A North Carolina hospital unhappy with the relief it received after asking a Medicare contractor to reopen a reimbursement decision is barred from seeking formal agency review because it voluntarily withdrew its first appeal, a federal court said Monday.
A Provider Reimbursement Review Board rule forbidding a second formal appeal when the first has been withdrawn didnât deprive FirstHealth Moore Regional Hospital of its appeal rights because FirstHealth opted to go through the reopening process, the U.S. District Court for the District of Columbia said.
âThis case offers a cautionary tale to any provider navigating the âlabyrinthine world of Medicare,ââ as FirstHealth based its strategy on the misunderstanding that the rules allowed it to reinstate its formal appeal after the reopening process ended, the court said.
A Medicare contractor determined that FirstHealth owed the government about $1.45 million for overpayments for fiscal year 2011. The hospital filed a formal appeal with the PRRB, but then withdrew the appeal after it asked the contractor to take another look at its reimbursement for uncollectible patient debts.
After reopening the case, the contractor allowed reimbursement for some previously denied bad debts, but not others. FirstHealth thus was eligible to receive an additional $833,000, reducing the amount it was required to repay to the U.S. Health and Human Services Department.
FirstHealth then tried to revive its PRRB appeal, but the board denied reinstatement. The court granted summary judgment to HHS in an opinion by Chief Judge Beryl A. Howell.
Under the PRRBâs withdrawal rule, itâs âthe providerâs responsibility to withdrawâ any issue a contractor has agreed to review from the appeal, the court said. FirstHealth argued the provision is mandatory and, thus, unlawfully deprived the hospital of its appeal rights.
The PRRB, on the other hand, argued the provision isnât a command. A providerâs withdrawal of its appeal is entirely voluntary, it said.
The court found both readings of the provision to be reasonable. But the ambiguity gave the advantage to the PRRB because an agencyâs interpretation of its own regulations is entitled to deference, the court said. PRRBâs interpretation, moreover, was reasonable, it said.
FirstHealth opted to pursue the reopening process, when it could have continued with the formal appeal, the court said. It wasnât âforcedâ to give up its appeal rights at any point, it said.
Law Office of Joseph D. Glazer PC represents FirstHealth. The U.S. Attorneyâs Office for the District of Columbia represents HHS.
The case is FirstHealth Moore Regâl Hosp. v. Becerra, D.D.C., No. 20-cv-1007, 9/20/21.
House Energy & Commerce Chair Frank Pallone recently pledged to work with lawmakers from both parties moving forward to avert physician pay cuts, but the New Jersey Democrat said nowâs not the time to act given CMS just received comments on its proposed 2022 fee schedule. Lawmakers from both parties want to eventually stop the cuts, but E&C Democrats rejected a GOP bid this week to add a pay fix to the emerging budget reconciliation bill.
Meanwhile, physicians and lawmakers are also pressing CMS to back away from the cuts on its own.
The American Medical Association has estimated that certain providers could be looking at an almost 10% cut, unless lawmakers step in.
Some providers could see pay cuts in 2022 due to a variety of policies, from the end of the sequester moratorium to a phase-in of certain cuts tied to changes to evaluation and management pay under the physician fee schedule and changes to clinical labor policies under the proposed 2022 physician fee schedule, among others.
Rep. Larry Bucshon (R-IN) said Wednesday (Sept. 15) during the Energy & Commerce reconciliation markup that Democratsâ bill essentially ignores that some physicians could see a substantial cut in 2022. He called for an amendment to extend for a year the 3.75% payment adjustment that Congress put in place last year in order to ease cuts tied to changes to evaluation and management pay policies under the physician fee schedule.
âThis idea isnât partisan,â he reminded lawmakers, pointing to efforts with Rep. Ami Bera (D-CA) to head off physician cuts. âAs we consider a bill that comes with a high price tag of a trillion dollars, why not set aside a very small fraction of that to say thank you to our health care heroes by providing them with the certainty and support they so admirably deserve.â
Bucshonâs comments came just days after Rep. Brad Wenstrup (R-OH) raised concerns at a House Ways & Means markup about adding more providers to a Medicare pay system that is already unstable, and he also pointed to the looming physician pay cuts.
Rep. Kurt Schrader (D-OR), who voted against adding hearing, vision and dental benefits to Medicare during the House Energy & Commerce markup, said dentists might not want to be part of a program that has had unstable pay rates, pointing to the historical Sustainable Growth Rate payment formula and fixes lawmakers routinely put in place to avoid cuts to doctors.
House Ways & Means Chair Richard Neal (D-MA) said he would work with Wenstrup on the physician pay issue, and, while Bucshonâs amendment was defeated, Pallone said he hopes to find a bipartisan solution in the future.
âI do not think this is the right time or place to address these issues,â Pallone said, noting stakeholdersâ myriad concerns. âThe comment period on the physician fee schedule only recently closed and the final rule is under development. I do think ensuring robust physician payment is an important issue…I look forward to working with stakeholders and members on these issues as we go forward.â
The American Medical Association late last month raised alarm about the upcoming Medicare cuts and asked that the reconciliation package be used to instruct lawmakers to draft and mark up legislation to prevent a so-called pay cliff for physicians come January 2022.
A draft letter to congressional leadership spearheaded by Bera and Bucshon said a short-term fix is needed to deal with payment instability while a longer-term solution for the Medicare pay system for providers is found.
âWe believe broad systemic reforms to the payment system are critical to speed the transition to value-based care. However, as Congress begins the complex process of identifying and considering potential long-term reforms, we must also create stability by addressing the immediate payment cuts facing health care professionals. These cuts will strain our health care system and jeopardize patient access to medically necessary services,â a draft of the letter says (emphasis theirs).
Reps. Bobby Rush (D-IL) and Gus Bilirakis (R-FL), meanwhile, spearheaded a letter signed by more than 70 lawmakers sent directly to CMS urging the agency not to move forward with their proposed changes to the clinical labor policy in the proposed 2022 physician fee schedule, as the changes could lead to up to 20% cuts for certain provider types. The lawmakers raised concerns in particular with the budget-neutral nature of CMSâ proposed changes — though the agency canât change the budget-neutral aspect of the rule.
âConsidering that the second-order negative effects of PFS âbudget neutralityâ strongly outweigh incorporating new clinical labor data, we strongly recommend CMS not finalize the clinical labor policy at this time in the 2022 PFS Final Rule,â the lawmakers said.
They also urged CMS to work with them to avoid the 3.75% cut that would come from phasing in the reductions tied to changes to evaluation and management pay changes.
âMoreover, considering PFS âbudget neutralityâ effects from the 2021 PFS Final Rule E/M policy are still causing negative impacts in the form of a scheduled 3.75 percent cut to the conversion factor in 2022, we urge you to work with Congress on fundamental reform to the PFS in order that we may better address the upcoming 3.75 percent cut in legislation later this year.â — Michelle M. Stein (mstein@iwpnews.com)
The Justice Department is targeting over $1.4 billion in alleged health-care fraud in a nationwide enforcement spree involving 138 defendants and 42 doctors and nurses.
The Friday announcement includes $1.1 billion in alleged schemes involving telemedicine companies arranging for fraudulent orders for expensive durable medical equipment and genetic testing, according to Assistant Attorney General Kenneth Polite, who spoke to reporters.
That part of the announcement could have a chilling effect on the future of telehealth, which has expanded rapidly during the Covid-19 pandemic but which has been the target of significant DOJ enforcement actions for three years running.
The Department of Health and Human Services Office of Inspector General is conducting a nationwide review of fraud and compliance trends in telehealth during the pandemic. The results of the audits could play a role in Congress as lawmakers consider whether to allow the Covid-19 expansion in telehealth to become permanent.
The enforcement action also involved $133 million in fraud connected to substance use facilities, $29 million in Covid-19 fraud, and $160 million in illegal opioid distribution and other health-care fraud schemes, the DOJ said in a Friday statement.
âThe ability to provide health care remotely is a critical tool in the delivery of health-care services, and is a reason the Department of Justice remains committed to ensuring that the adoption of this technology is not tainted by wrongdoers,â Polite told reporters.
The announcement involved a group of similar cases that were charged by the DOJ around the country between Aug. 1 and Sept. 17, according to Joshua Stueve, a department spokesman.
The telemedicine schemes involved companies allegedly paying doctors and nurse practitioners to order unnecessary durable medical equipment, genetic and other diagnostic testing, and pain medications, the DOJ statement said.
In many cases, the participating doctors and nurses entered orders without any patient interaction or with only a brief phone conversation with patients they had never seen, it said.
The DOJ alleged in the biggest of the cases that a Florida owner of several telemedicine companies carried out a $784 million scheme involving illegal orders for durable medical equipment and kickbacks to doctors and nurses who wrote fraudulent orders.
But telehealth advocates criticize the Justice Departmentâs rhetoric about these fraud cases and what they say is its failure to distinguish traditional fraud carried out using the reach of telemarketing from fraudulent claims for the provision of telehealth services.
Most of the cases charged Sept. 17 involved conduct that took place before the Covid-19 pandemic and before the Centers for Medicare & Medicaid Services relaxed restrictions on telehealth as a means of ensuring continuing access to health-care services amid pandemic-related restrictions, Allan Medina, chief of the Health Care Fraud Unit in the DOJâs Criminal Division, told reporters on the call.
The cases also didnât for the most part involve fraudulent billing for telehealth services, with the exception of a Florida case in which doctors took advantage of the relaxed regulations to bill for telehealth encounters that never took place, as well as to provide orders for unnecessary medical equipment, Medina said.
The Alliance for Connected Care, a supporter of expanded telehealth services, said in a statement that it was âconcerned by the incorrect narrative created by continued DOJ accusations of telehealth fraud.â
âWe encourage the DOJ to consider the meaningful corrections made by the HHS OIG in February 2021 when it clarified the difference between âtelefraudâ schemes (which this represents) from telehealth fraudâwhich there has been very little evidence of thus far,â Krista Drobac, the allianceâs executive director, said in the statement.
A September 2020 DOJ health-care fraud âtakedownâ included more than $4.5 billion in schemes involving telemedicine.
A takedown from the year before involved $2.1 billion in fraudulent claims for cancer-related genetic testing orchestrated by telemedicine companies working with testing laboratories and providers.
The alleged $784 million fraud scheme is United States v. Henry, D.N.J., No. 2:19-cr-00246, superseding indictment 8/10/21.
Senate Democrats put off plans to consider some of their annual government funding bills next week due to Republican opposition, Senate Appropriations Committee spokesman Jay Tilton said in a statement Friday.
Senate Appropriations Chairman Patrick Leahy (D-Vt.) âhad hoped to consider additional billsâ in the committee next week, but Republicans are opposed to further bills âuntil there is a budget agreement,â Tilton said.
The move highlights the lack of progress made toward a government funding deal as lawmakers have put off bipartisan talks on top-line defense and nondefense spending. House members will vote next week on a stopgap funding measure to avert a shutdown after the Sept. 30 deadline, House Majority Leader Steny Hoyer (D-Md.) said in a letter to colleagues Friday.
The panel was expected to hold markups next week on the Transportation-HUD spending bill, according to Sen. Susan Collins (R-Maine), and the Legislative Branch spending bill, according to Sen. Jack Reed (D-R.I.). Collins is the ranking member of the Transportation-HUD Subcommittee and Reed is the chairman of the Legislative Branch Subcommittee.
Republicans planned to attend the markups and vote against the bills, after briefly considering a boycott, Vice Chairman Richard Shelby (R-Ala.) told reporters Tuesday.
Tiltonâs statement said the markups were put off because Republicans decided to âblock movement.â He declined to say whether that referred to an anticipated boycott of the markups or simply Republican opposition to the bills.
âRepublicans were planning to go to markup but would have simply voted ânoâ on the bills, in the same way that the Democrats did previously,â Blair Taylor, spokeswoman for Shelby, said in a statement.
Taylor said Republicans have been âstonewalled in efforts to negotiate a deal on defense/non-defense spending.â
âDemocrats have refused a productive FY22 process by blocking all efforts to reach an agreement on topline numbers, policy riders, and poison pills,â Taylor said. âIt is clear to everyone involved that having an agreement on those things is the only path to success in the Senate.â
The Appropriations Committee is evenly divided between the two parties. In the event of a tie vote in the full committee, under the Senateâs power-sharing agreement, Leahy could transmit a notice to the Senate and Majority Leader Chuck Schumer (D-N.Y.) could seek to bring the bill to the floor through a motion to discharge, which would be subject to four hours of debate.
Senate appropriators marked up three bills in August, advancing the Agriculture-FDA (S. 2599), Energy and Water (S. 2605), and Military Construction-VA (S. 2604) spending bills by 25-5 votes. But Republicans warned appropriations bills wouldnât pass on the floor without a broader agreement on defense and nondefense spending levels.
Leahy has called for bipartisan, bicameral negotiations on top-line spending levels, but also thinks appropriators should continue working on their bills despite the lack of an agreement, Tilton said in the statement.
âThe Chairman has been working across the aisle for months now to draft additional bipartisan bills that could have, and should have, been reported from the Appropriations committee with majority votes,â Tilton said. âHe has been calling for bipartisan, bicameral, negotiations, to establish topline spending between defense and nondefense programs, and he will continue to press for progress on this front. But the Committee has work to do in the meantime and it should be doing it.â
Senate Democrats put off plans to consider some of their annual government funding bills next week due to Republican opposition.
Labor, aging, and disability advocates are fighting to get lawmakers to put at least $250 billion toward a plan to expand home and community-based care for the elderly and disabled and improve conditions for the poorly paid workers that tend to them.
The plan, which the White House wants funded at $400 billion over eight years, could fail, though, if Congress ultimately approves an amount thatâs less than what states deem adequate. In that case, states could choose not to take the money and leave their Medicaid programs running as is.
âIn order for states to take that on, they need to know that the funding will be there, and the funding will be robust enough to allow them to both set up the infrastructure and to deliver the services and the improved wages,â Ai-jen Poo, co-founder and executive director of the National Domestic Workers Alliance, said.
The proposed cash infusion into Medicaidâs Home and Community Based Services program has two goals: reducing waiting lists for support for older and disabled Americans who want to stay in their homes rather than go into assisted living facilities or other institutions, and raising pay for home health careâs largely female, minority workforce.
Medicaid is the largest payer of long-term support services such as home care for the elderly, but states are not required to participate in the home and community-based program.
Home care, though, is much cheaper, overall. The yearly average cost, per person, of a nursing home to Medicaid is $90,000 compared with $26,000 for home care workers, according to Poo.
And although home health workers are one of the fastest-growing segments of the labor market, they typically earn about $17,000 per year, often without benefits, Poo said.
Boosting the program âwould be the single largest direct investment in the creation of good jobs for women and women of color in the history of the country,â she said.
The home care initiative began to draw attention when then-candidate Joe Biden put it on his campaign platform. Heâs proposed the $400 billion as part of his $2 trillion infrastructure proposal known as the American Jobs Plan.
Advocates, worried after hearing that just $150 billion would be included for the program in the Houseâs $3.5 trillion budget reconciliation package, succeeded in getting the amount bumped up to $190 billion before the provision was approved by the House Energy and Commerce Committee, said Nicole Jorwic, senior director of public policy at The Arc, a nonprofit that advocates for people with intellectual and developmental disabilities.
âI was really concerned when some people were putting the number 150 on it. That was a level where we wouldnât be confident we could do it right,â Sen. Robert Casey (D-Pa.) said in an interview. The Congressional Budget Office told Caseyâs office that, based on its experience with Medicaid expansion under the Affordable Care Act, states wonât expand their HCBS program unless they get enough funding.
âYou have to make sure you build something where youâre going to both increase services, but you have enough resources to build wages also,â said Casey, the chief architect of the plan and lead sponsor of the legislation behind it.
âWhen budgets are tight, states lean towards services as opposed to raising wages, and itâs always the workers who get left behind,â Poo said.
Itâs possible that funding came in at $190 billion in the House bill because multiple committees have jurisdiction over health-care funding, Jorwic said.
She said she was âhopefulâ that, ultimately, the program would be funded at a higher level when the reconciliation bill goes to the Budget and Rules committees. Groups that work on the issue say the White House, Speaker Nancy Pelosi (D-Calif.), and Senate Majority Leader Chuck Schumer (D-N.Y.) all appreciate the importance of providing enough funding to get states on board, she added.
Although advocates are fighting for $250 billion, the program really requires $400 billion to deal with âthe scale and scope of the problem,â and to allow the U.S. to âturn home care jobs into good living wage jobs and expand access to care,â Mary Kay Henry, president of the Service Employees International Union, said. SEIU represents about 740,000 home-care workers.
SEIU doubled its ad campaign Tuesday in support of the home care plan, spending another $3.5 million to call on Congress to support ample funding. $400 billion would fuel 1.4 million direct and indirect jobs, and expand access to care for 3 million people, Henry said.
âThe additional money gives us a fighting chance at the state level to make these poverty jobs living wage jobsâ with sick leave and medical benefits, she said.
Meanwhile, the urgency underscoring the issue stems not just from a need to expand access to home services and improve wages but by the fact that 10,000 people are aging into retirement per day, Poo said.
âWhat weâre hearing is that the vast majority of Americans, 88%, want to age at home and in the community. And we just are not prepared for that,â Poo said.
The current access crisis âcould become a catastrophe if we donât invest in home and community-based care,â she said.
Biden asked for $400 billion, House is at $190 billion. Plan aims to boost access to home services, raise pay for aides.
With the sound of one final gavel, House Democrats on Wednesday completed the mammoth task of translating President Bidenâs economic vision into a $3.5 trillion tax-and-spending proposal â marking a major milestone in a fight thatâs still far from finished.
Assembling the House package proved to be an enormous undertaking, as Democrats raced over the past week to produce roughly 2,600 pages of legislative text spanning the partyâs vast policy ambitions. The measure seeks to shepherd major changes to federal health care, education, immigration, climate and tax laws, introducing a sprawling set of federal programs that Democratic leaders have described as historic in their size and scope.
But the fruits of lawmakersâ labors quickly seemed overshadowed by political reality. A proposal that would try to lower the cost of prescription drugs for millions of seniors appeared in fresh jeopardy, after a small group of Democrats dealt it an early blow in the House. The fuller $3.5 trillion plan, meanwhile, faced even more significant hurdles in the Senate â prompting Biden to embark on a renewed effort Wednesday to try to reassure wavering members of his own party.
In a burst of personal outreach, Biden huddled with Sen. Kyrsten Sinema (D-Ariz.) in the morning, then met withSen. Joe Manchin III (D-W.Va.) later in the day. Both centrists have signaled they are unwilling to vote for a final package unless Democrats come down in cost. Their opposition has infuriated liberal lawmakers, including Sen. Bernie Sanders (I-Vt.), who has rebuffed their attempts to whittle down the size of the plan â putting Democrats on a collision course in a chamber where they simply have no votes to spare.
âThe president certainly believes thereâll be ongoing discussions,â White House press secretary Jen Psaki said Wednesday. âNot that thereâs necessarily going to be a conclusion out of those today, but that was the primary focus and purpose of these meetings.â
If Democrats ultimately choose to reduce their spending, it may force the party to compromise on some of its core ambitions, a prospect that was not lost on Rep. John Yarmuth (D-Ky.), the Houseâs top budget-maker. He described the renewed objections as a âsource of great frustration,â adding in an interview earlier this week that the caucus is holding firm.
âA significant number of our caucus â at least half, and probably significantly more than half â wanted to do more than $3.5 trillion,â he said. âItâs very frustrating for most of us, and I think it strengthened our resolve to move forward.â
For now, at least, House Democrats have secured the general policy objectives Biden outlined in the two blueprints he unveiled earlier this year. The president and his congressional allies have framed their $3.5 trillion agenda through the prism of history, likening it to the Great Society and New Deal investments from generations past.
The Build Back Better Act aims to expand Medicare, offering seniors access to hearing, dental and vision benefits. It also would extend a flurry of tax credits and other programs that make insurance more accessible and affordable, including for low-income Americans who seek coverage under Medicaid.
âIt also finally closes the Medicaid coverage gap, which will expand coverage to more than four million uninsured Americans,â promised Rep. Frank Pallone Jr. (D-N.J.), the leader of the Energy and Commerce Committee, which debated the matter this week.
Democrats further set in motion a plan for roughly $750 billion to improve education and child care, including a new program that guarantees prekindergarten for all children ages 3 and 4. They authorized 12 weeks of paid family and medical leave for most working Americans, remedying a patchwork that leaves many without benefits today. And they crafted what lawmakers have described as the most significant set of legislative reforms ever to combat climate change, including a flurry of programs that reward clean energy, penalize polluters and help Americans finance more environmentally friendly homes and vehicles.
Much of the work is financed through a series of tax increases targeting wealthy Americans, profitable corporations and investors. The tax hikes stop short of what Biden initially had recommended, including by omitting new taxes targeting inheritances passed between family members. But they generally accomplish Democratsâ aims to unwind the tax cuts enacted under President Donald Trump four years earlier â all while raising about $2.9 trillion in revenue to cover the cost of the bill. Democrats contend the entire measure is financed in full since it fosters economic gains that essentially pay for themselves.
âMillions of Americansâ lives will change for the better thanks to these provisions,â said Rep. Richard E. Neal (D-Mass.), who chairs the tax-focused House Ways and Means Committee, during a hearing Tuesday. He said the tax increases ask the âbiggest companies and the ultrawealthy to contribute more to the common good.â
Republicans unanimously have opposed the $3.5 trillion package, swiping at it repeatedly over the past week as reckless and wasteful. GOP leaders have alleged the combination of spending and tax increases would worsen the deficit, intensify inflation and erase the economic gains they secured before the pandemic under Trump.
âThis is exactly what we said was coming: an economic surrender,â said Rep. Kevin Brady (R-Tex.), the top Republican on the Ways and Means Committee, during an interview on Fox Business. âWeâre going to lose jobs to China, Russia, Europe and other countries. Theyâre going to clean our clock.â
Democrats still plan to fine-tune the proposal before bringing it to the House floor, all the while continuing negotiations with the Senate on a package that can clear both chambers. They face a race against the clock to finish their work before Sept. 27, at which point House Speaker Nancy Pelosi (D-Calif.) has promised she would move the House to begin considering a roughly $1 trillion effort to upgrade the nationâs infrastructure.
To pass it, Democrats intend to use the process known as reconciliation, which will allow party lawmakers to sidestep a Republican filibuster â but only if Pelosi and Senate Majority Leader Charles E. Schumer (D-N.Y.) can keep their caucuses together. Pelosi has only three votes to spare in the House, and Schumer has none in a Senate where Democrats can only break ties, leaving the party unable to afford defections.
With time tight, and the margin for error increasingly slim, Pelosi issued a plea to her caucus earlier this week, writing in a letter that Democrats must âstay united in our quest to reach our goal and honor our values.â
Already, though, there are signs that Democrats have started to stray.
As House lawmakers finalized their work Wednesday, Sinema and Manchin individually met with Biden at the White House. Manchin only a day earlier reiterated his opposition to a $3.5 trillion bill, as he instead proposed a package that could be only half that size. Manchin also has taken aim at key elements of Democratsâ plans to combat climate change, setting up further infighting as the debate shifts to the Senate.
Officials on Capitol Hill and at the White House said the separate meetings marked the first substantive chance for Biden to engage directly with the two pivotal senators and declined to discuss the sit-downs in much detail. Sinema spokesman John LaBombard said only that her meeting with Biden was âproductiveâ and added: âKyrsten is continuing to work in good faith with her colleagues and President Biden as this legislation develops.â
Publicly, though, White House chief of staff Ron Klain said at an event Wednesday that the $3.5 trillion package could be scaled back by cutting down the size of some new programs or trimming the duration of some of the spending. But he also made the case â aimed at the deficit-minded centrists in the Democratic Party â that the package at its current size ultimately would be paid for.
âThe truth is, the cost of the Build Back Better plan is zero,â Klain said Wednesday during remarks at the SALT conference for investors and financiers.
House Democrats have spent the past week preemptively trying to ward off cuts to the cost, fearing that a smaller tax-and-spending package could imperil some of their most prized programs. That includes an extension of the expanded child tax credit, a program that aims to cut child poverty by allowing families to obtain bigger tax benefits paid on a monthly basis. Democrats opted to sunset the proposal in 2028, rather than extend it permanently as they initially hoped, to respond to spending concerns.
âI think the focus on a top line number is distracting from focusing on the substance of the bill,â said Rep. Suzan DelBene (D-Wash.), the leader of the moderate-leaning New Democrat Coalition. âYouâve got to look at what the other bill does.â
Senate Democrats have sought to tinker with a wide array of additional programs in the proposal. Manchin has raised the need for new work requirements on the child tax credit, an idea liberal lawmakers see as unacceptable. Other tensions linger among Democrats over climate change, as a subset of Democrats continue to push for a border tax targeting pollution and additional funding for other elements to combat emissions.
And Sen. Ron Wyden (D-Ore.), the leader of the chamberâs top tax committee, has pursued a series of additional tax increases targeting offshore earnings, stock buybacks and family inheritances that Neal in the House opted not to include in the proposal he advanced through the committee. Otherwise, Wyden maintained in a recent interview that the chambers are ârowing in the same directionâ on taxes.
With significant swaths of the reconciliation bill still unsettled, Yarmuth, the Houseâs budget chairman, said he anticipated the chamber may have to proceed in two steps.
âI think that it looks right now like weâll probably proceed to do our own bill and see if we can get 218 votes in the House to pass it, rather than wait for the Senate to act,â he said. âIt looks like right now weâre going to end up getting the bill back from the Senate. The Senate is not as far along with some of their deliberations.â
Even more severe headaches emerged this week over Democratsâ plans to try to pursue prescription drug pricing reforms as part of an up-to $3.5 trillion reconciliation package. Lawmakers including Pelosi, a fierce advocate for the proposal, say they must empower Medicare to negotiate friendlier rates for seniors. But they have faced immense opposition from the pharmaceutical industry, which has run ads attacking party lawmakers, as well as a set of centrist Democrats.
The tensions flashed publicly Tuesday, as three Democrats on the House Energy and Commerce Committee pledged they would vote against the drug pricing plan. Reps. Scott Peters (Calif.), Kathleen Rice (N.Y.) and Kurt Schrader (Ore.) ultimately kept their promise a day later, leaving the panel deadlocked and unable to advance the policy.
âI want to be clear â I support Medicare drug price negotiations,â Schrader said this week. In response, he put forward his own counter offer that would limit Medicareâs power to negotiate to âthe most expensive subset of drugs on the market.â
The pricing policy also has added significance, serving as a major financing piece of the broader $3.5 trillion package, as Democrats estimate it could raise billions of dollars to offset their spending. Another House committee has adopted the proposal, giving party leaders additional options to advance it â provided they can overcome dissent within their own ranks.
The still-widening schisms ultimately did not seem to faze Pelosi, who sent a second letter to House Democrats on Wednesday in the hours before lawmakers concluded their work.
âThe vision and knowledge of President Biden and Congressional Democrats,â she began, âhas enabled us to be on schedule in delivering the Build Back Better agenda.â
House lawmakers put finishing touches on their $3.5 trillion plan and the president meets with senators who hold pivotal votes.
House Democrats have taken their first steps to advance a sweeping social spending and tax package that would implement President Joe Bidenâs economic agenda.
Thirteen committees approved legislation to be included in a reconciliation package that can be used to try and pass Democratsâ policies without Republican support. The fiscal 2022 budget resolution (S. Con. Res. 14) adopted in August gave the panels until Sept. 15 to report legislation that would increase or decrease the deficit by specified amounts over 10 years.
The House Budget Committee will assemble the measures approved by the various committees into the reconciliation bill that could be considered by the House later this fall.
Below are highlights of the approved measures.
The budget resolution directed the Ways and Means Committee to reduce the deficit by $1 billion over 10 years, a ânominalâ amount intended to give the panel flexibility to draft its legislation, including offsets for the reconciliation package.
The measure covers taxes, health care, drug pricing, paid leave, infrastructure financing, community development, retirement, child care, and trade.
Tax Increases: The Ways and Means package includes sweeping tax changes to raise revenue for other portions of the package, including:
Tax Credits: Other tax provisions in the measure are designed to aid certain households and industries, such as:
Drug Pricing: The measure would create a âFair Price Negotiation Programâ for the Centers for Medicare and Medicaid Services to negotiate the price of 250 covered drugs and insulin. Prices couldnât exceed 1.2 times the average price of the drug in six other countries. They would also be available to private insurance plans.
Drugmakers that donât negotiate successfully would face an excise tax of as much as 95%. Those that charge more than the negotiated maximum price would pay as much as ten times the difference in prices.
The measure would also:
Medicare Coverage: The measure would expand Medicare coverage to include dental benefits beginning in 2028, hearing benefits beginning in 2023, and vision benefits beginning in 2022. For dental benefits, Medicare would cover 50% of the cost of major treatments and 80% of the cost of preventive services. Hearing coverage wouldnât include over-the-counter hearing aids.
Reinsurance Program: The measure would provide $10 billion annually for a fund to provide reinsurance payments to insurers operating in marketplace exchanges and assistance to individuals to reduce out-of-pocket costs.
Paid Leave: The measure would provide up to 12 weeks of paid leave for eligible workers for the birth or adoption of a child, a personal health condition, caregiving for a family member, circumstances related to a family memberâs deployment, and bereavement. Benefits would be administered by the Treasury Department and would begin in July 2023.
Infrastructure & Community Development: The measure includes several tax changes related to infrastructure financing and community development, such as:
Child Care: The measure would provide:
Retirement: The measure would require employers with more than five workers to automatically enroll new hires for retirement benefits. Employees could choose to opt out of the savings plan or modify contributions. Employers would be subject to an excise tax of $10 per day for each employee who isnât covered by an automatic retirement plan.
Trade:Â The measure would reauthorize Trade Adjustment Assistance (TAA) programs for seven years and provide $3.4 billion annually for those programs, including $1 billion annually through fiscal 2026 for new grants to help communities affected by global trade.
The measure includes provisions on education, child care, labor, and child nutrition programs.
Education: The measure would provide roughly $111 billion for higher education, including by:
It also would provide $82 billion to rebuild public elementary and secondary schools that have fallen into disrepair. That would include $40.9 billion for grants for school districts to construct or repair facilities, improve energy efficiency, and reduce health and safety hazards.
Child Care: The measure would provide $450 billion for child care and early childhood education, including by:
Labor: The measure would provide:
Child Nutrition: The measure would provide almost $35 billion for child nutrition programs and other activities to address child hunger, including:
The measure includes language related to health care, energy and environmental matters, telecommunications, and manufacturing. The panel didnât agree to drug pricing provisions, similar to whatâs in the Ways and Means package, in a tie vote with three Democrats joining Republicans in opposition.
Medicaid: The measure would close the Medicaid coverage gap for lower-income individuals in states that didnât expand the program under the Affordable Care Act by:
Medicare Coverage: The measure would expand Medicare coverage to provide dental benefits beginning in 2028, hearing benefits beginning in 2023, and vision benefits beginning in 2022.
CHIP: The measure would make the Childrenâs Health Insurance Program (CHIP) permanent and appropriate âsuch sums as are necessaryâ for it. It also would allow states to increase the income level needed for families to participate in CHIP and require states to provide one year of continuous eligibility for children enrolled in CHIP.
Other Health Programs: The measure would provide:
Energy and Environment: Funding for clean energy and environmental initiatives would include:
The measure would establish a fee on methane emissions from the oil and gas industry, the proceeds of which would be used to monitor and reduce greenhouse gas emissions at oil and gas operations.
Communications: The measure would provide:
It also would direct the Federal Communications Commission to auction 200 megahertz of spectrum to offset the cost of other provisions.
Manufacturing:Â The measure would provide $10 billion for efforts to strengthen and diversify critical manufacturing supply chains that affect interstate commerce.
Housing: The measure would provide:
Flood Insurance:Â The measure would wipe out $20.5 billion in debt owed by the Federal Emergency Management Agency for money it borrowed to pay claims through the National Flood Insurance Program. It also would provide $3 billion for flood mapping and $1 billion for FEMA to offer flood insurance discounts to low-income policyholders.
Immigration: The measure would make green cards and a pathway to citizenship available to Dreamers who were brought to the U.S. as children and reside here illegally, essential workers, and holders of Temporary Protected Status and Deferred Enforced Departure.
It also would roll over green cards from year to year, allowing for additional visas to be issued following years when the numerical caps arenât reachedâas happened during the Covid-19 pandemic.
Other Programs: The measure also would provide:
The measure would provide:
House Agriculture Chair David Scott (D-Ga.) said heâd work to add $28 billion in aid to farmers and ranchers related to climate and conservation before the House votes on the full package, Bloomberg Government reported.
The measure would provide funding for a variety of transportation projects, including:
The measureâs funding for science and technology programs would include:
The measure would provide around $31 billion over a decade for climate resilience, conservation, and other environmental initiatives. That total would be partially offset by increased fees on oil and gas companies to reach the $25.6 billion net spending target set by the budget resolution.
The spending would include $9.5 billion for environmental restoration in coastal areas and around the Great Lakes, $3 billion to create a Civilian Climate Corps at the Interior Department, and $2.5 billion for cleanup activities at abandoned mines.
Revenue raisers and other provisions aimed at the drilling and mining industries would:
The measure would provide $15.2 billion for infrastructure improvements to national cemeteries and memorials, medical facilities, and other property. It also would include $1.81 billion for major medical facility leases.
The measure would extend through fiscal 2026 the Veterans Affairs Departmentâs authority to enter into enhanced-use leases, which provide underutilized real estate to the private sector for supportive housing for homeless and at-risk veterans. They would be expanded to include leased property that provides services or benefits for veterans.
The measure would include the following amounts for the Small Business Administration:
The measure would provide $7 billion for the U.S. Postal Service to purchase electric delivery vehicles and related infrastructure, and $5 billion for the General Services Administration (GSA) to procure electric vehicles for other federal agencies.
Other funding for the GSA would include $1 billion for the Technology Modernization Fund, which was established to upgrade federal agency IT systems.
The measure would provide $865 million for the Cybersecurity and Infrastructure Security Agency, including to assist federal agencies with multi-factor authentication, endpoint detection and response, improved logging, and securing cloud systems.
More than 70 bipartisan House members have joined a slew of medical organizations in calling for the Biden administration to nix portions of a proposed rule that would cut Medicare payment rates for some specialists by up to 20% next year.
The lawmakers say the cuts in the proposed 2022 Medicare Physician Fee Schedule would undermine Health and Human Services Department efforts to improve health equity by cutting reimbursements for specialists who treat cancer, kidney failure, artery disease, and other diseases that disproportionately affect Black and Latino beneficiaries.
In a letter sent on Monday to Meena Seshamani, deputy administrator and director of the Center for Medicare within the Centers for Medicare & Medicaid Services, the lawmakers blamed the proposed cuts on the âbudget-neutrality effects of a CMS proposal to update clinical labor data.â
The fee schedule requires that any pay increases be offset by payment reductions of equal amounts elsewhere.
âBecause of the aforementioned physician fee schedule âbudget-neutrality,â the incorporation of new clinical labor data actually results in massive cuts of up to 20 percent to critical services,â the lawmakers wrote. âThese impacts also will have profoundly negative effects on health equity.â
The letter, led by U.S. Representatives Bobby L. Rush (D-Ill.) and Gus Bilirakis (R-Fla.), urges the CMS not to finalize the fee scheduleâs clinical labor policy and to âwork with Congress on fundamental reform to the physician fee schedule.â
Some reimbursement updates currently proposed include a 23% cut for a venous ulcer treatment; a 22% cut for certain treatments for peripheral artery disease; a 21% pay cut for a uterine fibroid treatment; an 18% pay cut for certain kidney failure treatments; and a 15% cut for radiation oncology treatments.
HHS on Friday (Sept. 10) announced it will distribute an additional $25.5 billion in COVID-19 relief funds to health care providers, including $17 billion in a phase 4 distribution from the provider relief fund and $8.5 billion in American Rescue Plan Act funds set aside for rural providers. The Biden administration has faced growing pressure from lawmakers, including Senate Minority Leader Mitch McConnell (R-KY), and providers to release the funds.
American Hospital Association President and CEO Rick Pollack praised the move. âThe AHA appreciates the Administration for announcing plans to get additional critical relief funding for providers out the door. Virus cases and hospitalizations continue to climb across the country so providers will continue to need support.â
But Pollack also said hospitals hope HHS will provide additional support moving forward because the most recent funding doesnât account for the spring and summer surges due to the Delta variant.
Providers can apply for both sets of funds through a single application process, which will open Sept. 29, according to AHA. Providers must document revenue loss and expenses associated with the pandemic to get the phase 4 funding.
Thereâs nearly $44 billion left in the $178 billion provider relief fund, though HHS typically says itâs only $24 billion, excluding whatâs leftover from specifics projects.
McConnell, along with four colleagues, had pressed the administration a little over a week ago to swiftly distribute the remaining provider relief and to announce by Sept. 23 whether it would change the initial spending deadline for provider relief recipients who are slammed with a new surge in COVID-19 cases.
The Republicansâ letter to HHS Secretary Xavier Becerra on Sept. 2 came as lawmakers, nursing homes and hospitals also pushed the administration to immediately distribute the estimated $43.7 billion remaining in provider relief, plus the $8.5 billion lawmakers allocated under the American Rescue Plan for rural providers.
â[The provider relief fund] has served as a targeted lifeline to the hospitals and providers on the frontlines who are providing care to patients during the pandemic,â wrote McConnell and Sens. Mike Crapo (R-ID), Roy Blunt (R-MO), Richard Burr (R-NC) and Richard Shelby (R-AL). âYet, during the first seven months of this Administration, the Department has refused to issue any PRF distributions. Our question to you is simple: Why?â
The senators criticized the administration for its missing strategy to disseminate remaining provider relief and reminded Becerra that he had told the House Ways & Means Committee and Senate Appropriations Committee in June that his goal was to avoid mistakes of the past when distributing relief.
âYet nearly three months later, no substantive changes have been made and no PRF funding has been distributed,â the senators wrote Sept. 2, a little more than a week before HHS released additional funds.
The senators had asked the administration to provide by Sept. 23 exact dates and timelines for spending whatâs left of the $178 billion provider relief fund. They also asked what steps HHS had taken to identify how to spend provider relief and to identify providers in need additional relief and how it would calculate the distributions.
They also asked for details on how the administration has engaged stakeholders and acting on their feedback.
Plus, they wanted to know whether the administration would adjust the June 30 spending deadline —Â a delay advocated by providers and lawmakers.
âSome hospitals and health care providers continue to experience increased expenses, delayed elective surgeries, and lost revenues,â the senators wrote. âIn addition, they are incurring the costs associated with vaccinating Americans, particularly partnering with the Department to fovus on those in vulnerable communities.â
Provider relief recipients who received more than $10,000 in relief before June 30, 2020 are required to submit a report of how they used their funds by Sept. 30. Those providers then have 30 days to return any unused relief to HRSA.
HHS on Friday (Sept. 10) announced it will distribute an additional $25.5 billion in COVID-19 relief funds to health care providers.
Nursing homes would get help in retaining workers and also face tougher federal oversight in a slate of elder-care measures advanced by a House panel Friday.
The House Ways and Means Committee approved the elder justice legislation by a 24-18 vote and the nursing home bill by a 24-17 vote. Both pieces will be included in Democratsâ $3.5 trillion sweeping domestic policy package, which the House and Senate aim to send to President Joe Bidenâs desk this month. Stephanie Murphy (Fla.) was only Democrat to vote no â Republicans all voted no.
The quality of nursing home care has come under question since last year, when Covid-19 hit seniors in long-term care facilities the hardest. The virus killed more than 186,000 residents and staff of nursing homes, according to an AARP database.
âThe U.S. population is aging, and to help Americans age and live safely in place without facing the risk of experiencing various forms of maltreatment,â Rep. Richard Neal (D-Mass.), chairman of the Ways and Means Committee, said.
The committeeâs proposal would open up $400 million in grants per year for three years to bolster pay for nursing home workers and help long-term care facilities retain staff through student loan repayment or child-care programs.
It would also empower the government to reduce payments to nursing homes that lie to authorities about their number of workers to hide understaffed facilities. The package would create ombudsman programs to flag elder abuse and neglect.
The American Medical Association is pushing for Congress to continue telehealth flexibilities past the COVID-19 public health emergency and postpone physician payment cuts set to go into effect in January by adding provisions to Democratsâ emerging reconciliation package.
The House Ways & Means and Energy & Commerce committees both released their proposed contributions to the reconciliation package earlier this week. Neither package includes the AMAâs stated priorities. The Senate Finance Committee has not yet unveiled its legislative language, but AMA’s priorities havenât been touted as reconciliation priorities by congressional leaders so far.
AMA supports permanently getting rid of originating site and geographic restrictions on telehealth use for Medicare beneficiaries, AMA Executive Vice President and CEO James Madara said in a Thursday (Sept. 9) statement.
âThe omission of retaining telehealth services for Medicare beneficiaries in the budget resolution is glaring,â Madara said.
Other telehealth advocates have said Congress needs to act on telehealth before the end of the year. The PHE flexibilities that make telehealth coverage so expansive at the moment will expire at the end of the emergency period, which Biden has currently only indicated heâll extend until the end of 2021. However, the PHE could be extended past that, which would give Congress more time to continue coverage.
AMA also wants Congress to use the reconciliation package to prevent what could be up to a 9.75% payment cliff for physicians from kicking in Jan. 1, 2022, and potential Merit-based Incentive Payment System penalties from rising to 9%.
CMS has proposed cutting Medicare physician payment by 3.75% in 2022. This would be on top of the reprieve of the 2% sequester expiring and the burden of a 4% pay-as-you-go (PAYGO) sequester from the American Rescue Plan Act. The 3.75% temporary physician fee schedule conversion factor increase tied to avoiding pay cuts related to budget neutrality adjustments in the physician fee schedule will also expire in 2022, and thereâs a pause in annual Medicare physician fee schedule updates under the Medicare Access and CHIP Reauthorization Act. AMA estimates all these elements together will lead to a 9.75% drop in payment.
Congress should âdraft and mark up legislation that will provide a clear pathway to preventing these cuts from taking place,â Madara said.
The American Medical Association is pushing for Congress to continue telehealth flexibilities past the COVID-19 public health emergency and postpone physician payment cuts set to go into effect in January.
House Democrats plan to pass a stopgap spending bill the week of Sept. 20 to wave off the threat of a government shutdown at month’s end.
Majority Leader Steny Hoyer (D-Md.) privately told Democrats of the plan on Friday, according to sources on the call. Party leaders are eyeing Dec. 10 as a possible end date for a continuing resolution to keep the government open beyond Sept. 30, although the length of that patch has yet to be finalized.
Democratic leaders are thinking about combining that funding bill with action to handle the debt ceiling, in addition to funding for hurricane and flood damages, Afghan resettlement efforts and other priorities. That move would be the majority party’s first step in forcing Republicans to either pony up the votes to avert the impending debt cliff or sink the combination plan to wave off multiple national crises.
Hoyer warned lawmakers on Friday that House leaders might have to add extra voting days in October to accommodate a jam-packed schedule, including passage of President Joe Bidenâs massive social spending plan.
âWhile the House has already completed the vast majority of our appropriations work, Congress must pass a continuing resolution to keep government open and serving our communities as we negotiate final funding bills that invest in working families,â House Appropriations Chair Rosa DeLauro (D-Conn.) said in a statement.
Republicans do not appear to be fazed byDemocratsâ attempts to tie action on the debt ceiling to a must-pass government funding bill. GOP leaders have vowed no help in raising or suspending the cap on how much money the government can borrow while Democrats pursue a multi-trillion spending package without GOP support.
A limit on the nationâs ability to borrow money was reinstated on Aug. 1. Since then, the Treasury Department has taken âextraordinary measuresâ to conserve funds and keep paying the governmentâs bills on time.
Treasury Secretary Janet Yellen warned earlier this week that those measures will be exhausted sometime next month. The Bipartisan Policy Center predicted on Friday that the government could default on its debt between mid-October and mid-November.
Such a breach would lead to economic turmoil, and Yellen has warned that even last-minute action could âcause serious harm to business and consumer confidence, raise short-term borrowing costs for taxpayers, and negatively impact the credit rating of the United States.â
Doctors, hospitals, and other health-care providers are eligible for a new release of $25.5 billion in pandemic assistance, the Health and Human Services Department announced Friday.
Of the funds, $17 billion will go to providers who can show they have lost revenue and expenditures between July 1, 2020 and March 31, 2021. Another $8.5 billion, included in the March $1.9 trillion pandemic-related stimulus package known as the American Rescue Plan Act, will go to doctors and other health workers who serve rural Medicare and Medicaid patients.
âThis funding critically helps health care providers who have endured demanding workloads and significant financial strains amidst the pandemic,â HHS Secretary Xavier Becerra said in a statement. âThe funding will be distributed with an eye towards equity, to ensure providers who serve our most vulnerable communities will receive the support they need.â
The $17 billion will go to smaller providers âwho tend to operate on thin margins and often serve vulnerable or isolated communitiesâ at a higher rate than larger providers. Facilities that serve Medicare and Medicaid patients will also get bonus payments, at Medicare payment rates, âto ensure equity for those serving low-income children, pregnant women, people with disabilities, and seniors.â
The $8.5 billion will go to providers based on the amount of services they provide to rural Medicare and Medicaid patients, also based on Medicare payment rates.
Acting Health Resources and Services Administrator Diana Espinosa said, âWe are committed to distributing this funding as equitably and transparently as possible to help providers respond to and ultimately defeat this pandemic.â
Providers can begin applying for funds Sept. 29.
The HHS also released how it calculated previous payments from the last phase of the Provider Relief Fund, the congressionally approved fund administered by the HHS thatâs designed to help health-care entities that have financially struggled during the pandemic. Providers can request their payments be reconsidered if they believe it wasnât calculated correctly.
Health providers will also have an additional 60 days to meet the fundâs reporting requirements due to ârecent natural disasters and the Delta variant,â the HHS said.
The U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), is awarding $20 million in American Rescue Plan (ARP) grant funding to State-based Marketplaces (SBMs) to increase consumer access to affordable, comprehensive health insurance coverage. The grants will be used by 21 SBMs to modernize IT systems and/or conduct targeted consumer outreach activities to help make health care coverage enrollment smoother. As a result, consumers will have access to increased financial assistance and eligibility determinations will be made faster.
“It should be easy and convenient for anyone to sign up for a health care plan,” said Health and Human Services Secretary Xavier Becerra. “This investment from the American Rescue Plan will help states cover more uninsured residents while providing a smooth transition to other sources of health coverage for Medicaid enrollees who may lose coverage. The Biden-Harris Administration is committed to ensuring access to health care for everyone is possible, and will continue to make improvements in the system.”
The grant funding issued today not only helps states provide swifter eligibility and enrollment processes for new consumers purchasing Marketplace coverage, but also helps states to reassess current enrollees’ eligibility for increased savings made available through the ARP. The ARP reduced health coverage costs for consumers with many consumers finding plans for $10 or less per month. As a result of the ARP, most consumers purchasing Marketplace coverage are now eligible for increased Advance Payments of the Premium Tax Credit (APTC) that reduce their portion of monthly premiums.
“When we improve access to quality, affordable health coverage â people sign up. With these American Rescue Plan funds, we are investing in increasing consumer education and awareness about the greater financial assistance now available,” said CMS Administrator Chiquita Brooks-LaSure. “Producing consumer notices in additional languages and targeting outreach to the underinsured and uninsured are just a few approaches states will use to connect members of these communities, particularly vulnerable and underserved populations, to affordable health coverage.”
The 21 SBMs that received the ARP grant funding include the District of Columbia and the following states: Arkansas, California, Colorado, Connecticut, Idaho, Kentucky, Maine, Maryland, Massachusetts, Minnesota, Nevada, New Jersey, New Mexico, New York, Oregon, Pennsylvania, Rhode Island, Vermont, Virginia, and Washington. States with a Federally-Facilitated Marketplace (FFM) were not eligible for this funding opportunity. Grant award amounts range from $500,000 to $1,107,392, and are based on the SBM model and number of successful applicants. The period of performance is from September 10, 2021 through September 9, 2022.
State-based Marketplaces Receive Grant Funding to Modernize and Improve Consumer Experience
The Biden administration is calling for Congress to pass a set of proposals already backed by Democrats to lower prescription drug prices, including one to let the government negotiate prices with drugmakers.
The proposals unveiled Thursday are part of a long-awaited report from the HHS to the White House that offers a wide-ranging series of recommendations on curbing rising drug costs. Lawmakers have pushed for much of these proposals for years, and former President Donald Trump took action on some.
The Health and Human Services Department attributed the high cost of prescription drug prices in the U.S. to âlack of competition,â and said Americans pay more than $1,500 per person a year for medications.
The HHS said the pharmaceutical industry is âcharacterized by multiple market failures,â attributable to several factors, including âmonopolistic or oligopolistic behaviorâ and âlegal abuses.â
U.S. prescription drug prices are 1.9 times as high as those in other Organisation for Economic Co-operation and Development countries, including rebates, according to a RAND study. U.S. insulin prices are about four times higher. Spending on retail prescription drugs represented 10% of national health spending and 13% of out-of-pocket spending in 2019.
âLife-saving prescription medication should not cost anyone their life savings. Yet too often, many low-income families cannot take their prescription medications because of cost concerns,â Health and Human Services Secretary Xavier Becerra said in a statement. âBy promoting negotiation, competition, and innovation in the health care industry, we will ensure cost fairness and protect access to care.â
The plan backs a proposal that House Democrats have long wanted to see pass, allowing the HHS secretary to negotiate the price of drugs in Medicareâboth those administered in a doctorâs office and those obtained in a retail pharmacyâwith drug companies and making those prices available to commercial insurance plans and employer-based plans.
Employers have urged the administration to allow Medicare to negotiate drug prices that private sector purchasers would also have access to, a policy included in the Biden administrationâs plan.
âIf price protections arenât extended to employers and employees, the cost balloon will be pushed down for Medicare and everyone else will pay for it,â Elizabeth Mitchell, chief executive of the Purchaser Business Group on Health, said in a statement Tuesday. The group includes large employers like Walmart, Boeing, and Intel.
House Democrats are expectedto reveal their policy agenda for drug pricing as soon as Friday, Democratic aides and lobbyists told Bloomberg Government. The House plan will align closely with their signature drug pricing bill (H.R. 3), which the House has already passed in a previous session. Senate Finance Chairman Ron Wyden (D-Ore.) has said allowing the government to negotiate with drugmakers will be a key part of his bill.
Drugmakers are vocally opposing H.R. 3 and its excise tax on drugmakers that wonât negotiate with the government.
If industry doesnât agree to the prices proposed by the HHS secretary, under H.R. 3 there would be a penalty of 95% of sales. Ken Frazier, executive chairman of Merckâs board of directors, told reporters Wednesday that is not negotiation, but a âsubstitute for the words price controls.â
âWe cannot support, and we will not support the very dangerous idea of allowing the government to simply set prices,â Frazier said.
However, the drug giant would support âmechanisms that would give the governmentâspecifically Medicareâthe negotiated prices in the private sector, the best prices available commercially.â
Advocacy groups are ramping up campaigns to influence lawmakers and public opinion. The group Patients For Affordable Drugs Now launched fresh TV ads this week urging Congress to support the drug-price negotiation plan.
The HHS plan is in response to a July executive order from President Joe Biden that called for a plan to âcombat excessive pricing of prescription drugs and enhance domestic pharmaceutical supply chains, to reduce the prices paid by the Federal Government for such drugs, and to address the recurrent problem of price gouging.â
The HHS plan also calls for legislation to create:
The HHS will also look at putting into place several policies that donât require action from lawmakers, including:
The plan suggests Medicare can use existing authority to bring down prices by linking payments for physician-administered drugs to patient outcomes. That may be relevant as the agency weighs how to reimburse for Biogen Inc.’s new Alzheimerâs drug. Regulators granted the the $56,000-a-year therapy accelerated approval despite uncertainty about its ultimate clinical benefits to patients.
Medicareâs innovation center could use mandatory models that tie drug reimbursements âto factors such as improved patient outcomes, reductions in health disparities, patient affordability, and lower overall costs,â the drug price plan says. The document doesnât refer to Aduhelm specifically.
The Biden administration is calling for Congress to pass a set of proposals to lower prescription drug prices, including one to let the government negotiate prices with drugmakers.
Invalid Email Address