HealthCare Roundtable e-News – January 9, 2023


Top News

Sanders to Chair Senate HELP Committee, Vows to Take on Drugmakers and Insurers

Sen. Bernie Sanders (D-VT) will be the Chairman of the Senate Committee on Health, Education, Labor, and Pensions (HELP) for the 118th Congress. On January 1st, Sen. Sanders released a video outlining his priorities for 2023. In the address, he vowed to stand up to drugmakers and insurers to substantially lower prescription drug costs. According to Sen. Sanders, the drug pricing provisions in the Inflation Reduction Act are not aggressive enough. He also emphasized the need for expanding Medicare benefits to include dental, vision, and hearing. Sen. Sanders has served on the HELP Committee since he was elected to the Senate in 2007. Sen. Bill Cassidy (R-LA) will become the new Ranking Member of the Committee and boasts a professional background in health care. Last month, Sen. Sanders said he wants to work with Republicans on issues where progress is possible.


PhRMA and PCMA Release Competing Proposals for Drug Pricing Reform

The pharmaceutical industry and pharmacy benefit managers (PBMs) continue to be at odds as to the reason for high prescription drug costs. Pharmaceutical Research and Manufacturers of America (PhRMA) released a report that found health insurers and PBMs are negotiating rebates and discounts that do not translate into lowering drug prices for patients. According to the pharmaceutical industry, Democrats and Republicans should work together on PBM reforms in the upcoming Congress. Last month, Pharmaceutical Care Management Association (PCMA), the national association representing America’s PBMs, released its policy recommendations on how to lower drug costs. Its proposal calls on Congress to cut drug costs by allowing for more negotiation by PBMs and faster biosimilar adoption.

Administrative Action

  • HHS’ Substance Abuse and Mental Health Services Administration (SAMHSA) released the results of its annual National Survey on Drug Use and Health (NSDUH), which provides data on the use of tobacco, alcohol, and drugs; substance use disorders (SUD); mental health issues; and the rates of SUD and mental health treatment. Findings from the report continue to show high rates of SUD and incidence of mental health disorders.

  • The Federal Food and Drug Administration (FDA) updated their Risk Evaluation and Mitigation Strategy (REMS) Information for the abortion medications Mifeprex and generic Mifepristone. Previously, FDA limited dispensing to specialty offices and clinics, due to safety concerns. In the updated rule, FDA greatly expands the number of online and retail pharmacies that can become certified to dispense the medications. At the end of December, the Department of Justice (DOJ) also issued an opinion stating that the U.S. Postal Service (USPS) can continue to deliver abortion medications, even in states with abortion restrictions. It is unknown how many pharmacies and pharmacy chains will opt into providing these medications, or if future legal challenges will block their implementation.

  • The HHS Office for Civil Rights (OCR) announced a Notice of Proposed Rulemaking (NPRM), entitled Safeguarding the Rights of Conscience as Protected by Federal Statutes, which proposes to restore the process for the handling of conscience complaints and provide additional safeguards to protect against conscience and religious discrimination. The Department also proposes to retain certain provisions of the 2019 Final Rule regarding federal conscience protections but eliminate others, noting that some provisions may be redundant or confusing, undermine the balance Congress struck between safeguarding conscience rights and protecting access to health care access, and raise legal authorization questions.


  • The Center for Medicaid and CHIP Services (CMCS) released an Informational Bulletin describing the 2023 Omnibus Package’s recent changes to the Medicaid unwinding process during the PHE. As a reminder, the package decoupled the increased FMAP amounts and maintenance of effort (MOE) requirements of the Family First Coronavirus Relief Act (FFCRA – passed in 2020) from the COVID-19 PHE, effectively initiating a phase-down of the longstanding 6.2% FMAP increase, to begin in April. This bulletin updates and revises key due dates for certain state unwinding deliverables and activities in light of these new requirements. CMS plans to provide additional information related to implementation of the redetermination process in the coming weeks.

  • The Centers for Medicare and Medicaid Services (CMS) issued guidance that permits states, for the first time, to expand Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries’ access to specialty consultations. When beneficiaries’ primary health care providers ask specialists for advice on patient care – also known as interprofessional consultations – states can now compensate them. CMS notes that these interprofessional consultations are particularly valuable for more complex Medicaid and CHIP beneficiaries, which tend to have higher rates of chronic disease, as well as improving access to child- and adolescent behavioral health provider. Administratively, this new policy eliminates the need for states to develop complex payment methods to compensate consulting providers, whereas now Medicaid and CHIP agencies can now directly pay practitioners.

  • CMS released guidance on use of in lieu of services or settings (ILOS) to help inform states of options they may consider employing in Medicaid managed care programs to address unmet health-related social needs (HRSNs), such as housing instability or nutrition insecurity. The guidance describes six ILOS parameters and specifies requirements that states must meet to obtain CMS approval of use of ILOS. CMS plans to provide additional information related to implementation of the redetermination process in the coming weeks.


The Biden-Harris Administration announced that Affordable Care Act (ACA) Marketplace enrollment continues to outpace signups from previous years. As of December 15, 2022, nearly 11.5 million Americans selected a plan, marking an 18% increase from last year. Further, 92% of Marketplace enrollees will have access to at least three insurance companies when shopping for plans. The Administration has also created standardized plans to make the selection process easier for consumers. The Marketplace Open Enrollment remains open until January 15, 2023.