual and small group markets, coverage and prices. There is legitimate concern that these actions could increase instability in the markets.

Speaking of instability, the President also announced on Twitter that he is ending the cost sharing reduction (CSR) payments. The speculation is that the President will halt the payments due in November.

It is entirely possible that the executive order and the decision on CSR could jump start bipartisan efforts to stabilize the insurance markets. The President tweeted an invitation to Democrats to call him, but in all likelihood the bipartisan consensus is likely to be formed on Capitol Hill with negotiations between Senators Alexander and Murray and the Problem Solvers caucus in the House.

  • Trump to Stop Paying Obamacare Cost-Sharing Subsidies – Roll Call (Oct 13)
    “The administration will stop reimbursing health insurers for the 2010 health care law’s controversial cost-sharing reduction payments, the White House said Thursday night.“Based on guidance from the Department of Justice, the Department of Health and Human Services has concluded that there is no appropriation for cost-sharing reduction payments to insurance companies under Obamacare,” the White House Office of the Press Secretary said in a statement. “In light of this analysis, the Government cannot lawfully make the cost-sharing reduction payments.””
  • ‘Call me,’ Trump Tells Democrats After Nixing Obamacare Subsidies – Roll Call (Oct 13)
    “That was the message early Friday morning from President Donald Trump to Democrats after he drew their ire late Thursday night for canceling health care subsidiesthey immediately said would drive up insurance premiums. Trump took to Twitter even earlier than usual, 5:36 a.m., to boast about his decision, which Democrats and some health experts say could hurt low-income individuals and families the most.”
  • Trump opposes bipartisan Obamacare rescue plan – Politico (Oct 13)
    “President Donald Trump will oppose any congressional attempts to reinstate funding for Obamacare subsidies — unless he gets something in return, his budget director Mick Mulvaney said in an interview Friday morning. The comments by the Office of Management and Budget chief delivered a severe blow to efforts by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) to strike a bipartisan deal on funding the subsidies. Trump canceled those payments to insurance companies on Thursday night, raising hopes among some Democrats and centrist Republicans that the Trump administration could accept a bill that would revive the subsides while offering states more flexibility to opt out of Obamacare.”
  • Trump’s not going to be able to avoid blame for kneecapping Obamacare – Washington Post (Oct 13)
    “Since the beginning of his administration, Trump has argued that Americans wouldn’t hold him responsible for any collapse of Obamacare. It was always an iffy proposition, given the control Republicans have had over policy development in the United States since Jan. 20. But it’s nothing short of baffling for Trump to apparently still believe this to be the case.”
  • Trump issues order expanding access to loosely regulated health plans – Politico (Oct 12)
    “President Donald Trump today signed an executive order aimed at allowing trade associations and other groups to offer their own health plans — a move seen as expanding cheaper insurance options while also threatening to destabilize the Obamacare markets. The order directs federal agencies to rewrite rules to allow the sale of so-called association health plans — which would be exempt from some of Obamacare’s strict regulations — across state lines.”
  • Trump’s salvo on Obamacare unlikely to result in quick changes – Politico (Oct 12)
    “President Donald Trump may be eager to dismantle the Affordable Care Act after months of failed GOP repeal efforts, but his promise to provide millions of Americans “with Obamacare relief” with the executive order he signed Thursday is sure to collide with the slow grind of the federal bureaucracy.”

October 12, 2017

Special Edition- The President’s Executive Order

The President signed an Executive Order today in an attempt to expand access to more affordable healthcare options. A fact sheet on the EO can be found here. The Administration has signaled that they would be taking actions on their own in light of Congress’s failure to pass a bill to “repeal and replace” the Affordable Care Act (ACA). There three main elements of the Executive Order.
  1. Association Health Plans – The Employee Retirement Income Security Act (ERISA) governs how employers offer health and retirement plans to their employees. This federal statute allows for companies to offer health insurance coverage to their employees located in multiple states. The Executive Order directs the Secretary of Labor to consider a broader interpretation of ERISA so that employers can band together to offer employees health insurance across state lines. The concept at hand is that trade associations would be able to offer this coverage to the employees of their member companies. Proponents of this policy believe creating a large enough insurance pool and selecting which state laws govern the insurance coverage could lead to lower cost insurance options.
  2. Short-Term Limited-Duration Insurance – The Health Insurance Portability and Accountability Act (HIPAA) created this category of insurance intended to be used in special circumstances such as when a person is switching employers. These plans are not considered individual coverage under the ACA and therefore do not have the same consumer protections. The Obama Administration issued a regulation at the end of 2016 limiting these plans to three months in duration out of concern that these plans were being sold to consumer as individual coverage. The Executive Order directs the Departments of Treasury, Labor, and Health and Human Services to consider expanding coverage through these plans.
  3. Health Reimbursement Arrangements – Health Reimbursement Arrangements (HRAs) are employer provided accounts to help employees pay for out-of-pocket medical expenses and individual insurance coverage. The Internal Revenue Service allows for a certain amount of pre-tax dollars to be contributed to these accounts. The Executive Order directs the Departments of Treasury, Labor, and Health and Human Services to consider changes to HRAs to give employers more flexibility. While the Executive Order does not direct this outcome, it is expected that the Trump Administration will seek to allow these dollars to be used to purchase more health insurance products.

The federal agencies included in this Executive Order will need to develop policies around these broad directives and issue regulations for implementation.  So we will wait for the details of the policies to know how broad these reforms will be and their implications.  It is entirely possible that if the Trump Administration is aggressive in their policy changes that the new regulations will be subjected to legal challenges.

October 6, 2017

This week has been very active even with the fallout from last Friday’s announcement that HHS Secretary Tom Price had resigned due to his use of private and military jets for his travels.  Early names that have surfaced as a replacement for him include CMS Administrator Seema Verma, FDA Commissioner Scott Gottlieb, Congressman Fred Upton (R-MI) and former Congressman Dave Camp (R-MI).

Funding for the CHIP program expired last week, but both the Senate and the House have bills coming out of their respective committees of jurisdiction for votes on the floor. The House bill, coming from the Energy and Commerce Committee, passed on a 28-23 vote while the Senate Finance bill was approved on a voice vote.  The House bill is paid for by changing Medicaid’s third-party liability, excluding lottery winners from Medicaid, increasing Medicare premiums on individuals making over $500,000 per year, and cutting the Affordable Care Act’s (ACA’s) Prevention and Public Health Fund.  The Senate bill does not yet include any pay-fors.

The Ways and Means Committee reported a bill to repeals the Independent Payment Advisory Board (IPAB).  The bill passed the committee on a largely party-line vote with only Congressman Bill Pascrell (D-NJ) and Congresswoman Linda Sanchez (D-CA) voting in favor.  Chairman Brady would like to include this measure in the extension of expiring health programs by the end of the year.

We’re still awaiting the individual market stabilization package the Sens. Murray (D-WA) and Alexander (R-TN) are said to be working on, but in the meantime the HELP Committee has been focused on the opioid crisis, holding a hearing on the federal response to it Thursday this week.  We are told the hold up on the market stabilization bill is issues around granting states more flexibility with their Medicaid programs.

The Department of Health and Human Services also pulled back four rules issued during the Obama Administration.  Those rules include a Medicare demonstration for Part B drug payment models that was trying to evaluate alternative payment approaches for medications administered in physician offices.  The other rules were a proposal on orthotics and prosthetics, a proposal on certifications of compliance for health plans, and a proposed rule that would have required long-term care facilities receiving Medicare or Medicaid payments to treat same-sex partners the same as other marriage partners.

  • Next Health Secretary Could Set Course for Insurance System – Roll Call (Oct 3)
    “With the health care debate sidelined on Capitol Hill, the next Health and Human Services secretary will have the ability to determine the Trump administration’s approach on the current health care law. Despite seven years of promises, Republicans have been unable to roll back the 2010 health care law as they’d planned before the end of September. The vacancy left by former Secretary Tom Price, who resigned last week amid scrutiny of his private jet use, added another challenge to a politically divisive battle.”
  • States Scramble to Overcome Congress’ Failure to Move on CHIP – Pew Stateline (Oct 6)
    “By failing to reauthorize the Children’s Health Insurance Program before last week’s deadline, Congress has nudged the state of Minnesota toward a painful solution to the loss of federal funds: Unless it can find $95 million, the state said it will continue to provide full health care for certain low-income pregnant women in the program, while either reducing the number of children eligible for CHIP or scaling back their benefits.”
  • Who will replace Price? – Politico (Oct 1)
    “A dozen names are being talked about as the next HHS Secretary, including several belonging to people already serving in the administration. But of course President Donald Trump often defies Washington’s conventional wisdom. The rumored short-list includes former Sen. Judd Gregg (R-N.H.), who would sail through Senate confirmation but would probably be considered too moderate on Obamacare, to Dr. Mehmet Oz, a cardio-thoracic surgeon made famous by his talk show, which Trump has appeared on. Other current or former members of Congress who could be considered include Rep. Fred Upton and former Rep. Dave Camp.”

September 29, 2017

The drama over the Graham-Cassidy bill did not play out as expected heading into last weekend as it quickly became clear there were not sufficient votes to get the bill out of the Senate.  At the Republican senators’ weekly lunch, it was decided to not call up the bill and keep working on the issue.

What does “keep working on the issue” specifically mean?  Well, there appears to still be several moving parts to the puzzle.  Senators Alexander (R-LA) and Murray (D-WA) continue their discussions over a bill to stabilize the individual insurance market.  We are told they are close to an agreement, but how far that bill can move beyond the Senate HELP Committee, where they serve as Chairman and Ranking Member, remains to be seen.

Senators Graham (R-SC), Cassidy (R-LA), Heller (R-NV), and Johnson (R-WI), who wrote the amendment to the reconciliation bill, say they are going to get back to work on the language on Monday.   But it is not clear if they are going to try and come up with policy that can pass the Senate on simple majority vote and move in a future reconciliation bill or something that can gain 60 votes.

The Problem Solvers Caucus in the House continues to try and move forward the legislative solution they put together.  We are told their solution will look very close to what Senators Alexander and Murray will come up with as a solution.

Meanwhile, House committees are moving on to bipartisan legislation outside of the Affordable Care Act.  House Energy and Commerce is poised to consider a bipartisan reauthorization of the Children’s Health Insurance Program (CHIP) next week.

  • Alexander, Murray inching toward deal to stabilize Obamacare – Politico (Sep 28)
    “A pair of deal-making senators is inching toward a bipartisan agreement to fund Obamacare’s insurance subsidies and provide some certainty to health insurance markets just two days after the GOP’s latest Obamacare repeal effort failed. Senate Health, Education, Labor, and Pensions Committee Chairman Lamar Alexander (R-Tenn.) and ranking member Patty Murray (D-Wash.) are moving toward a plan to stabilize Obamacare in the short term after meeting on Wednesday. Though they have not yet clinched a deal, their progress could ignite a new battle over how or whether to improve the law.”
  • Senate GOP effort to unwind the ACA collapses Monday – Washington Post (Sep 25)
    “The latest Republican effort to unwind the Affordable Care Act collapsed Monday as a third GOP senator announced her opposition and left the proposal short of the votes needed to pass. While one top Republican senator held out the possibility that the Senate might still vote on the bill, others accepted the reality that the push had sputtered out after Sen. Susan Collins (R-Maine) joined two of her colleagues in formal opposition.”
  • Here’s how the Trump administration is hurting enrollment in Obamacare – Washington Post (Sep 28)
    “…In other words, enrolling those healthy people is central to making Obamacare work. And in light of that, it’s probably not surprising to discover that the administration of President Trump is taking a number of steps that, intentionally or not, will undercut the number of healthy people who enroll. Here are a number of ways that’s happening.”
  • Trump blamed pharma’s political donations for ‘outrageous’ drug prices. The next day, those donations spiked – STAT (Sept 27)
    “Eight pharmaceutical political action committees made 134 contributions, spread over 77 politicians, on March 21. They spent $279,400 in all, showering Republicans and Democrats in both legislative bodies with campaign cash, according to FEC filings. The second-highest one-day contribution tally was $203,500, on June 20.”
  • Dems see 2018 gains in repeated Obamacare repeal tries – Politico (Sep 28)
    “To the Republicans vowing to keep their Obamacare repeal drive alive for as long as it takes, Democrats say: Please, and thank you. While Senate Republicans abandoned their last-gasp attempt to topple Obamacare before a Saturday deadline, they’re already suggesting they might try again next year. That timing — President Donald Trump said Wednesday that Congress would take up repeal again in the first quarter of next year — could keep the threat of upending the health care system front of mind in the thick of the 2018 campaign season.”

September 22, 2017

The plot has thickened as they say with respect to the so-called Graham-Cassidy bill.  We are told those two Senators are personally working extremely hard to line up the necessary votes from their colleagues.  We are also hearing that modifications to the bill are being discussed and negotiated to lock down 50 votes for the bill.

The Congressional Budget Office has announced it will release a preliminary score of the bill next week.  The preliminary score is not expected to have a lot of details and certainly will not include coverage estimates of this bill, but it will provide enough information to allow the Senate to turn to this amendment should Leader McConnell think he has the votes or is close to having the votes.

The Democratic Senators do not have many options for preventing this bill from moving forward.  The debate time on the reconciliation bill has expired so the Senate is in the vote-a-rama phase of considering the reconciliation bill which means any amendments get called up for a vote without debate.  The one tool the Democrats do have is to file as many amendments as possible under the hopes that the roll calls on those votes will not be completed before the September 30th deadline.  Yom Kippur beginning the evening of September 29th helps the Democrats if they pursue that strategy.

If the Senate does manage to pass the reconciliation bill next week, the House will not be faced with any deadline for considering the Senate-passed bill.  There was talk of including in “side car” legislation fixes for any problems/issues the House desires to be addressed.  The side car legislation would likely be included in a future must-pass measure such as supplemental funding for response to the hurricanes.

Regardless of the outcome of the Senate votes next week, these developments are likely to have a spill-over effect on other issues Congress must address such as the Dreamers and expiring provisions.

September 15, 2017

It was a big week for healthcare in Washington with two new significant bills being put forward.
Senators Graham (R-SC), Cassidy (R-LA), Johnson (R-WI), and Heller (R-NV) released a substitute amendment for the House-passed “repeal and replace” bill known as the American Health Care Act. The so-called Graham-Cassidy bill establishes a block grant to states to help individuals pay for healthcare coverage. The block grant is funded by repealing the premium and small business tax credits and pulling back the Medicaid expansion funding starting in 2020. The bill also provides $25 billion to states for transitional assistance until the new block grant programs are implemented. The individual and employer mandates are repealed in the bill as are some of the taxes introduced by the Affordable Care Act (medical device, over-the-counter medications, etc.).
We are told the sponsors of the bill are seeking a score from the Congressional Budget Office. However, it is not certain whether a score can or will be produced before the reconciliation privilege with the 2017 budget resolution expiring on September 30. It is also uncertain whether the score would produce the results necessary to meet the reconciliation instructions. Leader McConnell has said he is “all in” if they have a favorable score and the votes to pass the bill. President Trump put out a complimentary statement following the bill’s release, but did not indicate whether he would sign the bill into law if passed by Congress.
Should the Senate pass this bill, it would set up an interesting dynamic with the House given the significantly different approach the House took. As with many other issues in Washington these days, there are a lot of people taking a wait and see approach with the Senate on this issue.
The second healthcare bill was Senator Sanders’ (I-VT) single payer healthcare bill. The “Medicare for All” bill has 16 original cosponsors including Senator Baldwin (D-WI) who is up for reelection in a state Trump carried and Senators Harris and Gillibrand who are mentioned as possible candidates for President in 2020.
  • Cassidy says he’s close to having the votes to pass Obamacare repeal – Politico(Sep 15)
    “Sen. Bill Cassidy Friday sought to rally support for the last-ditch Obamacare repeal plan he co-authored, saying he believes he’s on the verge of winning the final votes needed to jam it through the Senate. Cassidy claims that as many as 49 GOP senators have expressed support but doesn’t have a hard whip count with just days left to use a fast-track process allowing the bill to pass with a simple majority. And his search for the elusive 50 “aye” votes got harder Thursday, when Sen. Rand Paul announced his opposition.”
  • GOP tries one more time to undo ACA with bill offering huge block grants to states – Washington Post (Sep 13)
    “With just 17 days left for Republicans to repeal the Affordable Care Act on a party-line vote, a quartet of GOP senators on Wednesday rolled out a plan to devolve federal health care spending into state-by-state block grants – legislation that South Carolina Sen. Lindsey O. Graham described as conservatives’ last shot at reform.”
  • Sanders’ single-payer push splits Democrats – Politico (Sep 13)
    “Bernie Sanders’ single-payer health care plan has won over most other liberal senators, including many weighing 2020 bids. The rest of the Democratic Party is another matter. As Sanders prepares to unveil his Medicare for All legislation on Wednesday, most of the party’s congressional leaders and vulnerable Senate incumbents are steering clear. Even as the left celebrates Sanders’ ability to push the Democratic agenda leftward after his primary challenge to Hillary Clinton last year, that success appears to have its limits.”
  • Governors Ask Congress to Help Stabilize Health Care Market – CQ Roll Call(Sep 11)
    “Governors are calling for multiyear funding for cost-sharing payments and for federal assistance to launch reinsurance programs as part of a bipartisan measure to stabilize the individual insurance market. The conversation among governors and senators in a Sept. 7 hearing before the Senate Health, Education, Labor and Pensions Committee echoed what insurance commissioners told the same panel earlier in the week about how to bring stability to the individual insurance market before the fifth open enrollment period.”

September 8, 2017

The Senate Committee on Health, Education, Labor and Pensions (HELP) held its first two hearings on stabilizing the individual insurance markets this week.  The first hearing featured state insurance commissioners from a cross-section of states.  Broadly speaking, the consensus from the group was that cost sharing reduction payments should be made and continued (preferably long term) and the creation of a federal reinsurance program would be helpful.  The commissioners also urged that states be given more flexibility in a streamlined way to address unique needs in their states.  The second hearing featured governors who largely agreed with the recommendations of the insurance commissioners.

HELP Chairman Alexander held bipartisan caucuses before each hearing to begin a dialogue amongst the senators about possible legislative solutions the committee can advance.  We are expecting that Senator Alexander will look to start the negotiations over a possible bill that is similar in scope to the legislative solution proposed by the bipartisan Problem Solvers Caucus in the House.

There are a number of expiring health care provisions including the Children’s Health Insurance Program in the month of September, but these provisions were not part of the deal cut by the President with Democratic leaders to process the big three issues of raising the debt limit, continuing funding for the government with a continuing resolution, and making the first payment to respond to the damage from Hurricane Harvey.  It is not clear what path the expiring health provisions will take at this point and there more provisions such as the Medicare extenders with year-end expirations.

  • Senate GOP accepting defeat on Obamacare repeal – Politico (Sep 7)
    “Senate Republicans are throwing cold water on the idea of holding another Obamacare repeal vote before their opportunity to gut the law on a party-line vote expires at the end of this month. Though President Donald Trump and some Senate Republicans are pushing a plan being devised by Sens. Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.) to block grant federal health care funding to the states and keep much of Obamacare’s taxes, the idea of passing the measure by month’s end appears almost impossible, according to senators and aides.”
  • State insurance commissioners under pressure in health-care drama – Washington Post (Sep 2)
    “With insurance premiums rising amid congressional Republicans’ failed attack on the Affordable Care Act, a group of bureaucrats whom few Americans can identify hold considerable power over consumers’ health plans: state insurance commissioners. Elected in 11 states, appointed in the others, they are central characters in the unfolding drama that is the nation’s health coverage.”
  • Senate’s Obamacare fixes would build on heavy lifting by states – Politico (Sep 5)
    “While Congress was busy bickering over repealing the health law, officials in red and blue states worked frantically to soothe anxious insurers, tamp down rate increases and insulate their markets from the ceaseless chaos in Washington. The result is an Obamacare system that’s still vulnerable, but far from the “disaster” President Donald Trump and his top health officials describe.”
  • Senate Appropriators Back NIH, Pell Grant Boosts in Draft Bill – CQ (Sep 6)
    “The Senate Labor-HHS-Education Appropriations Subcommittee on Wednesday approved by voice vote a bipartisan draft spending bill that would increase funding for the National Institutes of Health by $2 billion and provide more funding to low-income students attending college.”

August 18, 2017

Healthcare Today will be taking a summer break for the next two weeks. The next edition will be on Friday, September 8th, when Congress is back in town.

This week, the Congressional Budget Office (CBO) released a study on the impact of eliminating the cost-sharing subsidies under the Affordable Care Act (ACA). The report finds that eliminating these payments will increase the federal budget deficit by $194 billion over the next ten years. CBO cites two reasons for the spike in the deficit: subsidies for purchasing insurance will be greater, and more people will be receiving subsidies. CBO projects the subsidies would increase by $247 billion which is partially offset from some higher revenues from changes to taxable wages and additional penalties paid.

CBO is projecting the marketplace would remain stable but that insurance premiums would rise by 20 percent under this policy. The report also states that the uninsured population would decrease slightly because of the subsidies for purchasing insurance becoming more generous.

  • Trump administration will make this month’s Obamacare payments but leaves program’s future in limbo – Politico (Aug 16)
    “The Trump administration will make this month’s Obamacare payments to insurers, a White House spokesman confirmed today, despite the president’s repeated threats to cut off the subsidies and potentially tip the insurance markets into turmoil. It’s widely anticipated that insurers would jack up premiums or exit the Obamacare markets altogether if the subsidies, worth about $7 billion this year, are eliminated. Insurance premiums for the most popular Obamacare plans would likely rise by 20 percent next year if the payments are stopped, according to a Tuesday CBO analysis.”
  • CBO: Pulling Obamacare subsidies would drive up premiums, increase deficit – Politico (Aug 15)
    “Scrapping Obamacare’s cost-sharing subsidies would increase premiums on the most popular plans by 20 percent next year and swell the deficit by $194 billion over a decade, according to an analysisby the Congressional Budget Office.”
  • Dems ask Trump officials for briefing on ObamaCare – The Hill (Aug 18)
    “Top Democrats of committees overseeing healthcare are requesting a briefing on the administration’s plans for ObamaCare’s open enrollment season, which begins Nov. 1, amid uncertainty over how President Trump will administer the law. In a letter sent to Health and Human Services Secretary Tom Priceand Centers for Medicare and Medicaid Services Administrator Seema Verma, the lawmakers expressed concerns over what they see as the White House’s efforts to undermine the Affordable Care Act’s marketplaces.”

August 11, 2017

Last night, the White House announced that the President is instructing his administration to use all appropriate emergency authorities to respond to the opioid epidemic. This allows the federal government to waive certain rules governing how state and local governments respond to the crisis. It may result in the Public Health Service being deployed in the most affected areas of the country where there is not enough necessary medical staff present to respond.

The President received a briefing this week on the issue from Secretary of Health and Human Services (HHS) Dr. Tom Price. Reportedly, the President is still reviewing the draft report of his Commission on Combating Drug Addiction and the Opioid Crisis to determine which of the recommendations his administration will act upon.

The Centers for Medicare and Medicaid Services (CMS) issued a memo yesterday allowing more time for insurance companies to submit premium rate requests for plans sold on the exchanges under the Affordable Care Act. The deadline has been pushed back from August 16 until September 5. Under the new deadline, insurance companies will know the status of the cost sharing subsidies as the next payments are scheduled to be made on August 22.

We are expecting the Congressional Budget Office (CBO) to release a report on the impact of the cost sharing subsidies next week. Though August is usually a relatively quiet month in Washington D.C., there will likely be some drama building up to the scheduled payments as the administration has threatened to cancel them.

  • Bipartisan health policy coalition urges Congress to strengthen the ACA – Washington Post (Aug 11)
    “An unlikely coalition of liberal and conservative health-policy leaders is calling on Congress to strengthen the existing health-care law in a variety of ways to help Americans get and keep insurance. In particular, the group is urging the government to continue paying all the federal subsidies provided under the Affordable Care Act and to help Americans enroll in coverage.”
  • Tax writers see peril in Trump’s Obamacare persistence – Politico (Aug 7)
    “Republicans acknowledge that the aggressive timeline they have set up for overhauling the tax code this fall leaves them little room for error. There could be one problem with that: Obamacare isn’t going away. President Donald Trump has dropped hints that he might stop the Affordable Care Act’s cost-sharing reduction payments, through which federal funds flow to insurance companies to keep down coverage costs for low-income people.”
  • The tantalizing link between obesity and depression – Politico (Aug 9)
    “About 15 years ago, Sue McElroy, a psychiatrist in Mason, Ohio, started noticing a pattern. People came to see her because they were depressed, but they frequently had a more visible ailment as well: They were very overweight. McElroy was convinced there had to be a connection. “Many of my [depressed] patients were obese. And they were very upset by obesity,’’ McElroy recalled. “I looked into the literature, and it said there was no relationship. It didn’t make sense.””
  • HHS Secretary Statement on President Trump’s Opioid Announcement Today – HHS (Aug 10)
    “President Trump is taking strong, decisive action in directing the Administration to use all appropriate emergency and other authorities to respond to the crisis caused by the opioid epidemic. Today’s announcement demonstrates our sense of urgency to fight the scourge of addiction that is affecting all corners of this country.”

August 4, 2017

Senate Health, Education, Labor, and Pensions (HELP) Committee Chairman Lamar Alexander (R-TN) and Ranking Member Patty Murray (D-WA) announced this week that the committee will hold hearings and attempt to markup legislation to “repair” the Affordable Care Act (ACA).  It sounds as though their focus will be on stabilizing the individual and small group markets using measures such as formally authorizing the cost sharing subsidies and possibly designing a reinsurance program for the markets.  There is some discussion of offering states more flexibility from the ACA, but probably not as far as the House-passed bill went.

It is unclear whether Senators Alexander and Murray can build bipartisan consensus in their committee on these issues.  It will certainly be difficult, given the political spectrum of committee members from Senator Sanders (I-VT) to Senator Paul (R-KY).  However, Alexander and Murray recently wrote a consensus bill to reauthorize the Food and Drug Administration’s user fees and last Congress, the pair authored a rewrite of the controversial No Child Left Behind education bill – both of which made it through committee. Even if a bipartisan bill emerges from committee, it is yet to be seen whether Majority Leader Mitch McConnell (R-KY) will want to dedicate floor time to the bill.

On the House side, the Problem Solvers Caucus has developed a bill to stabilize individual and small group insurance markets, repeal the medical device tax, and grant states more flexibility under the ACA. The caucus comprises of members from both parties who have agreed to develop policy positions to impact legislation in the House. The Problem Solvers Caucus has agreed to internal rules wherein if a majority of members from each party support a particular policy position, they will all vote for it on the House floor.  The caucus is 45 members strong – a significant voting bloc in the House that should not be discounted.

Meanwhile in the White House, the Trump administration has been suggesting that the President may end the cost sharing subsidies through administrative action.  The next payment is due on August 22nd. Because of the impulsive tendencies of this administration, everyone is paying close attention to what action may come from the White House on this issue.

Elsewhere in healthcare:

  • New bipartisan Obamacare push faces steep climb – Politico (Aug 3)
    “There’s never been a major bipartisan Obamacare bill, and the path to passing one now — after the death of Senate Republicans’ repeal effort — is steep. Lamar Alexander (R-Tenn.), chairman of the Senate Committee on Health, Education, Labor and Pensions, and ranking Democrat Patty Murray of Washington are up against both time and history in their race to stabilize the shaky Obamacare markets and solidify their status as the chamber’s top deal-makers.”
  • Senate passes ‘right to try’ bill to help terminally ill patients get experimental drugs – Washington Post (Aug 3)
    “The “right-to-try” legislation has been championed by the libertarian Goldwater Institute, which has worked to pass similar legislation in 37 states. The federal version, now headed to the House, would bar the government from blocking patients from getting access to medications that have undergone only preliminary testing in humans. Patients first would have to try all other available treatments and be ineligible for clinical trials.”
  • GOP states move to cut Medicaid – The Hill (Aug 3)
    “At least six states with GOP governors— Arkansas, Kentucky, Arizona, Maine, Wisconsin and Indiana — have already drafted plans meant to introduce new rules people would have to meet to be eligible for Medicaid, which provides healthcare to low-income Americans and those with certain disabilities. Some want to add work requirements or introduce drug testing for recipients. Others want to raise premium prices.”
  • Trump decision looms on crucial Obamacare payments – Politico (Jul 31)
    “President Donald Trump at any time could make good on a threat to scrap crucial Obamacare payments to insurers — a decision that could raise Obamacare customers’ costs and potentially leave tens of thousands more without any coverage options next year.”

July 28, 2017

What a week to be in Washington, D.C.  One might say there was more drama in the Capitol building this week than there is during an entire season of House of Cards.

Last week, “conventional wisdom” dictated that there were not enough Republican votes to proceed to the bill on the Senate floor. But in a tense afternoon on Tuesday, Senator John McCain (R-AZ) walked on to the floor to a loud ovation of applause from both sides of the aisle to cast the 49th vote for the motion to proceed to debate.  Senator Ron Johnson (R-OH), after a heated exchange with Senator Mitch McConnell (R-KY) and realizing that the bill’s fate was now in his hands, voted to be the 50th vote in favor setting up Vice President Pence to break the tie.

The Senate went on to consider several amendments and motions ranging, from the “repeal only” bill that passed the last Congress to an amendment calling for a single payer health care system to motions to send the bill back to committee.  The expectation was that while the Senate did not have the votes to pass a bill like the one that passed the House, the Senate could at least pass a minimalist approach to the “repeal and replace” effort, dubbed “skinny repeal”, which would be repeal of the employer and individual mandates and the unpopular tax on medical devices.

However, the effort to pass the skinny repeal fell one vote short, despite assurances from the House that they would not take up the Senate-passed bill and send it to the President, but instead convene a conference committee with the Senate to attempt to come up with acceptable policies to both chambers.

Senator McConnell never called the question on passage of the House-passed bill so the bill remains on the Senate calendar.  He can now turn back to the bill should a solution acceptable to 50 senators can be put together.  What is not clear, however, is whether this will continue to be a partisan exercise or whether a bipartisan plan can be put together to address some of the challenges of the Affordable Care Act without repealing the law or significant portions of it.

For now, at least, Senator McConnell plans to move on to other agenda items in the Senate and take a pause on this bill.  Those items are likely to include cloture on 11th Circuit Court nominee Kevin Newsom (already scheduled for Monday at 5:30 pm), FDA user fee reauthorization, the nomination of FBI Director Christopher Wray, and the Coast Guard reauthorization.

Elsewhere in healthcare:

  • GOP Obamacare repeal bill fails in dramatic late-night vote – CNN (Jul 28)
    “Washington (CNN)The Senate has dealt a devastating setback to Republican efforts to repeal and replace Obamacare, defeating a GOP “skinny repeal” bill early Friday morning. Sens. John McCain, Lisa Murkowski and Susan Collins joined with Democrats to oppose the measure, a major blow to President Donald Trump and the Republican congressional agenda.”
  • HHS Unveils Improved Web Tool to Highlight Recent Breaches of Health Information – HHS (Jul 25)
    “The U.S. Department of Health and Human Services (HHS), Office for Civil Rights (OCR) today launched a revised web tool that puts important information into the hands of individuals, empowering them to better identify recent breaches of health information and to learn how all breaches of health information are investigated and successfully resolved.”
  • NIH Contractor Dispute Underscores Agency Conflicts – Roll Call (Jul 25)
    “A key contractor at the National Institutes of Health is urging employees to forgo compliance with federal guidelines, citing consent agreements signed by patients that acknowledge the risk of participating in clinical research at the agency, Roll Call has learned. The agency denies the contractor’s actions and that it would ever relax compliance.”
  • Thune: Senate won’t give up on Obamacare repeal if bill fails this week – Politico (Jul 23)
    “If the Senate’s latest Obamacare repeal efforts collapse this week, Republicans will “go back to the drawing board” and try again, Senate GOP Conference chairman John Thune said on Sunday. As Republicans’ efforts to undo the 2010 health care law hit seemingly insurmountable roadblocks, members of the party have floated working with Democrats to stabilize insurance markets or moving on to other priorities. But Thune, a Republican senator from South Dakota, insisted Sunday that the GOP is committed to dismantling the law that was the signature achievement of former President Barack Obama.”

July 21, 2017

All eyes are on the Senate where they are on track to have a vote on the motion to proceed to the House-passed American Health Care Act (AHCA).  The motion to proceed is not debatable and is a simple 50-vote test. While Majority Leader McConnell will need to tell senators what he intends to do should the Senate proceed to the bill, the motion itself is not tied to any specific proposal.

Leader McConnell was planning to offer a version of the Better Care Reconciliation Act (BCRA) as a substitute amendment but there is not sufficient support for that proposal. There was some talk about having Senator McConnell instead offer the reconciliation bill that passed in the last Congress to just repeal the Affordable Care Act (ACA) but similarly, it is not clear there are sufficient votes.

Senator McConnell has the option of just offering a more modest proposal such as just repealing the individual and employer mandates, thus achieving the necessary savings to meet the reconciliation instructions. But it is not clear whether an approach like that would win over 50 Republican senators.

We hear that if the motion to proceed fails there are a significant number of Democrats who are willing to work with Republicans on a bill to fix the ACA but it is not clear if that approach would be acceptable to Leader McConnell.

Trying to predict Senate actions is feeling a lot like forecasting the weather in Washington, where even conservative estimates can be way off base.

  • Cloud of confusion hangs over health-care bill – Washington Post (Jul 20)
    “Senate Republican leaders’ latest attempt to salvage support for a GOP health-care bill floundered Thursday as leaders struggled to explain to rank-and-file members what exactly they would be voting on next week. Senators left town for the weekend under a cloud of confusion after Senate Majority Leader Mitch McConnell (R-Ky.) reopened talks on a discarded plan to repeal and replace the Affordable Care Act under heavy pressure from President Trump. The White House intervention sparked a flurry of meetings and activity, but the rush produced no new evidence that the bill can pass.”
  • Senate ‘repeal only’ bill would leave 32 million more uninsured, CBO says – Politico (Jul 19)
    “A revived bill that would dismantle large parts of Obamacare without an immediate replacement would leave 32 million more people uninsured and double premiums over a decade, the Congressional Budget Office said in a report Wednesday.”
  • With collapse of GOP health care effort, Congress faces a long ‘to-do’ list for health policy – Stat (Jul 18)
    “But the abrupt change of plans brings to the fore a laundry list of other health policy bills that remain on Congress’ agenda for the coming months. Some are must-pass items with rapidly approaching deadlines: agreements that represent about $1 billion in private funding for the Food and Drug Administration, as well as the authorizations for federal funding for the Children’s Health Insurance Program and several Medicare programs, all of which expire in September.”
  • Medicaid shows its political clout – Politico (Jul 19)
    “Medicaid may be the next “third rail” in American politics. Resistance to cutting the health care program for the poor has emerged as a big stumbling block to Obamacare repeal, and Republicans touch it at their political peril.”
  • Trump threatens to gut Obamacare markets – Politico (Jul 18)
    “Donald Trump holds a fuse in his hands — and he could decide to light it and blow up Obamacare insurance markets as soon as Thursday. That’s the deadline for sending out the next monthly Affordable Care Act subsidies to health plans to defray the cost of care for individuals with low incomes. The president has toyed for months with the idea of stopping the payments to force Democrats to the negotiating table to avoid the prospect of millions of vulnerable Americans losing access to health coverage.”

July 14, 2017

There are enough Republican Senators who are holding out their support for the Better Care Reconciliation Act (BCRA) that is outlook remains very murky.  We are told there are continued negotiations and further changes are very likely to be made to the bill before it reaches the Senate floor.

If Leader McConnell is unable to get sufficient votes for BCRA, he could use the House passed bill as a shell to pass a tax bill in September so long as the bill includes $1 billion in savings from the Senate and HELP Committees’ jurisdiction.  Under this scenario, Congress would not need to wrestle with a fiscal year 2018 budget resolution.  There is not much speculation looking beyond health care but that certainly is an option for the leader.

  • Senate Republicans one vote away from Obamacare repeal failure – Politico (Jul 11)
    “Senate Republican leaders are praying that their fragile whip count holds over the weekend, as just one more “no” vote would doom the party’s Obamacare repeal effort from evencoming up for debate. Two GOP senators, Susan Collins of Maine and Rand Paul of Kentucky, said Thursday afternoon they will oppose a procedural vote next week to bring the bill to the floor. GOP leaders are putting immense pressure on about half a dozen other Republican senators not to join them and topple the entire effort. Another “no” is enough to kill the bill, and would also likely lead to mass defections.”
  • The new things in the Senate health bill – Axios (Jul 13)
    “Here’s what Senate Republicans have added to the latest version of their health care bill (summary here, text here)”
  • Insurance experts question Cruz’s assertion about single risk pool – Politico (Jul 13)
    “ Ted Cruz emphatically told fellow Republicans Thursday that his amendment to the Senate’s Obamacare repeal legislation would not split up healthy and sick people into two different risk pools,eliminating concern that an earlier version of his plan would drive up costs for sick people. But insurance experts say that’s not the case.
  • Medicaid Still Key Sticking Point in GOP Health Debate – CQ Roll Call (Jul 13)
    “Just hours after Senate Majority Leader Mitch McConnellunveiled an updated bill to overhaul the U.S. insurance system, lawmakers hesitant about the proposed changes to Medicaid huddled in the Kentucky Republican’s office in search of a solution. The members, which included Sens. Lisa Murkowskiof Alaska, John Hoeven of North Dakota, Shelley Moore Capito of West Virginia and Rob Portman of Ohio, were also joined by Centers for Medicare and Medicaid Services Administrator Seema Verma.”
  • Half a million Medicare recipients were prescribed too many opioid drugs last year – Washington Post (Jul 13)
    “Nearly 70,000 people on Medicare’s drug plan received “extreme” amounts of narcotic painkillers in 2016 and more than 22,000 others appeared to be “doctor shopping” for drugs, patterns that put both groups “at serious risk of opioid misuse or overdose,” a government watchdog reported Thursday. In all, about half a million people on the drug plan took amounts of the powerful drugs considered too large under standards set by the Centers for Disease Control and Prevention, according to the Inspector General’s office of the U.S. Health and Human Services Department. That number excludes people who had cancer or were in hospice, who may require large doses of painkillers.”

July 13, 2017

Senate Republican leadership just released an updated draft of the Better Care Reconciliation Act (BCRA). The most significant changes in the new bill include: leaving in place the Affordable Care Act’s (ACA) lifting of the limit on Medicare payroll taxes and the tax on passive income; allowing the purchase of health insurance from a health savings account (HSA); changing the inflation factor for the Medicaid Per Capita Cap program from the medical care component of the consumer price index for all urban customers to just the consumer price index for all urban customers; including $45 billion instead of $2 billion to fight the opioid epidemic; and providing additional funding to help vulnerable populations purchase insurance.

It is yet to be seen whether these changes will allow Senate Majority Leader Mitch McConnell (R-KY) to get the necessary votes to proceed to the bill where further changes could be made on the Senate floor if necessary to garner 50 votes for passage. We are hearing multiple senators are exploring further policy options, negotiating both individually and in groups.

The section-by-section summaries of the updated bill, as prepared by committee staff, are available here (Titles I & II) and here (Title III).

July 7, 2017

The Senate returns next week to see if they can find the right policy options to adjust the Better Care Reconciliation Act (BCRA) to garner the necessary 50 votes for passage. We had heard that Senate Majority Leader Mitch McConnell (R-KY) had sent several policy options for scoring to the Congressional Budget Office (CBO), but is not clear whether all or any of those options put forward will wind up in the bill.

Among them was an idea being promoted by Senator Ted Cruz (R-TX) to allow insurance companies to offer plans that do not comply with the Affordable Care Act (ACA) so long as they offer one ACA-compliant plan. There was also talk of leaving in place the Medicare tax and the tax on unearned income as a way to fund more subsidies for vulnerable population.

Senate GOP leadership is aiming to have BCRA on the floor the week of July 17th. However, it is possible the bill will slip to the following week leaving it very close to the August recess.

A draft of the executive order addressing drug prices was leaked this week. The document outlines a wide number of possible regulatory reforms for several agencies to take action upon including: the Food and Drug Administration; the Centers for Medicare and Medicaid Services; Health Resources and Services Administration; the United States Trade Representative; the Patent and Trademark Office; and the Internal Revenue Service. The document also includes a number of legislative options for discussion. Critics lambasted the leaked order, suggesting it was too favorable to the pharmaceutical industry.

Below are some highlights from the press about the past week’s developments in healthcare policy:

  • McConnell: If we can’t repeal Obamacare, we’ll fix it – Politico (Jul 6)
    “Senate Majority Leader Mitch McConnell said Thursday that if the chamber’s fledgling Republican Obamacare repeal effort falls short, Congress will have to pass a more limited bill to shore up health insurance markets. “If my side is unable to agree on an adequate replacement, then some kind of action with regard to the private health insurance market must occur,” McConnell said at a Rotary Club luncheon in Glasgow, Ky., the Associated Press reported. “No action is not an alternative. … We’ve got the insurance markets imploding all over the country, including in this state.””
  • How the GOP and Democrats might begin to compromise on health care – Stat News (Jul 5)
    “Senate Majority Leader Mitch McConnell warned last week that Republicans’ failure to pass comprehensive health care reform could have dire consequences. He even warned of one scenario rarely seen here lately: bipartisanship. There’s no guarantee that a holistic, bipartisan health care bill could succeed should McConnell’s nearly single-handed effortto repeal much of the Affordable Care Act fail. But Democrats at least claim they are willing to compromise.”
  • The biggest winner in the current health-care debate: Single-payer – Washington Post (Jul 1)
    “No, single-payer isn’t going to happen at the end of this debate — or even the end of this year or this decade, necessarily. But the logical foundations for it are being laid in our political debate just about every single day. And when you pair that with the rising public support for government-run health care, it’s clear in which direction this whole debate is trending.”
  • How the GOP Medicaid overhaul could become the next fiscal cliff – Politico (Jul 3)
    “The Senate health care bill, if it becomes law, would set in motion a massive rollback of Medicaid funding beginning in three years. But even some Republican supporters acknowledge the full cuts might never happen. Instead, they say it could become another Washington fiscal cliff, where lawmakers go to the brink of radical spending changes only to pull back — or have their successors pull back — just before the point of inflicting real pain in the face of intense pressure.”
  • Kasich: Opioid money in Obamacare bill ‘like spitting in the ocean’ – Politico (Jul 2)
    “An additional $45 billion to help combat opioid addiction in the Senate Republican Obamacare repeal and replacement bill isn’t enough, Ohio Gov. John Kasich said Sunday. In an interview on ABC’s “This Week,” Kasich, who was a contender for the 2016 Republican presidential nomination, called the extra money, which would be spent over a decade, “not enough” to stem the opioid crisis.”
  • The Heroin Crisis in Trump’s Backyard – Politico Magazine (Jul 4)
    “Across the bridge from Palm Beach’s oceanfront mansions and Mar-a-Lago, the private club owned by President Donald Trump, where he spent seven weekends this past winter golfing and entertaining visiting heads of state, it’s not uncommon to see teenage junkies nodding off on coffee shop couches or to come upon them shooting up in supermarket bathrooms. Palm Beach heroin addicts like to get high in public places because if they accidentally overdose, there’s somebody around to call an ambulance. Heroin’s cocoon-like embrace is a national affliction, but here, in the shadow of some of Florida’s priciest real estate, paramedics responded to 5,000 overdose calls last year, nearly 600 of them fatal.”

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Rich Meade

Rich Meade, a Vice Chairman at Prime Policy Group and Chair of the firm’s Healthcare Practice has over 25 years of experience in legislative, regulatory, political and public relations strategy. He previously served as Chief of Staff to the House Budget Committee. Rich has helped his clients navigate many complex regulatory and legislative landscapes to achieve many public policy successes including transitioning to a new Medicare payment and quality system, and developing, with the Centers for Medicare and Medicaid Services (CMS) and Office of the National Coordinator for Health Information Technology (ONC), a health information exchange (HIE) on the Nationwide Health Information Network (NwHIN).


Vickie Walling

Vickie is Co-Chair of Prime Policy Group’s Healthcare Practice and also works with a variety of the firm’s clients, including domestic businesses, multinational corporations and trade associations on federal legislative and regulatory issues. She has over 40 years of legislative and political experience and is widely recognized for her assistance and guidance in the creation of the Blue Dog Coalition, a coalition of moderate Democrats where she provided strategic, legislative and fundraising counsel for 15 years.


Mitchell Vakerics

Mitchell has been delivering trusted counsel across a diverse practice of legislative, policy and political issues for more than a decade. During his long-standing tenure both in Congress and throughout the political and policy sphere of Washington, he has tackled some of the largest healthcare, energy and regulatory issues presented before the federal government. He has a massive range of relationships and strategic congressional partnerships has paid dividends for consecutive congressional sessions. Mitch is a member of Prime Policy Group’s healthcare practice.


Jacob Beaver

Jacob is an Associate at Prime Policy Group, where he is an integral member of the Firm’s research team.