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June 2017


June 23, 2017

The Better Care Reconciliation Act (BCRA) legislative text released yesterday was marked as a discussion draft. We interpret this to mean that this is a “first draft”, and is likely to change before it is brought to the Senate for a final vote in order to get the necessary 50 votes for it.

There are concerns being raised from Senators Heller (R-NV) and Collins (R-ME) over the impact the Medicaid provisions will have on their states, with Sen. Heller formally announcing his opposition to the bill in its current form in the past couple hours. Our read of this initial draft is that it cuts more from the Medicaid program than the House bill does, so it would not be surprising to see some of those Medicaid funding cuts scaled back in a future draft.

While there are two sections of the bill to provide for state innovations, there is no explicit provision allowing states to opt out of provisions of the Affordable Care Act (ACA) as the House bill does with the so-called MacArthur amendment. While allowing states to opt-out of the community rating provisions of ACA gave pause to individuals with pre-existing medical conditions, we were expecting to see an opt-out for essential health benefits for states. That is another area that may be ripe for change in future drafts.

The stakes are high for certain. Senator McConnell’s history of pulling together compromises and moving legislation through the Senate suggests he will find a way to make the necessary adjustments to this discussion draft to pull together 50 Republican votes for it. If he can pull that off, then all eyes will fall on the House to see how they respond.

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

  • Heller comes out against Senate GOP health care bill – Politico (Jun 23)
    “Sen. Dean Heller said Friday that he won’t support the Senate’s Obamacare repeal bill without major changes. “This bill that’s currently in front of the United States Senate is not the answer. It’s simply not the answer,” said Heller, the most vulnerable Senate Republican in the 2018 midterm election. “In this form, I will not support it.” Heller did leave the door open to supporting the bill if changes are made.”
  • How the GOP health-care bill would address one of Obamacare’s big problems — but could cause an even bigger one – Washington Post (Jun 22)
    “Senate Republicans’ health-care bill makes a change to the way the government subsidizes individual health insurance that, if it works, would address one of the major deficiencies of the current health-care system. But health experts are skeptical that, in practical terms, the change would have the desired effect. The Senate bill would restructure the way the Affordable Care Act provides insurance subsidies. Currently, there’s a maximum and a minimum level of income at which a person qualifies for federal help. The Senate bill would remove that minimum, meaning that everyone who makes less than 350 percent of the federal poverty level would qualify for insurance subsidies.”
  • O.P. Rift Over Medicaid and Opioids Imperils Senate Health Bill – New York Times (Jun 20)
    “A growing rift among Senate Republicans over federal spending on Medicaidand the opioid epidemic is imperiling legislation to repeal the Affordable Care Act that Senate leaders are trying to put to a vote by the end of next week. President Trump had urged Republican senators to write a more generous bill than a House version that he first heralded and then called “mean,” but Republican leaders on Tuesday appeared to be drafting legislation that would do even more to slow the growth of Medicaid toward the end of the coming decade.”
  • Republicans’ new Obamacare repeal bill has a lot for insurers to like and for hospitals to hate – Washington Post (Jun 22)
    “Major health care industry groups largely fell into two camps on Thursday when Republicans released their Affordable Care Act repeal: There were those groups that criticized the bill, and those that preferred to say nothing at all. For the health insurance industry, the bill is a mixed bag. The major trade association for health insurers, America’s Health Insurance Plans, declined to issue a specific response to the bill, saying they were still evaluating it. But the proposed legislation contains several provisions that the industry has been fighting for, including a tax repeal worth $145 billion over 10 years to the industry and a guarantee that billions of dollars of federal subsidies would be paid in 2018 and 2019 to stabilize plans in the Affordable Care Act’s marketplaces before they are phased out. There are also two funds, adding up to $112 billion over a decade, to stabilize the market and make insurance more affordable.”

June 16, 2017

OMB Director Mick Mulvaney is convening a meeting today with HHS Secretary Price, CMS Administrator Verma, FDA Commissioner Gottlieb, Treasury Secretary Mnuchin, and White House staffers Gary Cohn and Reed Cordish to discuss drug pricing. We are told that this meeting will be a brainstorming session to think about possible administrative actions that can be taken concerning the most expensive medications. An executive order is expected to be issued quickly to begin to take some action on the issue of drug pricing; we understand more ambitious administrative actions will come later.

The President convened a luncheon with 13 senators to discuss the Senate version of the American Health Care Act (AHCA). We are told the President was critical of the House-passed version, and discussed a more generous version of the AHCA with respect to Medicaid and the subsidies for purchasing health insurance.  The senators who attended were positive about the meeting, sparking speculation that votes were secured in the process.  However, no details have emerged on the Senate version of the AHCA so it would be wise to not read too much into the meeting.

The window is beginning to close on the prospects of a Senate vote on the AHCA before the July 4th State Work Period.  The Congressional Budget Office (CBO) has asked for at least two weeks to score legislative language.  We do not believe a full Senate bill is at CBO for scoring.

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

  • Trump knocks House health care bill as too harsh – Politico (Jun 13)
    “President Donald Trump directed Senate Republicans to pass a generous health care bill at a meeting with more than a dozen GOP senators on Tuesday, arguing that the austere House health care bill is difficult to defend, according to people familiar with the meeting. The president also said Republicans risk getting savaged in the 2018 midterms if they fail to repeal Obamacare after a seven-year campaign against the law.”
  • In GOP health care struggle, it’s senator vs. senator – Washington Post (Jun 14)
    “Here’s one unique, easy-to-grasp way to understand the continued gridlock among Senate Republicans on how to change the health-care industry: Each senator is trying to get the best deal for his or her state. It’s a somewhat obvious observation, because that’s what happens in most congressional debates. But the last six weeks of Senate consideration of the Republican effort to overturn the Affordable Care Act has been somewhat lost in the weeds of Medicare regulations, the size and scope of tax credits and proposals to phase out benefits over a couple years or much longer.”
  • Doctors Fight GOP Senate’s Medicaid Clawback – Forbes (Jun 11)
    “The nation’s physicians are mobilizing once again to battle attempts to end health insurance coverage millions of Americans have gained over the last four years under the Affordable Care Act. Several groups within the American Medical Association are voicing support for policythat expands coverage even as the Republican-led U.S. Senate looks to reduce health benefits. The AMA’s policy-making House of Delegates meets through Wednesday in Chicago, amending and debating the advocacy agenda for the nation’s largest doctor group.”
  • One of the most prestigious brands in medicine is jumping into Obamacare – Washington Post (Jun 15)
    “Cleveland Clinic, a nonprofit academic medical center, is partnering with Oscar Health to sell individual insurance plans in five northeast Ohio counties. The plans will be available on the exchanges, where people can use government subsidies to purchase health coverage as well as off the exchanges, where people bear the full cost of their health coverage.”
  • Fate of Planned Parenthood funding tied to Senate moderates – Politico (Jun 11)
    “Two female Senate Republicans could stop the anti-abortion movement from achieving its most significant win against Planned Parenthood in decades. Most Republicans want to eliminate the group’s $555 million in federal funding as part of their bill to repeal Obamacare. But as Majority Leader Mitch McConnell tries to solve the legislative Rubik’s Cube of finding 50 votes for repeal, he may have to drop the Planned Parenthood cut to win the support of the two Republican moderates, Sens. Susan Collins of Maine and Lisa Murkowski of Alaska.”

June 9, 2017

The President is hoping to have the Senate act upon their version of the American Health Care Act (AHCA) by the July 4th state work period. Senator McConnell is working very hard to find consensus on the policy to hold the vote as quickly as possible.

Discussion this week was very positive from Senators. If the Senate is going to be able to meet the President’s time frame staff will need to start sending legislative language to the Congressional Budget Office (CBO) this weekend in order to have their analysis done before the Senate vote. Unlike the House, the Senate will need the CBO score before they vote to ensure the bill has the reconciliation protections.

We are hearing that the discussions in the Senate will likely lead the bill to be more moderate in its reductions to the Medicaid program and more generous in its subsidies for purchasing health insurance particularly for more vulnerable populations. While early reports suggested that the Senate would come up with their own legislation, we are hearing that they will be using the AHCA as their base legislative text.

Secretary Tom Price made the rounds yesterday, testifying in two hearings: one at Senate Finance, and the other in his former committee at House Ways and Means. These both focused on the HHS budget request for FY2018. Of particular interest was that Secretary Price noted that cost sharing reduction (CSR)payments are assumed in the budget request baseline, meaning it is more likely that Congress will take the lead on funding CSR. It’s possible that they include this funding in their healthcare bill, in addition to a separate appropriations bill.

The Centers for Medicare and Medicaid Services (CMS) issued a request for information this week to seek input from the public on regulatory actions they can take on the Affordable Care Act to improve the law in four areas:

  1. Empowering patients and promoting consumer choice;
  2. Stabilizing the individual, small group, and non-traditional health insurance markets;
  3. Enhancing affordability; and
  4. Allowing states more authority in regulating insurance in their state.

Starting on Monday, June 12 interested parties can submit comments on any one of these issues at the following location under ID#2017-12130.

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

  • Senate Moderates Say They Are Closer on Health Care – Roll Call (Jun 9)
    “Moderate Republicans on Thursday said they were getting closer to supporting an emerging Senate health package but are continuing to press for a slower phaseout of the Medicaid expansion than the House-passed bill set out. The Medicaid expansion question seems to remain the biggest unresolved issue as Republicans try to finalize a bill they can vote on before the end of June. To meet their timeline, they would have to send a bill to the Congressional Budget Office for a cost estimate by early next week, according to a Republican aide.”
  • Senate Republicans consider keeping parts of Obamacare they once promised to kill – Washington Post (Jun 8)
    “Senate GOP leadership told rank-and-file Republican senators during private talks this week that they favor keeping guaranteed protections for people with preexisting medical conditions — a departure from the House approach of allowing states to opt out of a regulation ensuring such individuals are not charged more for coverage. Senate Republicans have also been mulling options to more slowly roll back the expansion of Medicaid that most states accepted under Obamacare, and they are also openly talking about keeping many of the taxes the law imposed. The goal is to find a sweet spot of at least 50 votes in a sharply divided group of 52 Republican senators, many of whom are from states where coverage levels increased under President Barack Obama’s signature health-care law.”
  • Senate GOP may keep Obamacare taxes to pay for their repeal – Politico (Jun 7)
    “Repealing Obamacare’s taxes should have been a no-brainer for the GOP. Republicans have railed against the litany of new levies since the Affordable Care Act was signed into law, blaming them for killing jobs and driving up prices. The law imposed new taxes on many health sectors, including medical device makers, insurance companies, high-cost health insurance plans and even tanning salons. But the party’s orthodoxy on taxes is crashing against its accounting books: keeping the taxes around for even a few years raises money to pay for other parts of the bill.”
  • Trump will keep NIH director – Politico (Jun 6)
    “President Donald Trump has decided to keep Francis Collins as director of the NIH, the White House announced Tuesday. There has long been speculation about whether Trump would keep Collins on to oversee the $34 billion per year medical research agency. Rep. Andy Harris, a Republican doctor from Maryland, had also been in the running to be NIH chief.”
  • White House to Congress: Address Health Care, Debt Ceiling by August – Roll Call (Jun 5)
    “White House officials are pressing lawmakers to pass bills that would replace the 2010 health care law and raise the debt ceiling before they leave for their August break, clearing the fall months for tax overhaul and government spending fights. President Donald Trump intends to discuss Republicans’ “path forward” on a health care overhaul and his proposed tax package during a Tuesday afternoon meeting at the executive mansion, said Marc Short, White House legislative affairs director.”
  • Millions of dollars’ worth of research in limbo at NIH – Washington Post (Jun 4)
    “The leadership at the National Institute on Deafness and Other Communication Disorders […] has banned the use of data collected over 25 years from more than 1,000 volunteers in the lab of neurologist Allen R. Braun, citing “serious and widespread” record-keeping errors, all of them clerical matters related to forms used for matters such as screening volunteers or logging physical exams. But there have been no allegations that data was altered, plagiarized or fabricated, and no one’s safety was threatened — the kind of misconduct that usually leads to such severe penalties in scientific research. Many people say the harsh punishment stems, instead, from a long-standing conflict at the institute, whose leadership has forced numerous scientists like Braun to leave in recent years.”

June 2, 2017

With the House and Senate out on a district/state work week, we are told the Senate staff are trying to finalize a draft of a Senate version of the American Health Care Act (AHCA) for Senators to review upon their return.  The Senate Budget Committee is helping to coordinate the activities of the committees that received reconciliation instructions (the Finance and HELP Committees).   Even if an initial draft is ready for review next week, we are still expecting the Senate to turn to this bill in July rather than this month.

There was also speculation this week around the future of the Senate Parliamentarian as she wades into the perilous waters of what is considered “extraneous” in the reconciliation bill and therefore should fall out under the Byrd Rule.  Our newest colleague Marty Paone wrote about that in more detail here.

We are also expecting the House Energy and Commerce Committee to take further action on their version of the FDA reauthorization bill (the so-called PDUFA bill).  Committee staff are working hard to resolve the final issues so that it can be reported on a voice vote or a strong bipartisan vote.

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

  • GOP Senators Weigh Taxing Employer-Health Plans – Wall Street Journal (June 1)
    “Senate Republicans set on reworking the Affordable Care Act are considering taxing employer-sponsored health insurance plans, a move that would meet stiff resistance from companies and potentially raise taxes on millions of people who get coverage on the job. The move could raise billions in revenue that could be used to help stabilize the fragile individual insurance market.”
  • Trump moves to allow broad exemption from ACA birth-control coverage – Washington Post (May 31)
    “The Trump administration has drafted a regulationthat would dramatically scale back the federal mandate that employers provide free birth control coverage, by providing an exemption to anyone who raises religious or moral objections.”
  • States Press Senators on Medicaid Expansion Funds – Bloomberg BNA (May 31)
    “State officials and their lobbyists are pressing a group of U.S. senators privately crafting a health care bill to save Medicaid expansion funds under the Affordable Care Act. Federal health care legislation is the top issue coming out of Washington for state lawmakers and governors, state officials tell Bloomberg BNA. Gov. John Kasich (R-Ohio) said he is working with “like-minded” senators and governors to preserve coverage for people “dealing with mental illness, addiction and chronic illness.” In a statement to Bloomberg BNA, he said he was hopeful that senators “will find the right way forward.””
  • Health experts are furious with Trump for pulling out of the Paris climate agreement – LA Times (June 1)
    “But the people who pay attention to public health want to remind you that a warmer planet will bring more air pollution, fuel the spread of infectious diseases and increase the incidence of certain cancers, among many other things. (For a full accounting of how climate change impacts human health, check out this reportfrom the National Institute of Environmental Health Sciences or this assessment from the U.S. Global Change Research Program.)”
  • Health officials vow to develop drugs to curb the opioid epidemic – Washington Post (May 31)
    “Top federal health officials said Wednesday that they will launch a joint effort with pharmaceuticals companies to accelerate the development of drugs aimed at helping to curb the U.S. opioid epidemic. Francis S. Collins, director of the National Institutes of Health (NIH), and Nora D. Volkow, who heads one of its components, the National Institute on Drug Abuse (NIDA), announced a public-private partnership aimed at cutting in half the time ordinarily needed to develop new therapies.”