The Week in Review: April 26-30

Biden Makes Sweeping Health Care Proclamations in Address to Congress

President Biden declared “health care should be a right, not a privilege” in his April 28 address to Congress, where he formally unveiled the American Families Plan.  This proposal would make $2 trillion in investments to education, childcare, and paid leave, as well as make permanent the American Rescue Plan’s two-year increase in Affordable Care Act (ACA) premium tax credits.  During the address, the President also voiced a commitment to allow Medicare to directly negotiate with drug manufacturers on prices, which is not included in the American Families Plan.  Biden said the savings accrued by empowering Medicare to negotiate on drug prices could be used to strengthen the ACA and expand Medicare coverage, hinting at previous calls to lower the Medicare eligibility age to 60 and create a public option. 

CDC Loosens Guidance on Wearing Masks Outdoors

On April 27, the CDC updated its guidance to say vaccinated Americans do not need to wear masks when outdoors, except when in large crowds.  Masks are still recommended for vaccinated people in indoor public spaces, however.  The updated guidance comes after the US reached a milestone of 50% of adults at least partially vaccinated on April 18 as well as calls from public health experts to remove outdoor mask mandates.  On April 28, National Institute of Allergy and Infectious Diseases Director Anthony Fauci said “more liberal guidelines” could be down the pike as vaccinations continue and infection levels drop.

CMS Proposes FY22 IPPS, Boost Residency Slots

CMS proposed a 2.8% rate increase in the agency’s Fiscal Year 2022 Inpatient Prospective Payment System (IPPS) rule on April 27.  The proposal would also add 1,000 physician residency slots in accordance with last year’s Consolidated Appropriations Act.  To advance health equity, the proposal seeks comment on ways CMS can improve reporting of health disparities and develop a health equity score measure.  Hospital stakeholders including the American Hospital Association reacted positively to a provision that would strike a requirement for hospitals to report their median payer-specific charges negotiated with Medicare Advantage plans.

GOP Lawmakers Come Together for Vaccine Ad

A group of Republican members of Congress who are also health care practitioners released a video on April 27 urging the public to get vaccinated against COVID-19.   Among the 10 Republicans featured in the video are Sen. John Barrasso (WY), a physician, Rep. Buddy Carter (GA), a pharmacist, and Rep. Brian Babin (TX), a dentist.  In the video, the lawmakers emphasized the vaccines’ safety and effectiveness, and they framed vaccinations as a step towards returning to normal life.  The video’s release follows numerous reports of high levels vaccine hesitancy among Republican men, which some public health officials fear could be a major obstacle to achieving herd immunity.

New Census Data Give GOP Upper Hand in Redrawing Districts

The latest data from the US Census Bureau shows a continuation in migration patterns towards the South and the West.  States in the Northeast and Midwest including New York, Pennsylvania, Ohio, Michigan, and Illinois, will each lost one House seat, while Oregon, Colorado, Montana, North Carolina, and Florida will each gain one seat.  The census data comes as many states across the country prepare to draw new congressional districts.  Many of the states that have gained a House seat are under Republican control, meaning the GOP will determine the redrawing of a plurality of new congressional districts. 

ICYMI: DC Has a New Underground Tunnel

It’s not just the US Capitol Complex and Metrorail system that have underground tunnels in the Washington, DC.  DC Water just completed work on a 5-mile long, 23-foot-wide tunnel under the city that will help prevent sewage overflows in the Anacostia River and stop flooding that has plagued neighborhoods like Bloomingdale and Le Droit Park in recent years.  The tunnel was constructed by an over 360-foot boring machine called “Chris.”  DC Water hopes the tunnel will help make the Anacostia River open to swimming and fishing in the future.

Meet Deema Tarazi, Spartan and Health Care Advocate

Blog Post Draft: Meet Deema Tarazi, Spartan and Health Care Advocate (4/27/2021)

Having joined Chamber Hill Strategies in March 2021, Deema Tarazi draws from her background in advocating for maternal health policies and patient protections to help clients connect the dots in Washington.  During our conversation, Deema recounted her experience defending the Affordable Care Act (ACA) from attempts to repeal and replace the law in 2017, as well as her observations on the differences between state and local advocacy.

What are some of the highlights of your career?

I started my career in 2016 around the time when the Trump Administration and Republican-controlled Congress began their efforts to repeal and replace the ACA.  I had the opportunity to work with organizations for rare diseases and chronic conditions to lobby in support of key ACA provisions, such as Medicaid expansion and protections for those with preexisting conditions.  Later, at March of Dimes, I was working on extending Medicaid postpartum coverage from 60 days to one year, which I was happy to see that this policy was included in the American Rescue Plan. 

What prompted you to transition your career ambitions from law to advocacy?

Initially, I was interested in pursuing legal services, namely focusing on immigration law.  During my second year at the Michigan State University College of Law, I participated in a program that allows students to come to Washington, DC for a semester.  I always wanted to explore DC, and I was fortunate to be placed with the Hemophilia Federation of America (HFA) under the mentorship of a Michigan State law school alumna.  From my experiences working with legislators and advocates, and learning about policymaking, I fell in love with federal government affairs.  When I returned to law school, I set my sights on coming back to DC, and I was fortunate to be hired for a full-time position at HFA after graduation. 

What are some of the biggest challenges lobbyists and advocates face in 2021?

Lobbying is a face-to-face career.  Being in a room and talking to people is the best way to gauge people’s reactions.  The pandemic has really changed the way we communicate with and build relationships with people.  Since there are no opportunities to bump into someone in the hallway or meet them for coffee, you really are relying on email, texting, and calling.  That said, technology has made the advocacy process more inclusive, and advocates who previously couldn’t travel to Washington are now able to connect virtually with members of Congress and their staff.

How is state government advocacy different from federal government advocacy? 

State and local lobbying is different because some of the people who serve in state and local government serve part-time, and they are more connected to the daily coming and goings of the community. This creates the opportunity for more “personal touches,” and you can more effectively leverage advocates’ relationships with state and local lawmakers than you can federal lawmakers Additionally, each state has their own set of lobbying rules, so it was always important to review the laws to ensure compliance.

What’s some of the best advice you’ve received?

“Always remember why you started.” I relied heavily on this advice while studying for the bar and it has carried over into all aspects of my life. I find that it is important to keep everything in perspective, which sometimes can get lost as thing constantly change as we face difficult challenges, but usually the reasons of why we started doing something do not change.  This motivates me to keep moving forward no matter how difficult a challenge may seem to be.

What else should we know about you?

I’m a proud double-Spartan, meaning I went to Michigan State University for undergraduate and law school, and I love watching games during football and basketball season. Staying connected to the Michigan State community is important to me and there is even a restaurant in DC that I use to go to before the pandemic which hosts all DC Spartans during game days.

I’m also an avid reader – I do not have a favorite book – but anything with the typical love storyline I do enjoy. In 2019 I hit my reading goal of reading 60 books in a year and my favorite book that year was Educated by Tara Westover, a moving memoir about her life.

I’ve become more interested in activities outdoors like hiking and exploring parks since the pandemic started. I look forward to traveling to some of the national parks out West as I have yet to explore the Grand Canyon.

The Most Important Health Care Bill You’ve Probably Forgotten

The Medicare and Medicaid Act.  The Affordable Care Act.  These are the landmark laws that have irrevocably shaped America’s health care system.  However, there’s another law that’s made just as much of an impact on health care but hasn’t garnered attention in the last 20 years.  It’s called the Hill-Burton Act, and it’s poised to be potentially revitalized.

House Dems Revive Hill-Burton in Infrastructure Bill

On March 11, all 32 Democrats on the House Energy and Commerce Committee proposed the Leading Infrastructure for Tomorrow’s America Act, or the LIFT America Act.  The proposal calls for investing $312 billion in clean energy, energy efficiency, drinking water, broadband, and infrastructure.  Nestled within the proposal is a provision to reestablish the Hill-Burton Act by providing $10 billion in funding for the construction and modernization of health care facilities.  According to the LIFT America Act, projects that improve public health preparedness or cybersecurity would be prioritized. 

What Is the Hill-Burton Act?

President Harry Truman signed the Hill-Burton Act into law on August 13, 1946.   Known formally as the Hospital Survey and Construction Act, it provided construction grants and loans to communities to help build health care facilities.  To receive funding, communities had to demonstrate they had enough population and per capita income to sustain a hospital.  All in all, the Hill-Burton Act’s impact on the nation’s health care infrastructure was nothing short of monumental.  In total, the law financed the construction of nearly 6,800 hospitals, nursing homes, and mental health facilities in over 4,000 communities.  The Hill-Burton Act was also responsible for the construction of one-third of all US hospitals in the three decades following the law’s enactment. 

What Happened to the Hill-Burton Act?

Community-based health care construction under the Hill-Burton Act came to a close in 1997, when Congress last included funding for the program in its Fiscal Year 1997 appropriations bills.  Lawmakers’ decision to no longer fund the program is likely related to an overall trend towards cuts in federal spending throughout the 1990s, including passing the landmark Balanced Budget Act of 1997. 

It should be noted that the Hill-Burton Act was long in decline before funding finally dried up in 1997.  The federal government had already been drawing down funds for the Hill-Burton Act in accordance with then-President Richard Nixon’s Economic Stabilization Program (ESP).  Established in 1971, the ESP’s calls to cut health care spending catalyzed a trend among politicians from both parties that saw a shift away from funding inpatient care and toward supporting outpatient care. 

Reasons for the Hill-Burton Act’s Revival

The House bill, H.R. 1848, calls for funding to “increase capacity and update hospitals and other medical facilities in order to better serve communities in need,’’ with priority given to “projects that will include public health emergency preparedness or cybersecurity.”  Although public health officials have been provided billions of dollars in funding to help fight against COVID-19, there is concern that this money could dry up at the end of the pandemic, leaving the nation unprepared for a future public health emergency.  By prioritizing public health preparedness, the LIFT America Act help provide the infrastructure necessary to address the next public health crisis.   

Additionally, the impact of the COVID-19 pandemic on health equity cannot be overlooked.  Research from the Journal of the American Medical Association and Health Affairs has pointed to the pandemic’s impact on health disparities, particularly among communities of color and low-income Americans, and a plan to reinvest in health care infrastructure could be seen as a way to address these disparities. 

The pandemic has also exacerbated concerns over cybersecurity.  Recently, the FBI reported nearly 4,000 cyberattack complaints in one day, marking a 400% increase from pre-pandemic levels.  This increase can be attributed to a rise in remote workers and an expansion in telehealth.  Improvements in cybersecurity infrastructure can help mitigate the impact of future cyberattacks and protect patient and provider data. 

Is $10 Billion Enough?

The LIFT America Act specifically provides $10 billion for fiscal years 2022-2026 for hospital modernization and improvement.  The nation’s hospitals are certainly in need of modernization – of the 6,210 hospitals in the United States, a 2019 survey by the American Society for Health Care Engineering found 23% percent of operators are planning to renovate or build acute care hospitals.  With the average cost of a hospital modernization project ranging from $250 to $300 per square foot, the funds provided in the LIFT America Act are likely to come up short.  However, future appropriations bills could provide for the opportunity to increase Hill-Burton funding or extend funding beyond 2026, creating the potential for greater funding levels in the future.

Moving Forward

The Congressional debate on infrastructure is just heating up.  Along with the LIFT Act, Senate Republicans proposed $568 billion in infrastructure spending last week, an offer which was roundly criticized by Democrats as being insufficient.  President Biden is set to reveal his second infrastructure plan in recent weeks, dubbed the American Family Plan.  Along with the American Jobs Plan, the Administration and Congress will spend the rest of the spring and summer negotiating a legislative package to address all manner of infrastructure, including perhaps taking old ideas like Hill-Burton, and making them new again.

The Week in Review: April 19-23

Biden Celebrates 200 Million Vaccinations

On April 21, President Biden announced that the US had administered 200 million COVID-19 vaccine doses, meeting his Administration’s goal of putting 200 million shots into American arms within 100 days.  The President also urged unvaccinated Americans to fulfill their “patriot duty” and get their shots.  To encourage more Americans to get vaccinated, President Biden reaffirmed a commitment to a tax credit for small businesses to incentivize them to provide employees the day off to get vaccinated.

Are COVID-19 vaccinations starting to decline?

According to CDC data, the number of Americans who received COVID-19 vaccinations during the week of April 13 declined 11% from the previous week.  This marks the biggest decline in vaccinations since February, when winter storms delayed shipments and forced vaccinations sites to close.  The drop in vaccinations coincides with the federal government’s pause on the JNJ vaccine, forcing many vaccination sites to cancel appointments or switch to offering Pfizer-BioNTech and Moderna doses.  Public health experts attribute the drop to the interruption of the JNJ vaccines and waning interest in vaccinations among residents of rural areas.

ACIP Could Decide Fate of JNJ Vaccine Today

The CDC Advisory Committee on Immunization Practices (ACIP) meets today at 11:00 AM EDT to discuss whether or not the US should resume usage of the Johnson & Johnson (JNJ) COVID-19 vaccine.  ACIP initially voted to maintain the JNJ pause in its last meeting on April 14 after reports of six severe blood clot cases out of the 7.5 million people who had received the JNJ vaccine.  According to reports, ACIP may recommend resuming the use of the JNJ vaccine, but with new warnings about blood clots.  Alternatively, the advisory panel could impose restrictions on continued use of the JNJ vaccine, such as barring those in certain age groups from receiving JNJ shots, or maintain the pause to allow more data to be gathered. 

FDA Finds Overcrowding, Unsanitary Conditions at JNJ Contractor

Following an eight-day inspection, the FDA found multiple flaws at an Emergent BioSolutions facility in Baltimore that had been contracted to produce JNJ COVID-19 vaccines.  The Baltimore facility first hit the news on March 31 after reports that production mishaps required 15 million vaccine doses to be tossed.  Some of the problems FDA inspectors found include unsanitary conditions and insufficient space for materials and equipment.  While FDA and Emergent BioSolutions have committed to addressing the discrepancies, it seems unlikely that JNJ will meet its goal of delivering 100 million vaccine doses to the federal government by June.

Stivers Steps Down from Seat in Solid GOP District

On April 19, Rep. Steve Stivers (R-OH) announced he will leave Congress effective May 16, 2021, to serve as President and CEO of the Ohio Chamber of Commerce.  Stivers, a member of the House Financial Services Committee, has represented communities to the south and west of Columbus in Congress since 2011.   Ohio Governor Mike DeWine, a Republican, has yet to announce a special election to fill Stivers’ seat, which is a solidly red district.  The upcoming vacancy in Stivers’ seat will increase Democrats’ majority in the House from five seats to six.

ICYMI: DC Welcomes New WWI Memorial

The World War I Memorial, DC’s newest national memorial, opened in Pershing Park along Pennsylvania Avenue on April 21.  While the memorial is now open to the public, it’s notably missing its centerpiece – a free-standing bronze relief that won’t be completed for another three years.  However, visitors are still able to view water features, marble walls engraved with quotes and maps, and a statue of General John Pershing leftover from the previous iteration of the park.  The park’s unveiling coincided with a fighter jet flyover that surprised residents across the Washington, DC area.

Meet Ariel Gonzalez, Advocacy Expert and Basketball Coach

Ariel Gonzalez, one of the newest team members at Chamber Hill Strategies, has seen the advocacy landscape change considerably over the course of his 20-year career in Washington.  Each of Ariel’s accomplishments has provided countless learning opportunities that he uses to help clients achieve their goals.  We talked to Ariel about what he’s learned and about how his passions for basketball and martial arts keep him grounded. 

What are some of the highlights of your career? 

In my six years at AARP when I ran their health and family team on the federal level, I was able to prevent Medicare beneficiaries from paying more in out-of-pocket costs.  I’m really proud of being able to hold the line and protect tens of millions of Medicare beneficiaries from harmful proposals.  A little later in my career, I led and coordinated an effort to get substantial mental health and substance use disorder reform as a part of the first 21st Century Cures Act when I was Chief of Government Relations at the American Psychiatric Association.  It was wonderful to collaborate with some of the other large mental health organizations, like the American Psychological Association, Mental Health America, the National Alliance on Mental Illness, and others to advocate for substantive change in terms of how mental health and substance abuse is addressed.  

How has advocacy changed since you first started your career?  How has advocacy changed over the last 10 years?

Advancements in technology as they relate to grassroots advocacy have been outstanding over the last 20 years.  When I started the health care portion of my career in 2002 at Premier, Inc., the advocacy tools we had then were so elementary compared to the sophistication of grassroots advocacy tools that we have available today.  Within the last 10 years, the ability to have microtargeted messaging to legislators in real-time such as social media messages have been key.  Before, we had to rely on letter-writing, which transitioned to faxing, and then emailing.  Today, social media plays a huge role in everything we do, including digital advocacy from grassroots and grasstops perspectives that allows organizations to move the needle with legislators in real-time via targeted messaging.

What are some of the biggest challenges lobbyists and advocates face in 2021?

You can’t speak about advocacy in 2021 without speaking about the pandemic.  The transition to virtual advocacy was a significant challenge in 2020, and in 2021, I think most lobbyists and Hill staff have begun to understand that this is the new normal.  Certain Hill staff have even expressed they would like this to continue with virtual advocacy post-pandemic because they think it accelerates efficiencies in meetings and helps with their schedules.

On another note, I’d say another huge challenge in 2021 is the hyperpartisanship that is evident on Capitol Hill.  Over the last several years, it’s just gotten uglier and uglier between the parties.  I was just reading something from House Majority Leader Steny Hoyer (D-MD) where he was expressing concern in the House that even broadly supported, bipartisan bills that should be voted on under suspension are now being called out to do roll call votes just to be a thorn in the side of the majority.  That’s why as a lobbyist, I work to leverage our relationships in a way that benefits clients in this partisan environment. 

What’s some of the best advice you’ve received?

“The only thing constant in life is change.”  I use that as a mantra to continuously evolve as a person, a lobbying professional, a father, a husband, and as a contributing member of society.  Being able to understand the dynamic of things in Washington – the power changes, power shifts, being able to roll with the punches – is really critical.  The ability to believe in yourself has really been something that I hold close as I faced various challenges. 

What else should we know about you?

I’ve coached both youth and high school basketball since 2003.  I love to play when I can and teach my knowledge of the game to the kids.

I’ve also dabbled over the years in acting, both on stage and on screen as a way to develop tools to become a better public speaker.  Speaking publicly to strangers translates well in terms of performing live on a stage or in front of a camera. 

Finally, I’m a big martial arts guy.  I’ve been studying and training various martial arts on and off since the age of 5, and I’ve coached martial arts, too.  I definitely enjoy it, and it’s really helpful in a number of circumstances in life – from learning discipline when I was younger to feeling confident in handling myself in a variety of situations.

What Does the Rise of SPACs Mean for Health Care?

In 2019, special purpose acquisition companies (SPACs) raised $13.6 billion.  In 2020, they raised $83 billion.  The boom in SPACs hasn’t been lost on the health care industry, which saw 50 health care-focused SPACs go public in 2020 alone.  However, the rapid growth of SPACs has caught the attention of regulators and lawmakers, which means the boom may not last forever.

Also known as blank check companies, SPACs are shell companies that raise capital in an initial public offering (IPO) for the purpose of later acquiring a private company.  Typically, SPACs sponsors have 18-24 months to complete an acquisition.  If the acquisition fails, the SPAC is dissolved, and the money is returned to its existing shareholders.  Some investors see SPACs as more attractive than traditional IPOs because of faster access to the market and confidentially negotiated terms.   

SPACs are encroaching on the health care industry, albeit at a limited rate.  Of the 120 SPACs that were actively seeking an acquisition target in October 2020, only 15% were considered targets in the health care/life sciences space.  Among the health care companies that went public in the US last year through SPACs are MultiPlan, a health care cost management solutions platform, SOC Telemed, a telemedicine provider, and Cerevel Therapeutics, a biopharmaceutical company.

Take SOC Telemed.  SOC Telemed, a national provider of acute care telemedicine solutions, merged in July 2020 with special purpose acquisition company Healthcare Merger Corporation.  Now listed on Nasdaq (TLMD), SOC Telemed used its strong financial performance during the pandemic and its cash infusion from investors to acquire Access Physicians, a multi-specialty acute care telemedicine provider.  SOC Telemedicine is now the largest pure-play provider of acute care telemedicine, serving over 700 hospitals across 47 states.  All that in ten short months.

While health care SPACs under scrutiny per se, the rapid growth of SPACs is starting to catch the eye of government officials.  On April 8, the Securities and Exchange Commission said it will be heavily looking into SPACs going forward, with a focus on disclosures by sponsors and acquisition targets for any misleading statements or omissions, such as projections or valuations. 

SPACs are attracting attention in Congress, too.  In March 2021, House Financial Services Committee members Reps. Brad Sherman (D-CA) and Bill Foster (D-IL) recently expressed concern that companies may be using SPACs to evade disclosures and liabilities, thereby putting unwitting investors at risk.  While these concerns have yet to yield any serious congressional inquiries or legislation, consumer advocates are pushing Congress to take action.  In February 2021, Americans for Financial Reform sent a letter to House Financial Services Committee leaders with several policy recommendations to reign in SPACs, including enhanced disclosure requirements and more study into the risks of SPACs.

Until regulatory and legislative action is taken, however, there seems to be no end in sight to the growth in SPACs.  Therefore, only time will tell the implications of blank check companies for health care providers – and what these implications could mean for patients and consumers.

The Week in Review: April 12-16

Survey Finds Drop in JNJ Vaccine Confidence

On April 13, the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) recommended the US pause usage of the Johnson & Johnson (JNJ) vaccine after six women ages 18-48 developed a severe blood clot out of the 6.8 million doses administered so far. According to a poll conducted by YouGov and The Economist in the wake of the recommendation, the number of people who felt the JNJ vaccine was safe declined from 52% to 37%, while those who felt the vaccine was unsafe jumped from 26% to 39%.  Critics of the government’s recommendation say the pause is directly contributing to an increase in vaccine hesitancy, while federal officials say demonstrating the safety of vaccines is paramount to maintaining public confidence.  Notably, the public’s views on the safety of the Moderna and Pfizer vaccines remain unchanged.  

CDC Advisory Panel Punts Decision on JNJ Vaccine Pause

On April 14, the CDC Advisory Committee on Immunization Practices (ACIP) declined to vote on recommendations to continue using the JNJ COVID-19 vaccine, just a day after federal officials announced a pause in JNJ vaccinations over safety concerns.  ACIP opted to maintain the pause to allow more time to gather additional data about the blood clots that occurred in six vaccine recipients.  The Committee will reconvene in 7-10 days to decide whether to continue the pause, allow JNJ vaccinations to continue with certain restrictions, or bar the JNJ vaccine from continued use altogether.  Until the committee votes on recommendations, the pause will likely continue.

Pelosi Has “No Plans” to Bring Bill to Expand SCOTUS to the Floor

Speaker Nancy Pelosi (D-CA) told reporters on April 15 that she has no plans to bring to the House floor a bill from Rep. Jerry Nadler (D-NY) that would add four seats to the Supreme Court, which would effectively tilt the Court in Democrats’ favor.  However, Pelosi said expanding the court is “not out of the question,” and she expressed support for the Biden Administration’s commission to study changes to the Supreme Court, which include adding seats or instituting term limits.

Top W&M Republican Announces Retirement

Rep. Kevin Brady (R-TX), who currently serves as Ranking Member of the House Ways and Means Committee, announced on April 13 that he will not seek reelection to a fourteenth term in Congress.  Brady, who has represented the northern suburbs of Houston since 1997, was term-limited out of being the top Republican on powerful tax-writing committee in the next Congress.  Among the House GOP members eyeing Brady’s seat is Devin Nunes (R-CA), Vern Buchanan (R-FL), Adrian Smith (R-NE), Jason Smith (R-MO), and Mike Kelly (R-PA).

Dem Pollsters Admit to Flaws in Predicting Outcome of 2020 Election

Sure, most polls were correct in saying Joe Biden would win the presidency, but hardly anyone predicted Democrats would lose seats in the House and the Senate would be split 50-50.  Six months later, a group of leading Democratic pollsters reconvened to find out what went wrong.  According to a memo they released on April 13, the pollsters underestimated the amount of Republican turnout on Election Day and the reluctance among Republicans to participate in surveys.  Going forward, the pollsters say they are less likely to use live-interview phone calls and more likely to use innovative methods like text messages to prompt survey participation.

ICYMI: Poll Says DC Is the Worst State

A YouGov poll released on April 13 found the District of Columbia – which is not even a state – last in a ranking of US states from best to worst.  The poll, which asked respondents to choose the better of two states in a series of head-to-head matchup, ranked states according to how often they “won” in the matchups.  Fortunately, the District’s neighboring states fared better in the poll – Virginia came in third, while Maryland was ranked 26.

5 Things to Know about In-Person Advocacy

Will we get back to in-person meetings on Capitol Hill?  When??  How?  COVID-19 is still around, even as the country’s mood is lightening about the overall impact of the virus.  And the safety and security of lawmakers and staff are of top-of-mind after the deadly January 6 riot and April 2 attempt at breaching the Capitol grounds.  Let’s explore  when in-person meetings might return and what those meetings could look like.

It is happening?

By and large, in-person advocacy isn’t happening, at least not on the Hill.  Since March 2020, advocacy has shifted online to videoconferencing like Zoom and telephone calls.  However, that doesn’t mean Members haven’t been yearning for a return to normal.  On March 10, House Republican Leader Kevin McCarthy (R-CA) sent a letter to Speaker Nancy Pelosi (D-CA) requesting a timeline on when certain in-person activities can restart, including allowing visitors in House office buildings.  While Pelosi has not officially responded to the letter, many Democrats say it’s premature to relax restrictions, partially due to the fact that a number of Republican lawmakers have yet to be vaccinated.   

Any decision on when to loosen restrictions will ultimately be up to Democratic leadership in the House and Senate, in consultation with the Office of the Attending Physician (OAP).  While the Capitol complex and adjacent congressional office buildings are exempt from public health guidelines from the Government of the District of Columbia, leadership and the OAP are using local COVID-19 health guidances to inform decisions.  These guidelines were last updated February 23 and include masking, de-densifying Hill offices, staggered schedules, and teleworking.

What is open?

Presently, both the House and Senate office buildings are only open to Members, staff, and credentialed press, and while official business visitors are permitted in congressional offices, they must always require staff escorts.  House staff may only escort a maximum of nine visitors at a time, while Senate staff are limited to 15 visitors.  However, this does not mean that advocates have regular, unfettered access to congressional offices. 

What about off the Hill?

Over the past few weeks, some lawmakers and staff, mostly Republicans, have resumed some degree of in-person activities, including fundraising dinners, due to relaxations in local restrictions on event sizes as well as new CDC guidelines that allow small groups of vaccinated individuals to gather in-person.  Republicans are also hosting fundraising trips around the country.  Lobbyists and advocates are also interacting in-person with legislators instates and congressional districts where COVID-19 restrictions have been loosened more considerably. 

When will things get back to normal?

Anecdotally, some congressional staff and lobbyists are saying in-person meetings may not be permitted on Capitol Hill until 2022.  Whether this happens sooner or later depends on countless factors, including the pace of vaccinations, level of vaccination hesitancy, local restrictions in DC, and to what extent any COVID-19 variants impact the effectiveness of current vaccines. 

What will change permanently?

With most details about the future of in-person meetings on the Hill being speculative, one likelihood is the continued use of videoconferencing technology that can complement in-person meetings.  During the pandemic, teleconferencing has been used to great effect to connect advocates who normally wouldn’t be able to make a trip to Washington with lawmakers and staff, which leaves open the possibility for a “hybrid” approach that incorporates building relationships both in-person and virtually.

Furthermore, the aftermath of the January 6 riot on Capitol could serve as the basis for other permanent changes.  Even after the pandemic ends, some congressional staff and lobbyists feel that certain security measures could stick around, meaning limits on in-person meetings could persist.  For instance, limits on group sizes could continue, which would certainly impact large-scale fly-ins.  At the moment, however, both Members of Congress and lobbyists are more focused on removing physical barriers such as fencing and razor wire from the perimeter of the Capitol complex.  On March 15, for example, the National Institute for Lobbying & Ethics sent a letter to the Speaker urging the removal of all physical barriers by July 1. 

Is the Future Now for a Lower Medicare Eligibility Age?

Some birthdays are more special than others.  Turning 16 means a drivers license is within reach and turning 18 grants the ability to cast a ballot.  For many Americans, turning 65 means they are finally eligible for Medicare coverage.  However, this milestone for turning 65 could soon change, as top Democrats weigh the possibility of lowering the eligibility age for Medicare.

On April 9, 2021, President Joe Biden reiterated his goal to lower the Medicare eligibility age to 60, a policy position he first laid out as a presidential candidate in 2020.  According to the President, a lower eligibility age would help Americans retire early and provide insurance coverage for those who are unemployed. 

Allowing Americans under 65 to enroll in Medicare isn’t exactly a new proposal; for over a decade, many Democrats have suggested a Medicare buy-in that would allow those five to 10 years below the current eligibility age to receive coverage by paying a premium.  Additionally, many of these previous proposals called for people not to enroll in Medicare itself, but rather in a Medicare-like plan operated by the federal government. 

The President’s proposal, however, would simply entail lowering the eligibility age, thereby allowing everyone within the expanded age group to enroll in Medicare.   

What About Bernie?

Long-time single-payer proponent Sen. Bernie Sanders (I-VT) has also been pushing for a lower Medicare age.  His plan is more far-reaching than Biden’s in that it would lower the eligibility age to 60 or 55 and provide dental and vision coverage. 

Cha-Ching

Lowering Medicare’s eligibility age could be pricey.   The Journal of the American Medical Association (JAMA) estimates that there are currently 20 million Americans aged 60-64 with commercial insurance, Medicaid, or no insurance coverage at all.  With an estimated average $5,000 per year in per-capital spending on this age group, JAMA projects an infusion of 20 million beneficiaries to Medicare could cost the program up to $100 billion per year. 

However, one could surmise that the price of lowering Medicare eligibility could be, at least in part, offset by potential savings to the government that could result from persons receiving subsidized coverage through an Affordable Care Act (ACA) plan switching to Medicare coverage. For instance, should persons 60-65 years who are enrolled an ACA plans shift into Medicare coverage, what impact would this have on risk pools and could premiums for ACA plans, overall, drop in price as a result? It will be interesting to see how the Congressional Budget Office (CBO) projects this budgetary impact. 

Medicare Insolvency?

Regardless of whether any shifts from ACA coverage to Medicare coverage could offset the price of the proposal, there remains questions as to what the impact may be on the Medicare Hospital Insurance Trust Fund, which is projected to reach insolvency by 2024

The growth in Medicare spending has been a concern for years, leading for some to call for the program’s eligibility age to be RAISED in order to save money.  According to a Congressional Budget Office report from 2011, raising the Medicare eligibility age to 67 would save the program $125 billion over a decade.  Since then, several prominent Republicans including then-2012 presidential candidate Mitt Romney have called for the program’s eligibility age to be raised by two years. 

Proponents of a higher eligibility age say the move would be a better targeting of the government’s resources, given the rise in the nation’s life expectancy since Medicare was first created and the fact that younger Medicare beneficiaries are less likely to have health problems than their older counterparts.  Others have said a higher eligibility age could keep more Americans in the workforce.  Meanwhile, opponents say raising eligibility age would simply shift costs from Medicare onto commercial insurers, Medicare, and individual Americans. 

Opposition

But lowering the age for Medicare eligibility is on the table now, not raising the age.  So where do health care industry stakeholders stand on lowering the Medicare age?  They aren’t happy.  Hospitals, for instance, may have the most to lose from a lower Medicare eligibility age because Medicare pays hospitals at a lower rate than commercial insurers.  Additionally, the addition millions of new Medicare beneficiaries would give Medicare considerably more bargaining power when setting prices with hospitals and other providers, including nursing homes and dialysis facilities. 

For insurers, there could be winners and losers, depending on the strength of any given company’s Medicare Advantage (MA) market share.  MA has been one of the fastest-growing lines of business for insurers, and with new Medicare beneficiaries disproportionately more likely to choose MA over traditional Medicare, a lower eligibility age could mean a windfall for insurers with MA plans.  However, for insurers who have focused more heavily on their group market business, they could see insureds shifting to MA as a loss, unless they are able to become competitive in MA markets.

What’s Next?

It is difficult, given Democrats’ small margins in the House and Senate, to ascertain a quick path to enactment of dropping the eligibility age to 60.  Some in the caucus will argue it is not enough, that a public option is what is needed.  Others may view this as an incremental win towards government-run healthcare.  However, with the prospect of using the budget reconciliation process again, at least one more time and possibly two, in play, as well as Speaker Nancy Pelosi (D-CA) recently signaling support for lowering the Medicare age, a more fleshed-out proposal that expands Medicare access and contains other Democratic health priorities has the potential become the party’s newest target for policy action.  

The Week in Review: April 5-9

Senate Dems Have Two More Opportunities to Use Budget Reconciliation

The Senate Parliamentarian ruled on April 5 that Democrats may use budget reconciliation two more times this year to override a Republican filibuster and pass a major legislative package with 50 votes.  This sets the stage for Senate Democrats to use reconciliation to advance the Biden Administration’s $2.25 trillion infrastructure package if certain conditions on revenue and spending are met.  Senate Democrats already used budget reconciliation in March to advance the American Rescue Plan Act of 2021 (P.L. 117-2).

Administration Bumps Vaccine Eligibility Date to April 19

On April 6, the Biden Administration announced that every adult in the nation will be eligible for a COVID-19 vaccination by April 19, nearly two weeks ahead of the original deadline of May 1.  In a press briefing preceding the announcement, White House Press Secretary Jen Psaki said the new date can be attributed to an expedited supply of vaccine doses and improvements in distribution.  However, the Administration continues to urge Americans to remain vigilant and adhere to public health guidelines as parts of the nation see an increase in cases.

Florida Congressman Passes Away, Narrowing Democratic Majority

Representative Alcee Hastings (D-IL) died on April 6 at age 84 following a two-year bout with pancreatic cancer.  The Florida congressman’s death narrows Democrats’ majority in the House down to seven, leaving Speaker Nancy Pelosi (D-CA) with tighter margins to advance Democratic legislative priorities.  Voters in Hasting’s district, which stretches from Fort Lauderdale to West Palm Beach, will have an opportunity to choose a new Representative in special election that has yet to be announced by Republican Governor Ron DeSantis

Poll Finds Largest Gap between in Party Affiliation since 2012

A Gallup poll conducted in the first quarter of 2021 found an average of 49% of US adults identified with  or lean towards the Democratic Party, while 40% identify or lean Republican.  The nine-percentage-point Democratic advantage is the largest Gallup has measured since the fourth quarter of 2012.  The poll also found 44% of Americans identify as political independents, compared to 38% in the fourth quarter of 2020.  Most of the gains in independent affiliation came at the expense of Republicans who saw a 4% decline in party identification since the fourth quarter of 2020 compared to Democrats’ 1% drop over the same period.  This data means Republicans’ hopes of retaking Congress in the 2022 midterms may hinge on appealing to independent voters.

CMS Begins Proposing FY22 Payment Rates

This week, the Center for Medicare and Medicaid Services began proposing Fiscal Year 2022 payment rates for the following prospective payment systems:

Comments for all four proposed rules must be received no later than 5 PM EDT on June 7, 2021.

ICYMI: Trump Weighs In on 2022 Senate Races

Former President Donald Trump has already begun endorsing Republican candidates ahead of the 2022 midterms.  Republicans face an uphill battle to retake the Senate in 2022 – while Democrats only have to defend 14 seats, Republicans must defend 20.  On April 8, Trump issued a statement urging the currently undecided Sen. Ron Johnson (R-WI) to seek reelection.  Democrats flipped Wisconsin from red to blue in the 2020 presidential election, and Johnson’s Senate seat is sure to be hotly contested in 2022.  A day earlier, Trump endorsed Rep. Mo Brooks (R-AL) to succeed Sen. Richard Shelby (R-AL), who has opted not to seek reelection.

The Government’s Ambitions Plans to Grow Broadband Access

A major barrier to widespread telehealth adoption in the United States is lack of access to broadband internet.  While telehealth utilization has surged since the start of the COVID-19 pandemic, telehealth’s potential for growth is limited by lack of high-speed internet connections for both patients and providers.

However, not all Americans have access to broadband.  A 2019 Federal Communications Commission (FCC) report found 21.3 million Americans, or 6.5% of the population, currently lack access to broadband.  Furthermore, a 2021 survey by BroadbandNow found 42 million Americans are unable to afford broadband without any assistance.  According to the Office of the National Coordinator for Health Information Technology, broadband service provides a higher-level speed of data transmission, which is particular important for live videoconferencing with health care practitioners.  Additionally, broadband allows health care providers to meaningfully use patient information, such as electronic health records, to improve patient outcomes. 

Fortunately, the federal government has taken some steps to boost broadband access. To help patients afford broadband access, the Consolidated Omnibus Appropriations Act, 2021 (P.L. 116-260) provided $3.5 billion to the FCC to establish a program to help low-income Americans get or stay connected to broadband.  The program is required to provide a $50 subsidy for qualified households who must include at least one individual who is eligible for the Lifeline Program, the Supplemental Nutrition Assistance Program, or a Pell Grant.

Providing direct government subsidies to individuals to access broadband looks likely to be part of an upcoming legislative effort to address the nation’s infrastructure needs.  The American Jobs Plan, the Biden Administration’s highly anticipated $2 trillion infrastructure proposal, high-speed broadband to every American, including the 35% of rural Americans who lack high-speed broadband.  Among the ways the Administration plans to achieve this include:

  • Providing individual subsidies to cover internet costs in the short-term and reducing costs through widespread adoption in the long-term.
  • Prioritizing support for broadband networks owned or operated by local governments, non-profits, and cooperatives.
  • Promoting transparency and competition among internet providers and requiring providers to publicly disclose prices their charge.

Direct subsidies are also included in the Leading Infrastructure for Tomorrow’s (LIFT) American Act.  Co-sponsored by all 32 Democrats on the House Energy and Commerce Committee, this proposal will provide a basis for House Democrats’ action on energy and broadband in the Congressional infrastructure bill.  The bill would grow high-speed internet access by:

  • Authorizing an additional $6 billion for the FCC program that provides a discount of up to $50 off the cost of monthly broadband service for eligible households. 
  • Providing $80 billion to develop secure broadband nationwide by funding connections to underserved rural, suburban, and urban communities.
  • Allocating $5 billion in federal funding for low-interest financing of broadband deployment.

While health care providers are already advocating for making permanent some of the Medicare and Medicaid flexibilities for telehealth enacted into law as the result of the coronavirus pandemic, they should be keen to keep an eye out for additional discussion and debate on broadband access.  Both the government’s recent actions to expand broadband and Democratic proposals to boost broadband even further suggest a strong desire to build out an infrastructure that will allow telehealth to flourish in a post-pandemic world.

ICER’s Growing Influence on Drug Value

The Institute for Clinical and Economic Review (ICER) has grown to become a leading voice on drug pricing in the US.  As the emphasis on value in the US health care system and concern over high drug prices continues to grow, more stakeholders are likely to look to ICER for guidance on whether a drug is appropriately priced. 

ICER was founded in 2006 by Dr. Steve Pearson, an ethicist from Harvard Medical School, with the goal of improving value in health care.  One of the main ways ICER seeks to carry out this mission is by publishing reports on whether new drugs are cost-effective.  Using both economic and clinical evidence, ICER determines a “value-based price benchmark” for each drug it studies based on the based on how much a patient’s quality of life improves.   While ICER does take some membership-based funding from companies including CVS-Caremark and Pfizer, the organization does not accept funding to perform research on specific drugs or therapies. 

ICER’s influence began to grow in 2015 thanks to financial support from billionaire John Arnold, who provides the organization over two-thirds of its funding.  Now, the organization plays a critical role in driving the national conversation on drug prices and value.   Only a third of ICER’s reports have found a drug to be cost-effective and appropriately priced, and in response, many drug companies, payers, and providers have adopted some of the organization’s pricing recommendations.  For example:

  • CVS Health allows its commercial plan clients to exclude drugs from their formularies that fail to meet ICER’s cost benchmarks.
  • Novartis set the price of its gene therapy drug Zolgensma in line with ICER’s recommendations.
  • The Department of Veterans Affairs uses ICER drug assessment reports in drug coverage and price negotiations with the pharmaceutical industry.
  • ICER’s cost effectiveness reports on PSCK9 inhibitors, which are used to manage and prevent cardiovascular disease, drove annual list prices down from $14,600-$14,100 to $5,850.
  • A report by ICON plc found over a third of payers surveyed would be likely to request a rebate to match the net ICER cost-effective price.

ICER isn’t without criticism.  As a private organization, ICER has drawn concerns from patient advocates and physicians for its lack of oversight and regulations.  Additionally, the organization has faced pushback over the use of its quality-adjusted life years (QALYs) formula, which estimates a drug’s dollar benefit.  Some patient advocates say QALY determines costs in a discriminatory manner because the formula assigns individuals with a chronic condition or a disability with a lower value.  Notably, the federal government is prohibited from using QALYs to measure cost-effectiveness under the Affordable Care Act. 

In the future, Cost-effectiveness itself is a complicated concept in light of growing trends:  ICER could impact health care based on growing trends:

  • A heightened focus on health disparities could prompt ICER to review how different therapies affect certain demographic groups.
  • In the oft-chance the US adopts a public health insurance option or even a single-payer system, ICER could play a greater role in dictating cost-effectiveness.  For example, the United Kingdom-equivalent of ICER has significantly more clout in the country’s National Health Service. 
  • ICER may be forced to adjust its methodologies to address the growth of personalized medicines such as cell and gene therapies, which benefit a relatively limited number of individuals compared to therapies the organization has traditionally studied.

Furthermore, if the US adopts a public health insurance option or even a single-payer system, ICER could play an even greater role in drug coverage and pricing.  The United Kingdom-equivalent of ICER has direct decision-making authority within the country’s National Health Service.