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We barely had the chance to see the cherry blossoms with all the activity going on in DC! House Republican leaders are seeking to move quickly on the compromise budget resolution that the Senate passed over the weekend, so work can begin on reconciliation legislation. Meanwhile, the administration is making moves on Medicare Advantage and Medicare Part D. So, with that, let’s get into it. Welcome to the Week Ahead!
The Administration
The Centers for Medicare and Medicaid Services released its contract year 2026 Medicare Advantage and Part D final rule within 24 hours of CMS Administrator Oz being confirmed. Ironically, the final rule removes a provision from the Biden administration to expand Medicare coverage of GLP-1s, the obesity drugs of which Administrator Oz has been a proponent.
Speaking of rules, we are still waiting on the 5 calendar year payment rules, still under review at the Office of Management and Budget.
And don’t forget that Federal agency heads have until April 19 to submit deregulation plans in accordance with a February 19 Executive Order. We could see several health care regulations rolled back as part of this effort, including the nursing home staffing mandate and the Medicaid Managed Care Access rule implemented by the Biden administration. But Congressional Republicans have their eye on repealing the nursing home staffing rule to count toward their budget reconciliation savings goals.
The Senate
Despite impassioned arguments that the resolution would cut Medicaid and Medicare, and several votes on the subject, the Senate passed the compromise budget with only two Republicans, Sens. Collins (R-ME) and Paul (R-KY), voting against the bill. Movin’ on.
A couple key takeaways: Republicans passed an amendment with language they say will keep President Trump’s promise for no cuts in “patient benefits” for those on Medicare and Medicaid. Senate Democrats countered that the language was too vague to be of value.
Sen. Collins (R-ME) consistently voted for Democratic amendments related to Medicaid and Medicare and voted against the final budget. Sens. Murkowski (R-AK) and Hawley (R-MO) joined her in supporting many of these amendments, but in the end, they came home and voted yes on the budget.
How should we interpret that Hawley cosponsored the Sen. Ron Wyden (D-OR) amendment to strike the $880B savings directive to the House Energy and Commerce Committee? He’s paying close attention to Medicaid and Medicare in this bill; that’s all we can say for sure for now.
Looking ahead: The Senate Committee on Health, Education, Labor, and Pensions (HELP) plans to markup S.932, Give Kids a Chance Act, which would reauthorize the rare pediatric disease priority review voucher program at the Food and Drug Administration (FDA) and gives the agency more authorities regarding molecularly targeted drugs.
The House
House Republican leadership wasted no time after the Senate passed its amended version of the budget resolution, sending a letter to their caucus saying they plan to vote on the budget resolution the week of April 7.
However, a lot still needs to happen before President Trump can sign his “big beautiful bill.” First, House Republican leadership will need to pass the amended budget resolution through the narrowly divided House. Only then can the door be unlocked for Republicans to pass a reconciliation bill that President Trump can sign. And as arduous as passing a budget resolution can be, it pales in comparison to the work of getting a final reconciliation bill passed. Especially one that will satisfy deficit hawks looking for large spending cuts and members who are wary of how said cuts will impact their constituents. We are already hearing about dissatisfaction from a significant number of House Republicans about the Senate version of the budget resolution, which complicates an already complicated situation.
House Health Hearings
- April 8: Ways and Means Health Subcommittee hearing on the biosimilar market
- April 9: Oversight and Government Reform Committee hearing on the FDA and rooting out illicit products
- April 9: Appropriations Labor-HHS, and Education Subcommittee public witness day hearing
There You Have It
We’ve reached the final night of “the big dance,” with two teams facing off tonight in Texas for the championship. Who are you rooting for? Let us know. Make it a great week!
As Senate and House Republicans continue down the path of using budget reconciliation to advance President Trump’s legislative agenda, the strategy of putting together a majority vote on the budget becomes more and more complicated. One key figure in this made-for-TV (or at least CSPAN…) is the Senate Parliamentarian. Who is the Senate Parliamentarian and what does she do?
The Role of the Senate Parliamentarian
The Senate Parliamentarian is an office within the Secretary of the Senate. The job involves interpreting the complicated rules of the Senate.
Some of the things the Senate Parliamentarian does include:
- Advising the Senate’s presiding officer, or Majority Leader, on the appropriate procedure, statements, and responses of the Senate.
- Offering written guidance on procedural questions.
- Recommending the referral of measures to relevant committees.
- Maintaining and publishing procedural rules
Why is the Senate Parliamentarian Getting So Much Attention?
The Republican majority is using the budget reconciliation process to accomplish their policy goals. Using reconciliation does this in two ways: one, reconciliation speeds up the usually slow and deliberative Senate by avoiding the filibuster; and, two, Republicans can pass major legislation by simple majority, without Democratic support.
Big Decisions Ahead
Republicans want to extend the 2017 tax cuts from the Tax Cuts and Jobs Act (TCJA). And they are trying to do that as cheaply as possible from a legislative score-keeping perspective. Republicans would like to use a “current policy” budget baseline so they don’t have to offset the $4 trillion or so cost.
Therefore, enter the Parliamentarian, who decides what whether Republicans do this. The answers set up or complicate the path forward for Republicans on tax cuts and the rest of the reconciliation bill. The Parliamentarian also uses the “Byrd Rule” to analyze legislation and makes a determination on whether a provision produces a change in spending or revenues and does not increase the deficit within a set period. Each provision in the budget bill and the budget reconciliation bill has to save or spend money, and not insignificantly.
The Senate Parliamentarian has made unpopular rulings to the majority party before. In 2021, top Senate Democrats were upset by the Parliamentarian’s decision to not include a minimum wage increase in the American Rescue Plan due to an “incidental” impact on the federal budget.
A majority vote can overrule a Parliamentarian’s ruling but often Senators are creatures of habit and prefer to uphold the rules of the institution of the Senate.
Is the Parliamentarian Position Partisan?
The position of the Senate Parliamentarian is strictly non-partisan, and individuals are traditionally appointed to the role from senior staff in the Parliamentarian office. There have only been six Senate Parliamentarians since the position was created in 1935. Senate Parliamentarians have no defined term length and serve at the pleasure of the Majority Leader.
Who is the Current Senate Parliamentarian?
The current Senate Parliamentarian is Elizabeth MacDonough, who was appointed by then-Majority Leader Harry Reid (D-NV) as the first woman to hold the position in 2012. She previously served as senior assistant parliamentarian for 13 years. She studied English Literature at George Washington University and attended Vermont Law School.
Did You Know?
The Senate Parliamentarian’s salary is $203,700 as of 2022. For context, Senators earn $174,000 and Senate leaders earn $193,400.
It’s Not Just the Senate
The House of Representatives has its own Parliamentarian, too, with a similar salary and responsibilities. The current House Parliamentarian is Jason Smith (not to be confused with the Chair of the House Ways and Means Committee from Missouri), who was appointed in 2010.
The Controversy
The Senate Majority Leader does have the authority to fire the Senate Parliamentarian. This last happened in 2001, when then-Majority Leader Trent Lott (R-MS) fired then-Parliamentarian Robert Dove after he interpreted Senate rules in way that would have made it difficult to pass then-President George W. Bush’s tax cut proposal through budget reconciliation.
We aren’t saying Ms. MacDonough will get axed, but the Senate Parliamentarian is a tricky position to have.
While the men’s and women’s Final Four brackets are set, the Congressional budget is not at all locked up. Senate Majority Leader Thune (R-SD) is preparing to vote this week on a budget they’ve been negotiating with the House, while Speaker Johnson (R-LA) is hoping to add two members to his razor-thin majority by winning special elections in Florida. Will March Madness yield a “beautiful” budget in April?? Let’s see! Welcome to the Week Ahead!
The Administration
We are eagerly awaiting the final Medicare Advantage (MA) and Part D technical changes and rate announcement rules, as well as the proposed rules for the fiscal year payment systems. CMS Administrator-nominee Oz is waiting for his Senate floor vote, and he was not especially warm on MA during his confirmation hearing. We know the final MA rule will look different than the proposed rule released during the previous administration, but how much different? Will the rule come out on time – around April 7?
And how will the continued DOGE-ing complicate rule-making and public input? In case you were under a rock, you might have missed that the Department of Health and Human Services (HHS) announced plans to reduce its full-time workforce by 10,000 employees and consolidate the number of divisions from 28 to 15. The Department says this decision is about improving efficiency, saving taxpayer dollars, and better implementing the Trump administration’s focus on addressing chronic disease rates.
The Senate
The Senate aims to vote on the budget resolution this week they’ve been negotiating for the past few weeks with the House. While an agreement has yet to be shared publicly, rumors are the budget would set up a reconciliation bill that would require smaller cuts from Senate Committees (at least $3B) than from those in the House (at least $1.5T). Notably, the resolution may call for at least $1 billion in cuts from the Senate Health, Education, Labor, and Pensions Committee, which has jurisdiction over many HHS agencies.
Wait, what? How can they do that? Doesn’t the Senate and the House have to vote on the SAME budget?
Yes, they do, but the House and Senate do not have mirrored committees, so the Senate is really only voting on policies within the Senate’s committee structure, and the House is only voting on policies in the House’s structure.
The move here is essentially a way for Senators to delay making the tough decisions on policies like Medicaid, Medicare, and taxes later on in the process of budget reconciliation. Senators can vote for the budget this week and still vote against the final reconciliation bill if it doesn’t pass muster (ala the Sen. John McCain-style moment in 2017).
Senate Hearings This Week
- April 3: Senate Judiciary Committee meeting on April 3 on bills increasing transparency and promoting competition within the prescription drug industry
The House
The votes are tight – for everything in the House including the budget. Even with Democratic vacancies following the deaths of Reps. Sylvester Turner (D-TX) and Raul Grijalva (D-AZ), President Trump still felt the need to withdraw Rep. Elise Stefanik’s (R-NY) nomination to be UN Ambassador to boost his chances for a budget win. All eyes now turn to Florida, where Republicans hope to pick up two seats in special elections to replace former GOP Reps. Matt Gaetz and Michael Waltz on April 1.
These should be easy pickups for the GOP, but special elections should never be taken for granted. Republicans are growing anxious that Josh Weil, the Democratic candidate in the race to replace Rep. Waltz in Florida’s 6th congressional district, could pull off an upset against Republican Randy Fine. These races could either give Republicans more breathing room on forthcoming budget votes or make their lives even more difficult. Even if Republicans win both seats, they can still afford only 3 defections to reach the required 217 votes to pass a budget resolution and ultimately reconciliation.
House Hearings This Week
- April 1: House Energy and Commerce Health Subcommittee hearing on the regulation of over-the-counter monograph drugs
- April 1: House Energy and Commerce Oversight Subcommittee hearing on cybersecurity vulnerabilities in legacy medical devices
- April 1: House Veterans’ Affairs Committee oversight hearing on modernizing VA health care
- April 2: House Veterans’ Affairs Oversight Subcommittee hearing on the VA’s mental health policies
- April 2: House Education and Workforce Health, Employment, Labor, and Pensions Subcommittee hearing on employer-based health insurance
There You Have It
Speaking of March Madness, how are everyone’s brackets looking? Is your team still in it? Mixing hoops and vote-a-rama is a great way to watch the Senate floor. Let’s make it a great week!
After the confirmation process of former Congressman Dr. Dave Weldon to head the Center for Disease Control and Prevention (CDC) abruptly halted on March, various names were floated to be the new nominee, including former Congressman Dr. Michael Burgess. The White House announced their new nominee on March 24 is Susan Monarez, PhD. Who is she?
Since January, Dr. Monarez has been the acting head of the CDC. She was brought over to the CDC from ARPA-H, where she has been the Deputy Director since January 2023. She has a long history in the government, serving under both Democratic and Republican administrations at Health and Human Services (HHS), Homeland Security, the White House (Obama and Trump administrations), and Health Resources and Services Administration (HRSA). Prior to government service, Monarez was a postdoctoral fellow and graduate student, respectively, at Stanford University School of Medicine and the University of Wisconsin – Madison, where she focused on technology development to prevent, diagnose, and treat infectious diseases particularly impacting people living in low- and middle-income countries.
There are a few interesting facets of her nomination:
First, she will be the first person ever confirmed by the Senate to run the CDC. Prior to 2022, CDC directors were appointed; but Congress passed a law that year saying any future CDC heads would be confirmed by the Senate. Second, if she is confirmed, she will be the first non-medical doctor to run the CDC since 1953. Prior CDC heads were M.D.s – Dr. Monarez is a Ph.D., not an M.D.
A key difference between Dr. Monarez and the previous CDC nominee Dave Weldon is her support for vaccines. In her work at ARPA-H, Dr. Monarez has strongly supported APECx which is an initiative to use artificial intelligence to design antigens that target entire viral families. (She has spoken at public conferences in favor of the program.) ARPA-H argues the studied viruses (like herpesviruses and flaviviruses, such as Zika and dengue fever) pose serious threats to global health, causing pandemics, cancers, and chronic illnesses.
Anti-vax groups are concerned about her support for vaccines, but that support will certainly help her nomination chances in the physician-heavy Senate Finance Committee.
Dr. Monarez is also a strong proponent of the use of AI in health care. In her career, she has focused on understanding challenges within the health ecosystem and identifying opportunities for innovation to address them through AI, technology, and innovation.
Critics argue that her extensive background within the federal health bureaucracy and a heavy focus on technology-driven biosecurity suggests a continuation of the status quo rather than the long-overdue “Make America Health Again” reform.
Thus far, the announcement of her nomination has been well-received, with very little push back. We do expect her to field pointed questions from Senators regarding CDC actions over the past few weeks, including the cancelling of CDC grant funding and the delayed meeting of vaccine advisors (including for formulating strains for the flu vaccine for the 2025-2026 flu season). We will continue to watch what happens as her vetting continues.
