House Ways & Means ranking Republican Kevin Brady (TX) suggested President Joe Biden’s fiscal 2022 budget ignores a need to continue telehealth coverage after the COVID-19 public health emergency, but HHS Secretary Xavier Becerra told lawmakers Tuesday (June 8) he does not intend to go backwards on such coverage, although the department could use some help from Congress.
“I hope we can work together on issues like the underserved, the poor, the rural, as well as–as ensuring that telehealth, which was one of the saving graces in COVID, can become permanent access and flexibility to connect our patients with their healthcare providers,” Brady said at a Ways & Means hearing on Biden’s budget.
Brady noted that committee Republicans had said at an earlier hearing in April there is room for bipartisan work to expand telehealth use beyond the pandemic.
However, Brady also said that “[t]he possibility that telehealth benefits may soon be stripped from those who relied on it to get through the COVID pandemic is another problem ignored in the Biden budget.”
Becerra also received questions from other lawmakers on the future of telehealth. He responded to a question from Rep. Mike Thompson (D-CA) by saying telehealth was one of the bright spots of the pandemic but, as authorities to cover telehealth are expiring soon, “now it’s a matter of figuring out how we can deploy some of that long term.”
“We look forward to working with you because some of that authority will have to come through statute. Some of that we could probably do through administrative regulation. But what we do know is we can’t go back to the old way of doing business. We have to take advantage of telehealth,” Becerra said.
Becerra also emphasized a need for broadband across the country, which he had raised at a House Energy & Commerce Committee hearing last month. Plus he stressed the importance of accountability for telehealth services in Medicare and Medicaid. As HHS covers care “further and further from the source, we just want to make sure it’s accountable because taxpayer money, whether Medicare or Medicaid, is in there. We have to make sure we’re getting the value for our dollar,” Becerra said.
Becerra said providing such coverage in an equitable way is important, as well.
House Democrats are deploying a crunch-time plan to move forward on the coming year’s budget while still giving President Joe Biden more room to negotiate on infrastructure.
Budget Chair John Yarmuth (D-Ky.) plans to introduce a measure within the next week or so that sets forth about $1.5 trillion in government funding for fiscal year 2022 — which starts Oct. 1 — so appropriators can finish bills to boost federal agency budgets. That so-called deeming resolution would cut through hours of debate, allowing Democratic leaders to meet their goal of passing annual spending bills on the House floor by the end of July.
Normally, that’s all Democrats would technically need in order to eventually keep the government funded. But since Democrats expect to pass some version of an infrastructure bill without Republican support, Yarmuth must prepare a separate budget proposal in order to launch the process that will allow his party to press ahead on its own while avoiding a filibuster.
Progressives, fed up with the slow pace of bipartisan infrastructure talks, are ready to go it alone now. But Yarmuth’s plan is a signal that despite Democrats’ increasing impatience, the party is still deferring to the White House on when to proceed with reconciliation — the powerful budget tool already used by Democrats to pass Biden’s $1.9 trillion pandemic relief package along party lines earlier this year.
“I think we’re still waiting on the call from the White House as to when they do or don’t give up on a bipartisan infrastructure package,” Yarmuth said.
The separate budget resolution he’s preparing will include defense and nondefense funding for the coming fiscal year and a blueprint for using reconciliation to fulfill the president’s jobs and infrastructure priorities without GOP support. Timing is unclear and pulling that legislation together will take several weeks, Yarmuth said.
“Every day that goes by without a call on reconciliation delays it a little bit,” he said. “Theoretically we could do [a budget resolution] late this month, but I hesitate to put a target on it. It will be done before the August recess, that’s for sure.”
Biden has been talking for weeks with Sen. Shelley Moore Capito (R-W.Va.), a lead GOP negotiator on infrastructure. But talks officially collapsed on Tuesday afternoon, with both parties still about $700 billion apart. Biden is now pivoting to negotiations with a bipartisan group of 20 senators, but the administration has already signaled that it will wind down bipartisan discussions absent significant progress in the coming days.
Majority Leader Chuck Schumer also indicated on Tuesday afternoon that the party is increasingly committed to wielding reconciliation in the coming weeks.
“We all know as a caucus we will not be able to do all the things the country needs in a bipartisan way,” he said. “So at the same time we are pursuing the pursuit of reconciliation.”
Yarmuth — who said he’s meeting with Senate Budget Chair Bernie Sanders (I-Vt.) for dinner this week to compare budget resolution notes — expects Democrats to use reconciliation even if there is a bipartisan deal. It’s necessary to pass all of the priorities that Republicans will never agree to, Yarmuth said, like caregiving and climate change proposals included in Biden’s $2.3 trillion infrastructure plan and his $1.8 trillion families proposal.
The Kentucky Democrat isn’t sure if his party will use reconciliation to address the debt ceiling or pass elements of immigration reform.
“I can’t see any scenario in which there isn’t some reconciliation process,” Yarmuth said. “Because Republicans aren’t going to agree to a lot of what’s in the jobs plan and families plan.”
Democratic priorities are piling up with Congress’ August recess on the horizon. Congressional leaders struck a deal in 2019 that suspended the debt ceiling through July 31. While the Treasury Department can then take so-called extraordinary measures to keep paying the government’s bills on time while lawmakers work out another deal, Treasury officials have warned that those measures may run out sooner than expected due to pandemic-related uncertainty over spending and revenues.
Government funding expires at the end of September, with federally enhanced unemployment benefits also ending that month. Any deal to fund the government can’t be tucked into a reconciliation bill, however — spending bills require support from at least 10 Senate Republicans.
While reconciliation remains a big question mark, Yarmuth said he isn’t expecting a messy fight among Democrats over the defense and nondefense spending levels that would also be included in a forthcoming budget resolution. Back in 2019, Yarmuth was forced to “deem” the numbers amid a progressive revolt over military funding. The margins are much smaller now — Democrats can only afford to lose four votes as of June 21.
The top-line government funding numbers this time around will likely look similar to those outlined in Biden’s fiscal 2022 budget proposal, Yarmuth said. The administration’s request calls for a total of $769 billion for nondefense programs in the upcoming fiscal year, which begins Oct. 1. Biden has also asked for $753 billion for national defense programs, including cash for overseas activities. That amounts to a 16 percent increase over current funding levels for domestic programs, while providing a less than 2 percent increase for the military.
But that small increase is still too much for some progressives to stomach. Sanders, for example, has pushed for a 10 percent cut in Pentagon spending. But with massive investments in infrastructure and the middle class on the line, there’s more at stake for Democrats typically raring for a defense funding fight.
Yarmuth said Democratic leaders are proceeding on the assumption that a budget resolution allowing Democrats to pass significant increases for domestic programs on party lines will garner enough party support to pass on the House floor, despite defense funding concerns.
“But not without some pain,” Yarmuth said. “It will be difficult for a lot of members to swallow.”
President Joe Biden will direct federal agencies to shore up production and delivery of pharmaceuticals, computer chips, advanced batteries and critical minerals after completing reviews of their supply chains.
New task forces, production rules: The actions include a $60 million investment in research for advanced pharmaceutical manufacturing through the Department of Health and Human Services, and new domestic manufacturing rules and funding for batteries at the Energy Department, a senior administration official said.
The Biden administration plans to release a “comprehensive strategy” for diversifying the supply of rare earth minerals used in electronics, the official said, and assign multiple task forces to address shortages in “semiconductors, home building and construction, transportation and agriculture and food.” It also will form a new “supply chain strike force” to combat unfair trade practices from other nations.
100-day reviews: The moves come at the conclusion of 100-day reviews of supply chains for the four sectors that were launched in February. The reviews sought to ascertain whether industries critical to U.S. national security are overly reliant on foreign suppliers, particularly in China, or affected by pandemic-related shortages, like semiconductors and lumber.
Drug onshoring: To prevent shortages of key medicines, HHS plans to establish an onshoring consortium with major drugmakers under authority of the Defense Production Act, a Cold War-era law that allows the government to mandate domestic production of key products. That group’s first task will be to identify 50 to 100 drugs for an “enhanced onshoring effort,” according to a fact sheet released by the administration.
Battery, mineral task forces: DOE will release a 10-year “blueprint” for battery production and release $17 billion for manufacturing and recycling from its Loans Office. The administration also plans to create a cross-agency working group with corporations, tribes and other local governments to explore new mining and recycling options for rare earth minerals, with DOE making $3 billion available immediately for new projects.
Trade strike force, magnet investigation: The administration plans to establish a “strike force” office led by the U.S. Trade Representative to identify and combat unfair trade practices from other nations. And the Commerce Department will consider initiating an investigation of neodymium magnets commonly used in motors to ascertain whether tariffs should be placed on imports.
An investigation would come under Section 232 of the Trade Expansion Act, the same section Commerce used during the Trump era to cite national security grounds in placing tariffs on imports of steel and aluminum.
Longer term efforts: In addition to the 100-day reviews, the administration in February also set up year-long reviews for six broader sectors: defense, public health, information technology, transportation, energy and food production. Those reports are still on track to be delivered next February, the official said.
The Biden administration will soon release guidance on what health-care providers can do with unspent stimulus funds, Health and Human Services Secretary Xavier Becerra told lawmakers.
HHS this month will outline how health-care providers can “apply for and make use, good use, of their monies,” Becerra said Tuesday. He declined to say whether the department will extend the June 30 deadline for providers to spend Covid-19 stimulus funds.
Becerra signaled that HHS under the Biden administration will change how the remaining $24 billion in relief money will be distributed compared with the $150 billion already given out over the past year.
“We’re trying to make sure we don’t make the mistakes of the past,” Becerra told members of the House Ways and Means Committee.
Congress, through two laws, approved $178 billion in provider relief funds, money to hospitals and doctors that shut down services during the early spread of Covid-19. Those that received money through the two laws (Public Law 116-136, Public Law 117-7) face a June 30 deadline to spend it.
Hospital groups in May asked HHS to extend that deadline and distribute the remaining $24 billion in the relief fund. Long-term care groups have complained they didn’t get their fair share of the relief.
Providers must spend the relief money on Covid-related activities and many are still not back to pre-pandemic revenue, Michael Strazzella, head of federal government relations at Buchanan Ingersoll & Rooney PC, a law firm and lobbying group, said. Some hospitals want to funnel the funds to vaccination programs or to bring back staff cut during the pandemic, he said.
“Every dollar is meaningful to these providers,” he said.
The Trump administration released the relief money through several waves that each took a different tack: $46 billion was given to providers that billed Medicare; almost $6 billion went to providers in Medicaid; and $24.5 billion was distributed to providers who reported financial losses. Other funds were targeted to safety net and rural hospitals as well as other facilities.
Becerra said the HHS wants to give providers some flexibility in how they use the funds and remain transparent about how they’re distributed.
Sen. Bernie Sanders is using his new perch as head of a key health panel to expand the number of federally supported medical residency positions.
Sanders (I-Vt.) announced Thursday he’ll introduce legislation to add 14,000 Medicare graduate medical education slots over seven years, potentially training thousands of new doctors each year.
“This is a solvable program,” Sanders, who is head of the Senate Health, Education, Labor and Pensions Committee’s health panel, said during a Thursday hearing. “This is the wealthiest country on earth. We can have enough doctors and nurses in the places where we need them.”
Public health groups say the U.S. faces a shortage of at least 54,000 primary care and specialty doctors over the next decade.
Sanders said his legislation would reserve half of the new slots to train new primary care doctors.
David J. Skorton, president and chief executive officer of the Association of American Medical Colleges, said his group has asked for 3,000 slots to be added each year to Medicare’s graduate education program. That program, along with others, pays hospitals to train medical school graduates to become doctors.
Increasing Medicare funding for this program could allow hospitals to train more doctors, Skorton said.
A confluence of factors is creating a shortage of health-care providers in the U.S. The 65-and-older population grew by over a third, 13,787,044 people, during the past decade, putting pressure on the U.S. health system. At the same time, 40% of active physicians will reach 65 in the next 10 years, putting many into retirement, according to AAMC data.
The Senate parliamentarian’s ruling allowing Democrats to sidestep a GOP filibuster only one more time in 2021 is forcing Democratic lawmakers to rethink how they can advance President Biden’s agenda.
Democratic aides now say the $2.3 trillion infrastructure package will have to be even bigger since they have just one more opportunity before the 2022 election year to go it alone on major legislation.
“The bottom line is the next one is going to be bigger because you can’t divide it up,” said a Senate Democratic aide, referring to the remaining reconciliation package.
Democrats aren’t counting on passing another reconciliation package after April 1, 2022 — which they are entitled to do under the Senate rules — because it will be just months away from the crucial midterm elections and the political dynamic could be much different by then.
“Everybody’s a different person in an election year,” the aide said.
Senate Majority Leader Charles Schumer (D-N.Y.) thought as recently as April that he might be able to pass two more reconciliation bills this year — after the Senate used its first reconciliation vehicle to pass the $1.9 trillion American Rescue Plan in March.
Parliamentarian Elizabeth MacDonough indicated to Schumer’s staff in April that they would be able to create multiple reconciliation vehicles this year.
But in a more extensive ruling circulated in recent days, MacDonough clarified that reconciliation vehicles beyond the remaining one for 2021 would first require majority approval on the Senate Budget Committee, which is evenly split at 11 votes a piece for Democrats and Republicans.
As a result, Democrats have only one more chance this year to sidestep a filibuster, since there’s virtually no chance of a Republican on the committee voting with them.
Aides say there’s now more pressure on Biden to cut a deal with Senate Republicans on a scaled-down infrastructure package because that would allow for more spending in a reconciliation package with priorities that are unlikely to get GOP support.
Those include raising the corporate tax rate, repealing the cap on state and local tax deductions, tax breaks for clean energy and hundreds of billions of dollars for social programs ranging from expanded child care to long-term home care for the disabled and elderly.
Another reality dawning on Democratic aides and progressive activists is that with only one remaining reconciliation package available until April, passing this year’s might not happen until the fall. That would force the White House to reconsider its goal of passing an infrastructure bill before the end of the summer.
A second Senate Democratic aide said the prospect of not being able to move a reconciliation package until the fall or closer to the end of the year could put pressure on Biden to strike a bipartisan infrastructure deal before then.
“I think it does,” the aide said of the parliamentarian’s ruling putting pressure on Biden to reach an agreement with Republicans.
White House officials on Wednesday reportedly made a major concession to Sen. Shelley Moore Capito (W.Va.), the lead Republican negotiator on infrastructure, when they lowered their proposed spending target to $1 trillion and shifted away from their proposal to raise the corporate tax rate from 21 percent to 25 percent.
Instead, White House officials suggested a minimum effective tax rate of 15 percent for corporations that would otherwise pay almost nothing in taxes.
“I think it is more likely Biden will cut a deal on infrastructure just because he’s only going to have one reconciliation shot and there are other priorities where there’s no hope of getting Republican support that will be more important,” said Darrell West, director of governance studies at the Brookings Institution.
West says it’s a possibility that “hard” infrastructure priorities such as roads, bridges, public transit, rail, airports and expanded internet broadband access could be lumped into the same package but that it would make more sense to pass them separately.
“The bigger the bill, sometimes the harder it is to pass because any senator who objects to one provision may doom the entire package,” he said. “It’s going to be hard to keep the coalition together the bigger the package is and the more items are in there.”
West predicted the “overall number” of the reconciliation package “is going to be in the trillions.”
“That frightens voters and politically it becomes a more difficult challenge,” he added.
Now, many Democratic priorities will be competing for inclusion in this year’s remaining reconciliation package.
Sens. Sheldon Whitehouse (D-R.I.) and Brian Schatz (D-Hawaii) are pushing for an ambitious array of tax incentives and other provisions to combat climate change, while Sen. Elizabeth Warren (D-Mass.) wants to dramatically boost the funding Biden has proposed for child care. Sen. Bob Casey (D-Pa.) wants to ensure there will be $400 billion for long-term home care for the elderly and disabled.
Senate Budget Committee Chairman Bernie Sanders (I-Vt.), meanwhile, says he is focused on including language to expand Medicare and lower the cost of prescription drugs in the reconciliation package.
Matt House, a Democratic strategist and former senior aide to Schumer, said the parliamentarian’s ruling will make it more “complicated” to pass a reconciliation package, but he doesn’t think it upends Biden’s negotiations with Capito on a scaled-down infrastructure package.
“It was always going to be the case that Democrats would give bipartisan negotiations a chance to either flourish or fail or move forward on their own, and I think that’s still the case in the wake of the parliamentarian’s ruling and it doesn’t affect that fundamental dynamic,” he said.
House said that while a reconciliation package may not move until the fall, it won’t significantly change how much time the administration and Senate Democrats will be willing to devote to infrastructure negotiations with Republicans.
“The dynamic that governs the length of time is more, ‘What is the level of Republican seriousness in the talks?’ Not just Shelley Moore Capito but Republican, because she’s not the center of gravity in those talks,” he said.
“Step two may get a little bit more complicated because of the restrictions on reconciliation,” House said of the road ahead for Schumer and other Democrats once those talks fail, as many Senate Democrats expect.
Robert Borosage, co-founder of Campaign for America’s Future, a progressive advocacy group, said Biden may feel more pressure now to strike a deal with Republicans, but he doubts Senate Republicans will agree to anything that can pass the House, where progressives wield more power.
He said the parliamentarian’s ruling would make it more likely that Biden strikes a bipartisan infrastructure deal “if you had 10 Republicans who would make a serious offer.”
Borosage said the GOP counteroffers on infrastructure so far have been a “joke” because they’ve proposed spending only a fraction of what Biden wants in new money.
“Progressives were always for one big bill and then the parliamentarian made a ruling [in April] and so that allowed Biden to argue, ‘Let’s keep the bills separate, we can do them in different reconciliation [packages] when we prove we can’t get Republican support,” he added.
“It’s a huge change because we’re all the way down this rabbit hole of infrastructure negotiations.”
President Joe Biden’s budget request, which was released Friday, May 28, includes $133.7 billion for the Department of Health and Human Services – a 23.4% increase from the fiscal 2021 enacted level of $108.6 billion. Some of the biggest items on Biden’s health agenda will require extensive work with Congress. The request doesn’t specify how much those policies would cost or how to pay for it – but instead urges Congress to enact some of his other healthcare initiatives.
The American Hospital Association looks forward to working with CMS on implementing the good faith estimates and advanced explanation of benefits (EOB) required by the No Surprises Act. We are very supportive of efforts, such as these, to better help patients access the information they need as they prepare for their care, including price information.
View the entire letter here
Includes proposals to extend expansion of health insurance coverage and funding for preparedness, among other health care provisions
President Biden today submitted to Congress his budget request for fiscal year (FY) 2022. The budget primarily includes proposals from President Biden’s American Jobs Plan and American Families Plan.
The budget request, which was released this afternoon, is not binding, but can act as a guide for Congress and the Administration as they debate health care issues this year. Highlights of some of the provisions affecting hospitals and health systems follow. More details about these and other proposals are included in the Department of Health and Human Services’ (HHS) Budget in Brief document.
The budget includes a discussion of certain health care policies, such as a public option, lowering the Medicare eligibility age to 60, reducing the costs of prescription drugs and expanding coverage in non-Medicaid expansion states through a Medicaid-like federal public option, but does not include details on these proposals or their fiscal impact in the budget.
In addition, the budget says that “evidence shows that we can reform Medicare payments to insurers and certain providers to reduce overpayments and strengthen incentives to deliver value-based care, extending the life of the Medicare Trust Fund, lowering premiums for beneficiaries, and reducing Federal costs.”
The budget calls for making permanent the marketplace subsidy expansions that were temporarily enacted as part of the American Rescue Plan that was signed into law and were proposed by the Administration to be extended in the American Families Plan. These provisions reduce the cost of Marketplace coverage for subsidy-eligible individuals and families by increasing the dollar value of premium tax credit subsidies and expand eligibility to individuals with incomes above 400% of the federal poverty level. The 10-year cost of this is estimated at $163 billion.
The budget does not reflect any reductions in Medicare or Medicaid payments to health care providers.
The budget proposes $6 billion in new mandatory funding for HHS in FY 2022, as part of a multi-department four-year program totaling $30 billion to prepare for future pandemics.
As part of the community health and hospital resilience portion of the American Jobs Plan, the budget proposes $1 billion to increase support for hospital infrastructure, $250 million for health emergency preparedness, and $250 million to build resilience against climate effects.
The budget includes several sources of new funding to address issues of health equity and racial disparities in health care. This includes $3 billion over five years to invest in maternal health and reduce the maternal mortality rate and end race-based disparities in maternal mortality.
As previously released on April 9, the budget calls for $1.5 trillion for appropriated spending in FY 2022, including $769 billion for domestic programs, a 16% increase over last year’s level.
The budget proposes nearly $134 billion for HHS, a 23% increase over last year’s enacted level. This includes the following policies and funding levels:
President Biden May 28 submitted to Congress his budget request for fiscal year 2022. The budget primarily includes proposals from President Biden’s American Jobs Plan and American Families Plan. The budget request is not binding, but can act as a guide for Congress and the Administration as they debate health care issues this year.
On Wednesday, Sen. Patty Murray (D-Wash.), chairwoman of the Senate Health, Education, Labor and Pensions (HELP) Committee, and Rep. Frank Pallone Jr. (D-N.J.), chairman of the House Energy and Commerce Committee, issued a public request for information to solicit feedback on different aspects of the bill.
“We believe bold steps are necessary in order to achieve universal coverage and lower health care costs,” the lawmakers wrote. “As we work to draft bold legislation, our goal is to ensure that every American has quality affordable coverage regardless of income, age, race, disability, or zip.
Murray and Pallone want feedback from key stakeholder groups, as well as the general public, on some of the most basic, but thorny questions.
For example, they want to know what criteria should be considered in determining prices. They also want to know what the role of states in a federally-administered plan will be, as well as how the public option will interact with other public programs, like Medicaid and Medicare.
President Biden campaigned on creating a public option, touting it as a way to reduce costs without completely ending private insurance, in contrast to “Medicare for All.” The Medicare-like government insurance plan would be sold on ObamaCare’s marketplaces.
“While the Biden Administration has taken a number of steps to expand coverage, including opening a special enrollment period that enabled over one million people to sign up for coverage on the Federal Marketplace alone, tens of millions of American still remain uninsured or underinsured,” Murray and Pallone wrote.
The idea polls well. Seven in 10 Americans support a public health insurance option. But the process faces an uphill battle. Republicans are almost universally opposed, as is the deep-pocketed health care industry. Centrist Democrats may also balk at supporting such a plan. plan.
During the campaign, Biden said his plan would cost $800 billion, a massively daunting price tag without a viable way to pay for it right now. The administration is currently focused on passing the American Families Plan, which includes $200 billion for permanent expanded ObamaCare subsidies, but no public option.
Congressional Democrats urged Biden to include a plan that would allow Medicare to negotiate drug prices, which would bring in $450 billion in savings to pay for coverage expansions. But that was also left out of the families plan.
Two key committee chairs in the House and Senate are taking the first step toward crafting legislation to create a public health insurance option, reviving a debate between the parties on the federal government’s role in coverage and setting up a fight with the insurance industry.
Senate Health, Education, Labor and Pensions Chair Patty Murray, D-Wash., and House Energy and Commerce Chair Frank Pallone Jr., D-N.J., issued a request for information Wednesday asking for input on a public option, which would establish a government-run health plan to compete with private insurers.
“Our goal in establishing a federally administered public option is to work towards achieving universal coverage, while making health care simpler and more affordable for patients and families,” the pair wrote.
Democrats abandoned plans to establish a public option through the 2010 health care law, but the proposal has gained support among Democrats in the ensuing years. The debate over whether to move toward a public option or a more ambitious Medicare for All, government-run program was a defining issue of the 2020 Democratic primary, with President Joe Biden supporting a public option.
Since taking office, Biden has focused on other goals, such as expanding the size of subsidies under the 2010 health care law and broadening eligibility for them. He did not include a public option in the economic proposals he is working to pass this year.
Democrats are also writing legislation to lower the cost of prescription drugs, which would create savings they could use to finance other priorities.
With razor-thin majorities in both the House and Senate, Democrats would have a difficult time passing legislation to enact a public option, which Republicans oppose. Democrats could use the reconciliation process to consider public option legislation, which would allow them to pass legislation without Republican support, but that would require adherence to budget rules and no defections among Senate Democrats.
The health care industry has already mobilized to oppose this type of legislation.
“Now is not the time for us to become embroiled in debates over issues like public option,” Chip Kahn, president and CEO of the Federation of American Hospitals, said in a statement. “It would be a mistake to allow such distractions to stand in the way of enacting legislation that sets the pathway to all Americans having the health coverage and health care security that all of us deserve and should expect.”
Democrats in both chambers have proposed different bills that would establish a public option, but Murray and Pallone indicated they would develop a new proposal.
There are several different ways lawmakers could set up a program. Murray and Pallone’s information request poses questions including who should be eligible for coverage through a public option, how the benefits should be structured and how prices for health care items and services should be set. The pair also asked how Congress could ensure that people enrolled in a public plan have adequate access to providers, what type of premium assistance should be available under a potential plan, what role states should have in administering a federally run option, how it might interact with Medicare and Medicaid and how a public option could address other health care objectives, like delivery system updates and reducing health inequities.
Other lawmakers who support a public option praised the effort and touted their own ideas.
“We are glad to see a public option gaining momentum in the Senate. Over the last five years, we have worked with people from Colorado to Virginia and everywhere in between to draft the Medicare-X Choice Act, which we believe is the best public option proposal available,” said Sens. Tim Kaine, D-Va., and Michael Bennet, D-Colo., who reintroduced legislation for a program they call “Medicare X,” earlier this year. “We look forward to working with the Biden Administration and our Senate leadership and colleagues in moving a public option forward to bring us one step closer to achieving universal health care in this country.”
Interested parties, which might include industry groups, health insurance experts and employers, have until July 31 to send Murray and Pallone their suggestions.
On May 25, 2021, the Senate Committee on Health, Education, Labor & Pensions approved three hospital industry-supported bills aimed at improving maternal health and supporting front-line health care workers.
Draft legislation to update the landmark biomedical innovation law 21st Century Cures will likely come out in early June, lawmakers behind the bill said.
Reps. Diana DeGette (D-Colo.) and Fred Upton (R-Mich.) indicated they want to pass their bill, known as Cures 2.0, by the end of the year, although they acknowledged the pandemic has set back their work.
The bill offers a chance for an increasingly divided Congress to pass legislation to remove hurdles to cutting-edge treatments when science is moving at a rapid pace.
The 2016 law has led to better screening for certain cancers, better understanding of the human brain, advances in regenerative medicine and more funding for Alzheimer’s research, a record number of drug approvals, and new opportunities for young scientists, DeGette said.
“That effort has been really hailed as one of the most comprehensive pieces of health-care legislation,” DeGette said at the Alliance for Regenerative Medicine’s Cell & Gene Legislative Fly-In, the group’s policy and advocacy event, Monday.
“But what we realize is that we’re still not there, that there were still some things that weren’t perfected under 21st Century Cures.”
The draft bill will focus more on the delivery of cutting edge treatments, whereas 21st Century Cures (Pub. L. 114-255) aimed to modernize the development of new therapies by focusing on the Food and Drug Administration and the National Institutes of Health. The legislation will include language to fold in the Advanced Research Projects Agency for Health, the new agency within the NIH for which President Joe Biden requested $6.5 billion in his initial budget proposal to build. The new agency would help translate discoveries into patient care, based on a program at the Pentagon and the Department of Energy that paved the way for the internet and GPS.
DeGette and Upton recently met with the Biden administration to discuss the ARPA-H proposal and have recently begun discussions with their Senate counterparts. The bill will include language on how to improve pandemic preparedness, and Sen. Patty Murray (D-Wash.) has also said she’s working on bipartisan legislation to prepare for future pandemics. Murray is the chair of both the Senate health committee and the health spending panel on the Senate Appropriations Committee.
Lawmakers are also looking for recommendations on how to modernize the Centers for Medicare & Medicaid Services to help speed up their decision-making process, DeGette said. “It doesn’t do any good if you have drugs or devices that people can’t afford.”
They indicated the draft bill is just a first step and they are looking for feedback to shape the next iteration of bills to speed the delivery of new drugs and devices. For example, there currently isn’t language on value-based agreements—which tie payment to how well the treatments actually work—but DeGette indicated they are open to it.
“Fred and I are not researchers; we are just lowly members of Congress,” she said to the regenerative medicine group. “If we don’t get those finer points that are specific to regenerative medicine, then we can’t make as robust or effective of a bill.”
The lawmakers indicated they were open to tying Cures 2.0 to upcoming user fee legislation, as negotiations between industry and the FDA are ongoing with the current agreement expiring in September 2022. The FDA collects user fees from drug manufacturers, and in return, the agency commits to performance goals.
DeGette said it’s unlikely a bill that includes the ARPA-H proposal will be folded into the next user fee agreement. At the same time, she said, “We just want to pass the bill. So whatever method we can do, we will do.”
The bill will include a provision for increasing diversity on clinical trials. There was some language in the 2016 21st Century Cures, but “we’re still not yet where we need to be, and as Fred says, we’ve really realized during Covid that we need to get better data in all the clinical trials,” DeGette said.
Upton added there’s a proposal to require the Department of Health and Human Services to submit a report to Congress regarding the current state of cell and gene therapies, particularly identifying any regulatory challenges for the FDA.
Employers that are having trouble explaining why their mental health coverage for employees differs from medical coverage aren’t going to get sympathy from the Department of Labor.
The DOL began auditing employer-sponsored health plans in April for compliance with the Consolidated Appropriations Act enacted in December 2020, which requires the plans to analyze and document why they provide mental health benefits that differ from other medical benefits.
Employer attorneys and lobbyists say they are ill-equipped to provide the analysis. The information should come from the administrators, typically part of health insurance companies, that design and run the plans, they say.
But Ali Khawar, the principal deputy assistant secretary for DOL’s Employee Benefits Security Administration, isn’t buying it. The Mental Health Parity and Addiction Equity Act, which requires parity with medical coverage, was enacted in 2008, he said.
“This isn’t a new requirement,” he said in an interview. The agency has issued regulations and a significant amount of guidance on what companies should be doing to document their justification for any discrepancies between mental health and medical-surgical benefits, he said. “The fact that now it’s a documented requirement, I don’t really see that as changing all that much.”
Ensuring that health plans comply with the mental health parity laws is a top priority for the Biden administration, Khawar said. That may result in companies scrambling to get the analysis they need from the administrators that run their plans.
“I don’t think I can understate the priority we’re putting on this issue,” Khawar said. “This is really one of our highest enforcement priorities. And certainly in the health area, I would call this our highest enforcement priority.”
The mental health parity law “is intended to help people who are suffering or who have mental health conditions or substance abuse disorders and who need help,” Khawar said. “Really, it is well past time for us to start seeing that the promise of parity is being met.”
Most health plan sponsors are employers, many of which provide coverage for employees regulated by the federal government under the Employee Retirement Income Security Act (ERISA).
At issue is a document explaining the factors used to justify so-called non-quantitative treatment limitations (NQTLs) on mental health coverage that differ from limits imposed for medical and surgical benefits. Those limits differ from quantitative limits that can be more easily measured, such as limits on the number of visits covered for a particular treatment.
A common example of a non-quantitative treatment limit is requiring approval before covering a treatment or drug, known as prior authorization.
Khawar didn’t have details on the number of health plans that have been queried to provide the documentation, saying it is early in the agency’s efforts to check compliance. “We are going to our existing inventory of cases and identifying where we think there may be an issue, and we are reaching out to those plans,” he said.
Plans that aren’t in compliance may be required to notify their participants that they are not meeting the law.
The DOL also plans to educate the public about the requirements health plans must meet under the mental health parity law, Khawar said.
Further, he said, if companies believe that health insurers they work with aren’t complying with the law, they should report that to the DOL. But, he added, “It’s pretty troubling to me that people in May of 2021 are saying that they’re having trouble ensuring that their analysis is documented for a legal requirement that’s been on the books for 10 years.”
Mental health parity rules require plans to look at why they imposed limits on mental health services, Kim Wilcoxon, a partner in the Cincinnati office of Thompson Hine LLP, said in an interview. “We have to look at the strategies that we used to develop the limit; the factors that we considered; the evidence that we reviewed,” she said. Those factors shouldn’t be more stringent than what is considered for medical and surgical coverage, she said.
The concept is “admirable, but difficult for a lay employer to complete,” Wilcoxon said. “Much of the thought process that goes into these limitations is actually done by an insurance company, a third-party administrator,” she said.
Plan administrators that pay claims typically design company health plans and have medical expertise to identify areas “to make sure we’re not paying for something that’s not medically necessary,” Wilcoxon said.
“We just have not yet seen analyses that would satisfy the requirements of the DOL’s requests,” Wilcoxon said.
The EBSA and other agencies issued guidance April 2 on complying with the requirements of the new law regarding the limits for mental health coverage.
Liability for plan administrators who fail to meet mental health parity requirements is unclear, according to many who work on the issue. However, a March 5 decision from the U.S. District Court for the Northern District of California in Jane Doe v. United Behavioral Health has gotten attention because it finds the plan administrator liable for not meeting the law instead of the company sponsoring the plan.
The court ruled that United Behavioral Health, which manages behavioral health services for insurer UnitedHealthcare, violated the mental health parity law by denying coverage for applied behavior analysis therapy for autism for a participant in a plan sponsored by technology company Wipro Ltd., which has offices throughout the U.S. and was not a party to the suit.
“We are committed to ensuring our members have the mental health support they need, when they need it, as part of our broader commitment to accessible, quality care,” a company spokesman said in an email. Because the case is ongoing, the company has no additional comments, he said.
“With respect to employer-sponsored coverage that is self-funded, it is almost always the case that these plans are administered by the same companies that underwrite insurance,” Meiram Bendat, founder and president of Psych Appeal and the attorney who represented the plaintiff in the United Behavioral Health case, said in an interview.
“The third-party administrators, or claims administrators, are really the de facto administrators of these plans, because they really do manage the day-to-day operations of these plans,” approving coverage, making decisions about reimbursements, and creating medical provider networks, Bendat said.
“My sense is that employers really need to hammer down on the claims administrators to articulate the non-quantitative treatment limitations that are applied,” Bendat said. The administrators already do that with their fully insured health plans, he said.
At an April 15 hearing held by the House Education and Labor Committee’s health subcommittee, Bendat called for enactment of the Parity Enforcement Act (H.R. 1364), introduced by Rep. Donald Norcross (D-N.J.), which would create new civil penalties for employer health plans or health insurers for violating the mental health parity law. Currently employers bear sole liability.
Many practices involving the limits aren’t dependent on plan language, but instead rely on policies used by plan administrators, Bendat said.
Plan administrators may impose a variety of requirements for prior authorization, Bendat said. Administrators may impose utilization reviews more frequently or stringently for in-patient mental health treatments than for in-patient medical treatments, which makes it more difficult to get benefits approved, he said.
Plan documents typically just specify that some services require prior authorization “and leave it up to the claims administrators to do what they see fit,” Bendat said.
“Employers don’t design NQTLs,” James Gelfand, senior vice president for health policy for the ERISA Industry Committee (ERIC), which represents large employers on employee benefit policies, said in an interview.
“We have behavioral health vendors who help us to design those in a way to ensure that they are in compliance with parity rules,” Gelfand said.
ERIC supported the provision of the Consolidated Appropriations Act requiring plan sponsors to document the limits, he said.
However, “in the last five months, there has been kind of a mad scramble from the employers to take possession of this information,” Gelfand said.
“We assumed the vendors have always had this information, and now they just need to hand it over to us so that we have it for when the government or a patient comes knocking,” Gelfand said. “Getting information from any of the vendors has been a much longer and more complicated process than was initially imagined,” he said.
The DOL’s position “was that employers essentially should already have had this data, which was news to us,” Gelfand said. “They were of a mind that we should have already had it; if our vendors had it, then we should be able to get it from them immediately. They weren’t sympathetic to this issue of it taking time and negotiations, etc.”
It will be important to see how the DOL treats the issue, Gelfand said. “It may turn out that as the audits have actually started, that the vendors are going to pick up the case, and everything will be fine. But that’s the best case scenario, and we get paid to worry about the worst case scenario.”
Democrats are beginning to lay the legislative groundwork for President Joe Biden’s infrastructure priorities, flagging their must-haves as the final package is hashed out.
The bills Democrats have introduced in recent weeks would expand the low-income housing credit and streamline clean energy incentives. The proposals are seen as negotiating tools, as Biden and his administration work to fine tune his sweeping infrastructure proposal. What makes it into the final package will require careful maneuvering given competing priorities between Congress and the White House, and the narrow majority held by Democrats.
Former Congressman Charles Boustany (R-La.) said that when the president and the administration make a major push, members look to jump on board and act as “policy entrepreneurs” using work they have already done on a particular issue.
“In some cases, they’ve worked on legislation for years, to no avail,” said Boustany, now with Capitol Counsel. At other times, they want to be part of a “legislative victory” that they can talk about back home, he said.Biden’s plan includes a 21% global minimum tax and a corporate rate of 28% as part of a $2.25 trillion effort to invest in roads and bridges. He has also offered a sweeping plan aimed at American families that would be funded in part by tax hikes on the wealthy. Some Democrats have already objected to the plan’s lack of a fix for the $10,000 limit on federal deductions for state and local taxes paid—a sign that what the administration is seeking is far from final.
Senate Finance Chairman Ron Wyden (D-Ore.) built on Biden’s energy plan with his own proposal that would replace a few dozen tax breaks with a technology-neutral tax incentive.
“It would both put us on the path to achieving our emissions reductions goals and create good-paying jobs, and should be the linchpin of our clean energy efforts as we consider President Biden’s jobs package,” Wyden said in a statement at the time.
Biden’s plan would extend existing tax credits for wind and solar power and energy storage.
Wyden’s bill is an example of something Marc Gerson, a member at Miller & Chevalier Chartered, said is common when presidents offer policy proposals: A White House proposal is often very high-level, and members will either flesh it out or offer their own version.
Another piece of clean-energy legislation building out Biden’s plan comes from Rep. Earl Blumenauer (D-Ore.). His bill would require companies to pay an excise tax for producing products that generate hazardous waste. It would restore taxes that expired in 1995.
The Biden administration wants to expand the low income housing tax credit because of a housing crunch that has become worse during the pandemic, calling on Congress to produce and preserve more than 1 million affordable, energy-efficient units. A bipartisan group of lawmakers have expanded on that idea.
A bill ( H.R. 2573, S.1136) from Rep. Suzan Delbene (D-Wash) and Sen. Todd Young (R-Ind.) would expand the credit. The measure would increase the credits to each state by 50% for the next two years and make permanent a temporary 12.5% increase in the credit.
“Our nation’s need for more affordable housing is at an all-time high because of the Covid-19 pandemic,” DelBene said while introducing the bill earlier this month. “Congress should leverage the proven success of the Housing Credit to build more affordable housing units.”
With Biden’s tax hikes still up for debate in Congress, financing infrastructure with government debt may be an option—an approach that was part of former President Barack Obama’s stimulus package early in his presidency.
A bipartisan bill introduced this month by Sens. Michael Bennet (D-Colo.) and Roger Wicker (R-Miss.) would create American Infrastructure Bonds to pay for projects.
Interest on the bonds would be paid, in part, by the federal government. The Treasury Department would pay a percentage of the interest to the issuing entity, according to a news release from Wicker’s office.
Wyden has consistently pushed for debt financing to fund infrastructure, and the next few weeks could show how much force Democrats want to put behind the policy.
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