HealthCare Roundtable e-News – June 19, 2023


Save the Date

2023 Federal Advocacy Workshop

Washington, DC | Wednesday, July 12, 2023

The Public Sector HealthCare Roundtable will present a hybrid Federal Advocacy Workshop on Wednesday, July 12, 2023. The Workshop will focus on the Roundtable’s federal priorities, particularly as they relate to current initiatives of the Biden Administration and timely Congressional activity. In addition to hearing from Administration officials and Congressional staff, the workshop will include engagement and networking with many of the Roundtable’s allies and friends.

The Workshop agenda will include the following presentations:

  • Federal Health Care Policy: Progress and Priorities
  • What’s Next in Health Care: Perspectives from Capitol Hill
  • Past, Present, and Future: Trends in the Employer-Sponsored Market and the Potential Impacts of Policy Reforms
  • Trends in Specialty Drug Spend
  • Partnerships for Success: Advancing Shared Priorities
  • Amplifying Your Voice: Advocacy as a Tool

Whether your health plan is able to actively advocate on behalf of our shared priorities or not, the agenda will include information that is very relevant to your role as a public sector health care purchaser. Whether we call it advocacy, education, or simply information-sharing, it’s important for federal officials to understand how their policies and programs impact the benefits you provide to the public employees, retirees, and survivors of your plans.

The Workshop – which will be complimentary for Roundtable members and friends – will take place at the Healthsperien Office, 601 Massachusetts Avenue, NW, Suite 520 West, Washington, DC. The program will begin at 11:00 AM and will conclude at 3:30 PM.

For those attending in person – The agenda has been developed to make it possible for many to come to DC in the morning and leave in the early evening. For those who choose to arrive on Tuesday, July 11, the Roundtable will be hosting a casual reception and dinner. Roundtable staff will also be available to help attendees plan (contact lists and handouts) Hill visits on Tuesday, July 11, Thursday, July 13, or both. Although the Roundtable hasn’t secured a block of hotel rooms, we have prepared a list of hotel recommendations that are within easy walking distance to the Healthsperien office. Click here for hotel recommendations.

For those attending virtually – The agenda will be presented in two segments – a morning program and an afternoon program – for the convenience of online participants.

Registration Form is now available.

Top News

House Committee on Education & the Workforce Passes Bill to Bolster Telehealth Accessibility

The House Committee on Education & the Workforce held a markup that featured the passage of H.R. 824, the Telehealth Benefit Expansion for Workers Act of 2023. The bill passed out of committee by a vote of 21-14. The legislation advanced largely along party lines with Democratic Representatives Susan Wild (D-PA) and Frank Mrvan (D-IN) voting in favor of the bill along with the 19 Republicans on the committee. The bill featured an amendment from Representative Walberg (R-MI) that would reaffirm that beneficiaries are protected from discrimination against preexisting conditions and against participants based on health status. The amendment also prohibits plans from rescinding coverage and ensures that employees are notified up front that the plans are not considered full coverage. H.R. 824 would treat telehealth services offered under a group health plan or other group health insurance coverage as excepted benefits. This would help ensure workers do not lose access to critical telehealth services they have come to rely on for the past three years by allowing employers to offer standalone telehealth coverage, increasing access to mental health services, lowering the cost of care for patients by widening provider networks, and providing timely access to medical care for individuals in rural areas. Full notes on the hearing can be found here.


Biden-Harris Administration Announces New Tools to Lower Prescription Drug Costs for Low-Income Seniors and People with Disabilities

The Biden-Harris administration announced new actions to lower prescription drug costs for low-income people with Medicare through the Extra Help program, which follows President Biden’s signature of the Inflation Reduction Act in August 2022, which expanded eligibility for the Extra Help program to individuals with limited resources and incomes up to 150 percent of the federal poverty level who meet eligibility criteria.

The Department of Health and Human Services (HHS), through the Administration for Community Living (ACL) and the Centers for Medicare & Medicaid Services (CMS), announced new tools to reach eligible seniors and people with disabilities and improve enrollment in the Extra Help program, including:

  • Targeted efforts, informed by a comprehensive equity analysis, to reach, screen, and enroll people in the Extra Help program, focused on Americans living in rural and underserved communities.
  • Release of new national data from CMS on people with Medicare Part D prescription drug coverage living in the community who currently benefit from Extra Help, those who are expected to save more on prescription drug costs thanks to the program’s expansion in 2024, and those who are likely eligible for Extra Help but not enrolled.
  • The launching of an outreach toolkit for beneficiary advocates and community-based organizations to raise
    awareness of the Extra Help program’s benefits. The tool kit will provide details on enrolling in the program, including social media content and a consumer-friendly article. Further, it will encourage drug plans to assist eligible individuals in enrolling in Extra Help.

These resources build on forthcoming expansions to Extra Help benefits and aim to ensure that more people eligible for benefits are enrolled in the program.


PFAD: IRA’s $2,000 Spending Cap Will Save Seniors $7,590 On Cancer Drugs

A report published Wednesday (June 14) zeroing in on the financial burden high-cost oncology medicines place on patients says the Inflation Reduction Act’s Medicare Part D spending cap will save money for nearly 100 percent of seniors taking brand cancer drugs. The report, commissioned by the advocacy group Patients for Affordable Drugs Now, projects that the new policy capping the annual out-of-pocket drug spending for Medicare beneficiaries at $2,000 beginning in 2025 will benefit 99 percent of the 61,968 seniors taking brand cancer medications. The report also projects seniors will save $7,590 on average in 2025 due to the drug spending cap, and some may save up to $19,296. Without the $2,000 drug spending cap, beneficiaries would be projected to spend $9,590 out-of-pocket for cancer medications in 2025. The report also highlights how the $2,000 drug spending cap may produce significant savings for seniors across seven high-cost blockbuster cancer drugs. The report also suggests lawmakers pass patent reforms to boost drug savings for patients outside of Medicare.

Regulatory Action

ACL released a notice of proposed rulemaking to update the Older Americans Act (OAA SummaryAnnouncement). ACL is proposing many substantive changes to OAA programs and Area Agency on Aging operations. This is the first major regulatory update since 1988, in which ACL is attempting to align regulations with the current statute and needs of older adults. Comments on the proposed rule are due on August 15. Proposal changes include: 1) Updated requirements for state and area plans on aging, including new definitions and operational consistency and coordination requirements; 2) Codifying requirements that area plans on aging incorporate services to address hunger, social isolation, and physical/mental health conditions; 3) Standard expectations for serving those with the greatest economic and social needs; 4) Codifying caregiver definition and including family caregivers as a service population; 5) Modernizing senior nutrition programs by continuing some COVID-19 practices; and 6) Clarifying expectations for provision of legal assistance.

Congressional Action

  • The House Committee on Education & the Workforce held a hearing titled: “Examining the Policies and Priorities of the Department of Health and Human Services.” Chairwoman Foxx (R-NC) provided opening statements explaining the Committee’s oversight duties, including: 1) Identifying if HHS is a good steward of taxpayer money; 2) If HHS is promoting a healthier America; and 3) If HHS will uphold Americans’ constitutional rights. Ranking Member Scott (D-VA) followed by explaining that Committee Democrats will continue working to lower prescription drug prices, improve transparency for consumers, and maintain the ACA. Witness Testimony was delivered by the Secretary of the U.S. Department of Health and Human Services, Xavier Becerra. Secretary Becerra explained that President Biden’s Fiscal Year FY 2024 Budget commits to shifting from an illness care system to a wellness care system by addressing food and nutrition, mental health, substance use, and strengthening Medicare home and community-based services, among other areas.


  • Senate Finance Committee Chairman Ron Wyden (D-Ore.) and Ranking Member Mike Crapo (R-Idaho) alongside Senators Bob Menendez (D-N.J.), Marsha Blackburn (R-Tenn.), Jon Tester (D-Mont.), and Roger Marshall (R-Kan.) introduced the Patients Before Middlemen (PBM) Act to uncouple pharmacy benefit managers’ (PBM) compensation from drug price and utilization metrics. The bill’s primary aim is to better align incentives to help lower prescription drug costs for Medicare Part D beneficiaries. Specifically, the bill would: 1) Prohibit PBM compensation based on the price of a drug as a condition of entering into a contract with a Medicare Part D plan. Services fees will not be connected to the price of a drug, discounts, rebates, or other fees. and 2) Create an enforcement mechanism requiring PBMs to pay to the Secretary any amount in excess of the designated service fees. This action comes after Senate Finance Committee leadership released a legislative framework in April to address PBMs and issues with the prescription drug supply chain.


  • The House Energy & Commerce Subcommittee on Health held a hearing on improving access to care for patients and supporting research for rare diseases. The hearing allowed legislators to discuss programs that provide access to care for mothers, children, cancer patients, and firefighters with a variety of expert witnesses. The hearing also served as an opportunity to identify where gaps exist and reveal any improvements needed as Congress considers reauthorizations. The committee is currently working to reauthorize a number of key programs that provide access to care for mothers, children, cancer patients, and first responders. While most of the legislation discussed throughout the hearing was bipartisan, disagreements over alterations to H.R. 3887, the Children’s Hospital GME Support Reauthorization Act of 2023 remained a theme throughout the hearing. Ranking Member Eshoo (D-CA) and other House Democrats expressed concerns over the inclusion of provisions in H.R. 3887 that would potentially cut access to Children’s Hospital GME resources for providers who provide specific procedures and hormonal therapies that act as gender-affirming for transgender youth.


  • The Senate Health, Education, Labor and Pensions Committee (HELP) held an executive session on six bipartisan reauthorization bills. The bills pertained to research into combatting Alzheimer’s Disease, rural emergency services support, livestock additives, Sickle Cell disease and legislation to combat diabetes. The HELP Committee, chaired by Senator Bernie Sanders (I-VT), amended and favorably reported the following six bills: 1) S. 133 NAPA Reauthorization Act (Sen. Susan Collins, R-ME) – the amended bill was favorably reported and forwarded with 20 in favor and one opposed. 2) S.134 Alzheimer’s Accountability and Investment Act (Sen. Susan Collins, R-ME) – favorably reported with 20 in favor and one opposed. 3) S. 265 SIREN Reauthorization Act (Sen. Richard Durbin, D-IL) – favorably reported with 20 in favor and one opposed. 4) S. 1844 Animal Drug and Animal Generic Drug User Fee Amendments of 2023 (Sen. Tammy Baldwin, D-WI) – the amended bill was forwarded with unanimous support. 5) S. 1852 Sickle Cell Disease and Other Heritable Blood Disorders Research, Surveillance, Prevention and Treatment Act of 2023. (Sen. Tim Scott, R-SC) – reported favorably with 20 in favor and one opposed. 6) S. 1855, Special Diabetes Program Reauthorization Act of 2023 (Sen. Susan Collins, R-ME) – forwarded to the chamber with 20 in favor and one opposed.


  • The Alliance of Community Health Plans (ACHP) proposed a major revamp of Medicare Advantage (MA) to strengthen its guardrails, calling for CMS and Congress to overhaul quality measures and bonuses, restructure marketing parameters and broker compensation, and realign the risk adjustment system. ACHP’s new plan, MA for Tomorrow, breaks down those policies into five areas: improving quality, streamlining consumer navigation, restructuring risk adjustment, modernizing network composition and realigning benchmarks. ACHP released details on the first three policies, but details on the final two pillars are not expected until later this summer. ACHP notes that CMS should reorganize its auditing processes on Risk Adjustment Data Validation (RADV) to target outlier plans with track records of coding abuses or a higher likelihood of upcoding, which would help the agency make more efficient use of its resources and funding. ACHP also stated that CMS should consider including a tiered coding intensity adjustment to cut down on differences in coding among plans.


  • The Medicare Payment Advisory Commission (MedPAC) announced that Executive Director James E. Mathews will leave the agency at the end of August 2023. Mr. Mathews has led MedPAC since November 2017 and previously served as its Deputy Director for nearly a decade. Following Mathews’ departure, MedPAC Chair Michael Chernew has appointed Paul Masi, Unit Chief of the Health Systems and Medicare Cost Estimates Unit at the Congressional Budget Office (CBO), to serve as the new Executive Director. Masi has 15 years of health policy experience and served as MedPAC’s Assistant Director from 2017 to 2019.


  • CMS’ Office of the Actuary released projections of National Health Expenditures (NHE) and health insurance enrollment for the years 2022-2031. The report contains expected impacts from the Inflation Reduction Act (IRA), including that people with Medicare prescription drug coverage (Part D) are projected to experience lower out-of-pocket spending on prescription drugs for 2024 and beyond as several provisions from the law begin to take effect. CMS projects that over 2022-2031, average annual growth in NHE (5.4%) will outpace average annual growth in gross domestic product (GDP) (4.6%), resulting in an increase in the health spending share of GDP from 18.3% in 2021 to 19.6% in 2031.


  • HHS announced new flexibilities to ensure Americans stay covered as states resume Medicaid and Children’s Health Insurance Program (CHIP) renewals. The new flexibilities were announced in a letter Secretary Becerra sent to governors urging them to adopt all available flexibilities to minimize avoidable coverage losses among children and families. Some of the new flexibilities announced include: 1) Allowing managed care plans to assist people with Medicaid with completing their renewal forms, including completing certain parts of the renewal forms on their behalf. 2) Allowing states to delay an administrative termination for one month while the state conducts additional targeted outreach. 3) Allowing pharmacies and community-based organizations to facilitate reinstatement of coverage for those who were recently disenrolled for procedural reasons based on presumptive eligibility criteria.


  • On Tuesday, HHS through CMS announced New York’s extension of comprehensive coverage after pregnancy through the Medicaid and the Children’s Health Insurance Program (CHIP) for postpartum individuals for a full 12 months. This announcement marks critical progress in implementing the CMS Maternity Care Action Plan, which supports the Biden-Harris Administration’s Maternal Health Blueprint, a comprehensive strategy aimed at improving maternal health, particularly in underserved communities. New York is the 35th state to be approved for the extended coverage, made possible by President Biden’s American Rescue Plan (ARP) and made permanent by the Consolidated Appropriations Act, 2023 (CAA, 2023). As a result of today’s announcement, up to an additional 26,000 people in New York will be eligible for Medicaid for a full year post-pregnancy.


  • The Medicaid and CHIP Payment and Access Commission (MACPAC) published its June 2023 Report to Congress on Medicaid and CHIP, which includes the following four chapters of interest to Congress: 1) Chapter 1 makes recommendations on payment policy for safety net hospitals. The recommendations include automatic adjustments to disproportionate share hospital (DSH) payments and four actions to improve the relationship between total DSH funding and the need for DSH payments to provide states with greater certainty regarding available DSH funds. 2) Chapter 2 builds upon the Commission’s previous work on integrating care for people who are dually eligible for Medicaid and Medicare. 3) Chapter 3 focuses on improving access to Medicaid coverage for adults leaving incarceration. 4) Chapter 4 identifies barriers to Medicaid HCBS services.


  • Last Friday, the parties in Braidwood v. HHS filed (IHP subscription required) a proposal that would pause a district court order barring the Department of Health and Human Services (HHS) from enforcing the Affordable Care Act’s (ACA) preventive service mandate as the case moves through the appeals court. In the proposal, the Texas plaintiffs agree to remain on the district order while the case is appealed, and HHS would accept that it still would never enforce the preventive service requirement against the Texas plaintiffs if the district ruling were to be vacated or reversed. At issue in the case is the ACA’s mandate that insurers cover, without cost-sharing, preventive services with an “A” or “B” rating from the United States Preventive Services Task Force (USPSTF). The government is expected to submit its first brief in the appeal on June 20.


  • Late last week, the US Chamber of Commerce filed a lawsuit against HHS, challenging the Inflation Reduction Act which gives Medicare the power to negotiate drug prices with pharmaceutical companies. Filed in the federal court of Dayton, Ohio, the chamber states that the pricing program violated the drugmakers’ due process rights by giving “unfettered discretion” to the government in dictating maximum prices. The Chamber notes that the program would impose excessive prices on drugmakers that refuse to accept those prices. Friday’s lawsuit came three days after Merck & Co. filed a similar lawsuit in Washington, D.C. Both lawsuits state that price controls would force drugmakers to pull back on developing new drugs, which would cause long-term harm to Americans. The Biden Administration hopes to save $25 billion annually by 2031 by having Medicare negotiate drug prices.