Capitol Insights Newsletter

Authors: Luke Schwartz, Caroline Oliver, and Matt Reiter

What happened in Congress this week?

With Congress out of session, this week featured a few health-related congressional field hearings. On Tuesday, April 2nd, the House Democratic Steering and Policy Committee held a field hearing in Ft. Lauderdale, FL on attempts to restrict abortion access where HHS Secretary Xavier Becerra testified. The following day the Senate HELP Committee held a field hearing in Boston on the impacts of profit-driven corporations on access to health care. Senator Edward Markey (D-MA) presided over the hearing.

Additionally, the House Energy & Commerce’s Health Subcommittee announced an April 10th hearing that will discuss a wide range of telehealth bills, including a few that would make pandemic-era telehealth flexibilities permanent for Medicare providers and beneficiaries

The Senate Finance Committee also scheduled a hearing for next Thursday, April 11th to explore potential changes to the Medicare physician payment model, specifically focusing on care and management of chronic conditions.

President Biden’s Healthcare Agenda Outlined in FY2025 White House Budget Request

Last month the White House released its annual budget request to Congress for Fiscal Year (FY) 2025. While the President is required by statute to submit an annual budget to Congress, the annual budget request is non-binding. Few, if any, recommendations ever become legislation that is passed by Congress. These budgets serve as an outline of the President’s priorities for the upcoming fiscal year.

Notably, the Budget Request seeks to increase the Department of Health and Human Services (HHS) discretionary spending by nearly $5 billion, to $133.8 billion total. Of that total, $116 billion is allocated to the Centers for Medicare and Medicaid Services (CMS).

Biden hopes to use that increase in spending to bolster Medicare’s Drug Price Negotiation Program, a defining feature of the Inflation Reduction Act (IRA). This year Medicare is negotiating prices of 10 drugs and will negotiate another batch of 10 next year. In President Biden’s State of the Union address, he announced his goal of negotiating 50 drugs a year over the next decade. This discretionary spending would help create the foundation to successfully approach these negotiations and, according to the President, would save the federal government $200 billion over the next decade. The additional funding for HHS would also help the executive branch make a push to extend Medicare’s $2,000 annual out-of-pocket cap to private health plans.

Additionally, President Biden suggested closing loopholes that limit the Medicare tax rate from at 3.8% for earned income over $400,000. This would help ensure the Medicare program remains solvent. Current estimates indicate that without government action, the program would run out of money by 2031. Biden estimates that this change would expand the life of the program by 25 years.

Another key healthcare component of President Biden’s budget request is creating “Medicaid-like” coverage for people in states that have not expanded Medicaid. This would provide 1.5 million Americans healthcare who currently do not have access to it.

Program integrity continues to be a strong focus for Medicare, which remains susceptible to waste, fraud and abuse. The Budget Request proposes investing $4.1 billion into mandatory Health Care Fraud and Abuse Control (HCFAC) over the next 10 years to fund program integrity efforts by HHS and U.S. Department of Justice. This investment in enhancing program integrity oversight is expected to yield $5 billion savings over the next 10 years.

The budget highlights the Centers for Medicare and Medicaid Innovation’s (CMMI’s) work to develop new Medicare value-based payment models with health equity as a core principle. The budget also includes $15 million to build analytic capabilities that integrate data and identify disparities related to underserved populations across programs, enhance language access and culturally tailored services, provide tools to help states, territories, and tribes with identifying barriers and opportunities to advance equity as they implement CMS programs, and expand research opportunities to improve minority health.

Of the $3 billion Medicare operations budget, about one-third of this total would be spend on administering Medicare fee-for-service (FFS) contractor operations for claim processing and related activities.

The request also expresses the importance of investing in programs that specifically promote mental health, strengthen nursing home oversight, and enhance program benefits. The request also focuses on ensuring transparency and competition among Medicare Advantage and Medicare Part D plans, especially as these plans continue to grow in popularity. Another area that got flagged in the budget request is streamlining enrollment for dual-eligible enrollees.

This list is non-exhaustive but highlights many of the key priorities for President Biden’s health policy agenda in advance of the 2024 election.

However, many felt that the budget request left out some key health policy issues. For example, Biden’s budget request did not include Medicare physician payment reform, Medicare Advantage reform, or site-neutral hospital policies.

Top Stories in Healthcare Policy

The Center for Medicare and Medicaid Services (CMS) announced updates to the 2025 Medicare Advantage and Part D payment rates this week. Medicare Advantage plans will have an expected 3.7% rate increase, translating to $16 billion. This expected increase is the same as the one proposed in the advance notice in January.

CMS also announced its final rule on Notice of Benefit and Payment Parameters for 2025 this week. The regulation updates essential benefits to include dental services, establishes network adequacy standards, and extends the special enrollment period for Affordable Care Act plans.

Medicare drug price negotiations continue as the Biden administration announced their response to offers from the ten selected manufacturers. Negotiated prices are expected to be finalized by August 1st and implemented beginning in 2026.

The Department of Health and Human Services (HHS) released guidance requiring teaching hospitals to obtain informed consent from patients before physicians conduct sensitive examinations, including pelvis and prostate exams. The letter to teaching hospitals acknowledges that media and scientific literature have pointed out instances in which informed consent was not obtained before examination. 

Oregon Governor Tina Kotek signed a bill on Monday that will criminalize drug possession as a misdemeanor, reversing a ballot measure passed in 2020 that decriminalized drug possession of small amounts of hard drugs. The new law will provide more funding for substance abuse treatment.

Various public health advocacy groups are suing the FDA and HHS over the delayed ban on menthol cigarettes. Advocates worry that the ban will only continue to be delayed because of concerns about losing voter support in the election year.

Following the decision that Medicare will cover Wegovy to reduce the risk of cardiovascular events for patients with heart disease, there is concern about the possibility that Medicare premiums will increase. The current list price for Wegovy is about $1,350.

President Biden and Senator Bernie Sanders (I-VT) spoke together at an event at the White House on Wednesday about lowering prescription drug costs and asthma inhaler prices in the U.S. Addressing high drug costs continues to be one of President Biden’s top priorities as he looks to the election in November.

A report by the HHS Office of Inspector General highlights that access to mental health services is limited for underserved populations enrolled in Medicare and Medicaid. Within the counties surveyed, the report found less than five mental health service providers per 1,000 enrollees for traditional Medicare, Medicare Advantage, and Medicaid.

CMS released a final rule on Thursday regarding prior authorization and marketing for Medicare Advantage. Specifically, the regulation requires that utilization management committees involve a health equity expert.