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On March 14, 2025, the Senate Finance Committee held a hearing to consider the nomination of Dr. Mehmet Oz to be the Administrator of the Centers for Medicare and Medicaid Services (CMS). There was bipartisan agreement about certain topics, such as the need to address the high cost of health care, concerns about rural health, the benefits of telehealth, and the need to address concerns about the Medicare Advantage (MA) program. The biggest partisan difference on display was on the topic of how Republican reconciliation legislation would impact Medicaid funding. Democratic Senators argued that the proposal would lead to losses in coverage for those who needed it, and Republican Senators countered that Medicaid reform was about protecting coverage for those who really needed it.
OPENING STATEMENTS
WITNESS TESTIMONY
MEMBER QUESTIONS
Medicaid
Democratic Senators expressed concerns that the proposed Republican reconciliation legislation, as passed by the House of Representatives, would lead to Medicaid cuts that would hurt families, mothers, children, and providers (especially rural providers). In response to questions as to his thoughts about these potential cuts, he said he had not seen legislation that would cut Medicaid funding but said protecting Medicaid means making sure it is stable over the long term. When asked about his thoughts on work requirements from Sen. Raphael Warnock (D-GA), Dr. Oz said he supported them because of his support for the dignity of work but did not think they should be a barrier to coverage. Other Democratic Senators brought up the Medicaid expansion population. Sen. Maggie Hassan (D-NH) expressed her concerns that Medicaid budget cuts could lead some states to drop coverage for the expansion population. When asked directly about his thoughts on Medicaid expansion by Sen. Maria Cantwell (D-WA), Dr. Oz said it works for some states, but other states may try other ways to provide coverage to the uninsured.
In contrast, Republican Senators who spoke about Medicaid funding tended to talk about the need to ensure the program was stable for those whom it was initially intended to help, that is, the poor, mothers, children, and people with disabilities. Sen. Ron Johnson (R-WI) said there was a need to distinguish between Medicaid before and after the Affordable Care Act (ACA). Specifically, he argued that Medicaid expansion has been expensive, threatens the program’s ability to provide care for individuals such as people with disabilities, and has allowed certain states to game the system through the use of tools such as provider taxes. Dr. Oz agreed that by expanding the number of people on Medicaid without providing more resources to providers, you do stretch resources in a way that could impact those Medicaid was originally designed to help. Both Sens. Johnson and Marsha Blackburn (R-TN) cited concerns about Medicaid coverage for undocumented immigrants and foreign nationals. Dr. Oz said he would ensure that both Medicaid and Medicare eligibility are calculated accurately. He specifically cited an article about California’s effort to use federal dollars to pay for Medicaid coverage for undocumented immigrants. On another Medicaid-related topic, Committee Ranking Member Ron Wyden (D-OR) defended the nursing home staffing rule promulgated by the Biden administration. Sen. James Lankford (R-OK) countered that the rule may sound good but would lead to widespread closures, especially in rural areas. Dr. Oz said that examining this rule is something he wants to do early on if confirmed.
Medicare Advantage
Today’s hearing demonstrated that Senators on both sides of the aisle have concerns about the MA program. Specifically, Senators expressed concerns about charges that plans are upcoding to make patients appear sicker than they are, that they improperly deny coverage, that they engage in deceptive marketing, and that the program costs the government more than traditional Medicare. Even though Dr. Oz at one point proposed transitioning all Medicare patients to MA, he acknowledged these concerns and pledged to work with Senators on both sides of the aisle to address them. Notably, when asked by Ranking Member Wyden about what he saw as the biggest area of abuse in the private insurance market, he responded with MA sales practices. In answer to other Senators’ concerns about improper denials, he said he thinks there are too many procedures that require prior authorization and that standardization is needed when it comes to what does and what does not require prior authorization.
Chronic Health and Nutrition
Several Senators expressed concerns about the rate of chronic disease in America and asked Dr. Oz how CMS might address this concern. In answer to a question about this from Sen. Roger Marshall (R-KS), Dr. Oz said that incentivizing beneficiaries to make healthy choices was a worthy goal and said he had conversations with Ranking Member Wyden about this. Sen. Todd Young (R-IN) asked what reforms could be made in CMS to promote prevention efforts for chronic diseases. Dr. Oz gave the example of how, in MA, some plans provide a food allowance, but there is no guidance on how to eat healthy. Sen. John Cornyn (R-TX) argued that the Supplemental Nutrition Assistance Program (SNAP) subsidizes unhealthy foods.
Rural Health
Senators on both sides of the aisle expressed concerns about rural health. Sens. Blackburn and Tina Smith (D-MN) highlighted their concerns about the closures of rural hospitals. In answer to a question from Sen. Blackburn about the low wage index, Dr. Oz committed to working with Congress. Senator Chuck Grassley (R-IA) brought up his concerns about the placement of graduate medical education (GME) slots in rural areas. Additionally, Senators such as Steve Daines (R-MT) and Cortez Masto (D-NV) expressed their support for telehealth. Dr. Oz also shared his support for telehealth and noted how larger institutions in specific areas can serve their regions.
Prescription Drugs
Senators on both sides of the aisle mentioned concerns about the cost of prescription drugs. Sens. Lankford and Chuck Grassley (R-IA) expressed their support for pharmacy benefit manager (PBM) reform. Dr. OZ said that while he believes PBMs do play a role, there needs to be reforms to increase transparency. Democratic Senators such as Ben Ray Luján (D-NM) and Peter Welch (D-VT) asked Dr. Oz about his position on solutions such as Medicare price negotiation and international reference pricing. Dr. Oz says he wanted to use all available tools to lower prescription drug costs.
Other Issues
- Sen. Steve Daines (R-MT) expressed his concerns about restrictions on Medicare beneficiaries’ access to innovative medical devices. Dr. Oz said the gap between when the Food and Drug Administration (FDA) approves a product and when Medicare and Medicaid patients can access it needs to be shortened.
- Sen. Cantwell asked Dr. Oz if he would support bundling patients at or below 150% of the poverty line to ensure affordable access to care, especially if ACA tax subsidies expire. He said he would commit to looking at it as a solution.
On March 11, 2025, the House Ways and Means Health Subcommittee held a hearing on Ensuring Access to Quality Post-Acute Care. Democratic members centered their questions on potential Medicaid and Medicare budget cuts, while Republicans concentrated on the nursing home staffing rule and home health services. Both parties addressed the need for telehealth services. Both parties agreed that there should be quality post-acute care.
OPENING STATEMENTS
WITNESS TESTIMONY
- Dr. Dana Madison, DNP, MBA, BSN, RN, Compassion Home Health Care
- Paul Dongilli, Jr., PH.D. CEO, Madonna Rehabilitation Hospitals
- Jonathan Fleece, President and CEO, Empath Health
- Lisa Grabert, MPH, Visiting Research Professor, Marquette University
- Eric Carlson, Director of Long-Term Services and Supports Advocacy, Justice in Aging
MEMBER DISCUSSION
Medicaid and Medicare Budget Cuts
Democratic members focused their discussion on potential Medicaid and Medicare budget cuts. Rep. Judy Chu (D-CA) emphasized her view that Republicans are planning to cut $880 billion from Medicaid and that would negatively impact seniors’ ability to access long-term care. She pointed out that Medicaid already only covers a limited number of rehabilitation days and asked how cuts would affect seniors relying on both Medicaid and Medicare. Mr. Carlson responded by highlighting that Medicaid assists millions of Americans in covering Medicare premiums, with 10 million relying on it to manage significant health care expenses. He emphasized that long-term care costs are a major burden for individuals across various income levels and that Medicaid serves as a critical safety net. He warned that any cuts would be devastating.
Rep. Steven Horsford (D-NV) added that Medicaid is the primary payer for 60% of long-term care spending. He expressed his concerns that cuts would force providers to reduce hours, increasing the risk of inadequate care. He then asked what steps were being taken to protect nursing home workers from the impact of Medicaid cuts and what the consequences of cuts would be for the long-term care workforce. Mr. Carlson warned that if cuts of the magnitude described by Democratic representatives were implemented, providers would struggle to continue operating, with the consequences ultimately falling on the health care providers and workforce.
Rep. Don Beyer (D-VA) expressed his concerns about what he described as cuts to health care services in the continuing resolution (C.R.). He argued that the bill was not a clean proposal but rather one that would cut $280 million from Alzheimer’s, kidney, and heart disease research. He questioned whether patient care would be impacted by budget cuts of this size. Mr. Carlson’s response was straightforward: “The simple answer is no.” He emphasized that the research programs could not continue to provide the necessary support under such severe budget reductions.
Nursing Staffing Rule
Rep. Scott Fitzpatrick (R-PA) highlighted the staffing shortages in his home district, noting the increased pressure on health care providers. He asked how staffing has changed in recent years and what challenges these shortages pose in treating patients. Dr. Madison responded that the shortage of registered nurses (RNs) has been a persistent issue, with a deficit of about 1,000 RNs in the past. She emphasized that telehealth could help alleviate some of these challenges but noted that many nurses left the profession during the COVID-19 pandemic.
Ranking Member Lloyd Doggett (D-TX) referenced a 2023 Medicare Payment Advisory Commission (MedPAC) report that found skilled nursing facilities had funds exceeding 22% more than necessary, yet 20% of facilities relied on Medicaid to cover costs. He questioned whether there were enough workers to meet the required staffing standards. Mr. Carlson responded that regulations must be practical. He noted that while the staffing standard is not as high as some advocates had pushed for, 60% of facilities nationwide already meet it. He also argued that rural facilities have an extended phasing period until 2027 and 2029 to comply. Additionally, he also argued that if facilities demonstrate that labor shortages prevent them from meeting staffing requirements, they are exempt from penalties in that region.
Rep. David Kustoff (R-TN) then inquired about workforce shortages, asking whether many certified nursing assistants (CNAs) pursue higher levels of nursing education. Mr. Fleece acknowledged the challenges in recruiting and retaining workers, particularly given the pressures of runaway inflation. He stressed that hiring staff remains a significant challenge in the current health care landscape.
Home Health Services
Rep. Lloyd Smucker (R-PA) discussed the importance of occupational therapy (OT) as a service available to patients through Medicare Part A for home health and introduced a bill aimed at streamlining the process for accessing home health care. He asked how the bill would improve patient access to care and what the financial implications might be. Dr. Madison responded that the bill would allow payment for any episodes of care, and if OT services were to be provided independently, they would be able to deliver the necessary care. She explained that this approach could lead to cost savings for agencies by reducing the expenses they would otherwise need to spend on other services.
Rep. Kustoff inquired about how home health services are provided in rural areas and how rural-based services align with the national average. Dr. Madison explained that home health services currently offer patient monitoring, such as blood pressure management, but pointed out that these services are not reimbursed at all, which presents a significant challenge.
There was concern from Rep. Greg Steube (R-FL) about the drastic decline in the number of home health providers and he asked for insights into the widespread closure of home health agencies. Mr. Fleece responded by emphasizing that home-based care is a key solution to today’s health care challenges. He discussed various models within the home-based care environment, noting that larger, not-for-profit agencies play a significant role in providing care, especially in underserved areas.
Telehealth
Rep. Carol Miller (R-WV) discussed the challenges rural patients face due to a lack of critical support, noting that the absence of central care increases recovery time and raises the risk of complications. She suggested expanding telehealth usage in post-acute care settings, which would allow for face-to-face visits via telehealth, as a solution to address these gaps. She asked about the impact of limited access to care, and the difficulties families face when visiting their loved ones. Dr. Dongilli acknowledged that this is a real issue for families, highlighting the challenges they face in relocating and accessing the necessary resources to care for their loved ones. He emphasized the importance of making it easier and more helpful for families to receive payments and support, with the goal of improving care for both patients and families.
Rep. Fitzpatrick pointed out that his home district is facing staff shortages, which are compounded by increasing pressure. He asked how staffing has changed in recent years and how these challenges impact the ability to treat patients. Dr. Madison responded by noting that there used to be a shortage of around 1,000 registered nurses (RNs), and that telehealth could help alleviate some of the strain. She also noted that many nurses left the profession during the COVID-19 pandemic, further exacerbating the shortage.
Rep. Blake Moore (R-UT) added that in most cases, telehealth is the best option for ensuring access to care and asked how the quality of telehealth services could be improved. Mr. Fleece emphasized that his organization serves rural communities and noted that telehealth is the primary means of ensuring access to care, especially for individuals suffering from chronic or acute conditions. He stressed the importance of maintaining and expanding telehealth services to ensure these patients receive the care they need.
We’re in a three-week push to see where Republicans land on uniting behind an ambitious budget and setting up reconciliation. Yes, the Senate is working on getting the nominees for FDA, NIH, and CMS through the confirmation process, but the real focus of health care policy right now is behind the scenes on reconciliation. What key decisions do Republicans need to make? Let’s get into it – welcome to the Week Ahead!
One Bill or Two
Didn’t they already decide it’s going to be one bill? Well, not exactly. The Senate budget sets up 2 reconciliation bills and the House sets up 1 bill. For now, Republicans are strategizing around creating one massive reconciliation bill given President Trump’s endorsement of “one big beautiful bill,” and Speaker Mike Johnson’s (R-LA) impressive vote maneuvering in February. It’s nearly April and Republicans want a win. If things start to fall apart, a two-bill strategy might come back into play.
How to Treat the Tax Cuts
One issue Republicans are united on is extending (for as long as they can) the 2017 tax cuts passed under the Tax Cuts and Jobs Act (TCJA). The question is what cost scoring method to use. If Republicans choose a current LAW baseline, they have to pay for the tax cuts to the tune of some $4 trillion. If Republicans choose a current POLICY baseline, they don’t. Current law means the tax cuts expire at the end of 2025 and any tax cuts after that are “new” and must be paid for. Current policy means the tax cuts that expire in 2025 are assumed to continue past December 31. Sound fishy? Surprisingly, it’s not. Both parties have used both types of baselines at different times depending on the goals they wanted to achieve at the time.
How to Treat Spending
The debate over using current law or current policy baselines also affects how the bill could consider increasing in spending. While not super important to get into right now, Republicans could set up a budget that treats spending differently than what is assumed, making it less expensive on paper to spend money on programs they want to boost.
What About Medicaid?
Is the $880 billion over 10 years in the House bill a ceiling and $1 billion in the Senate bill a floor? Not really. First, the Senate didn’t touch the tax cuts in their bill, so the Senate position on a dollar amount to cut Medicaid is unknown. The last major Republican attempt to reduce Medicaid spending in 2005 started as an ambitious $60 or so billion bill and got whittled down to a $10 billion cut.
Also, on Medicaid, for Republicans, it’s not solely about offsetting other spending or the tax cuts. While the tax cuts may not have to be paid for because of the budget baseline they choose, Republicans see their majority as an opportunity to address certain issues in Medicaid. First off is the Biden minimum nurse staffing rule – that one is certainly wiped out in a reconciliation bill. But that is not the only target – think about programs that states use to increase federal money coming into their coffers like state directed payments, provider taxes, and intergovernmental transfers.
What About Medicare?
Isn’t reconciliation just about Medicaid? Nope, as soon as you bring in the Senate Finance Committee’s jurisdiction into reconciliation, you have Medicare AND Medicaid on the table. While a lot of attention is being paid to Medicaid changes, expect Medicare changes. What might they be looking at? Think the greatest hits of recent Congresses – PBM reform, site-neutrality, Medicare Advantage coding changes, and more.
Could There Be Health Care Spending?
Yes, think physician payment reform and the potential of permanent extensions on telehealth. Don’t forget the advanced premium tax credits that expire at the end of 2025. If there is one bill, it will definitely be “big.” Big doesn’t mean a lot of spending – Republicans will want to offset spending in Medicare by reductions in Medicare (or potentially Medicaid, though that’s not been their approach for the last 25 years).
BUT WAIT…
Before we get too far ahead of ourselves, remember the Senate and House have to agree on an overall approach to the BUDGET. The budget is really a set of directions to the committees of jurisdictions to make policy based on a dollar target; the budget is NOT reconciliation. The Senate and House have to agree to the same budget and then pass it in both chambers before the (health care) committees can put together legislation. Then, those committees have to pass their reconciliation bills, the Budget committees have to package them up into one reconciliation bill, and then that reconciliation bill has to pass both the Senate and House.
It’s a gauntlet, ladies and gentlemen.
What’s the Timeline?
These three weeks are critical for Republicans to try to coalesce around a BUDGET before they leave for April break. Can they do it? It seems ambitious when you can’t lose more than 2 votes in the Senate and only a handful in the House. Florida’s special elections on April 1 to replace two vacant House seats are likely to grow the House Republican majority. But it’s one step forward and two steps back for Speaker Johnson, as Rep. Elise Stefanik’s confirmation to be the UN Ambassador will mean a likely Democratic pick-up through a governor appointment.
There You Have It
Are you exhausted yet? You can’t be! This is the biggest year for health care policy since the Affordable Care Act (ACA). Where were you during the ACA debate? Let us know!
On March 7, 2025, the Medicare Payment Advisory Commission (MedPAC) held the second day of the March 2025 meeting. The first session focused on examining home health care use by Medicare Advantage (MA) enrollees. The second session discussed institutional special needs plans (I-SNPs). Findings from these sessions will be reported to Congress as part of MedPAC’s June 2025 report.
EXAMINING HOME HEALTH CARE ON MA ENROLLEES
MedPAC staff examined home health care use among MA enrollees, comparing it to Fee-for-Service (FFS) beneficiaries. A key focus was assessing data completeness and identifying patterns of home health care utilization. Researchers combined MA encounter data with the Outcome and Assessment Information Set (OASIS) records with the goal to obtain a more comprehensive picture of usage. MedPAC staff reported that they did get a more comprehensive picture of usage; however, reporting remains incomplete. The study found that 8.5% of MA enrollees used home health care in 2021, with higher utilization among older adults, low-income individuals, and those with prior hospital stays.
On average, MA enrollees who received home health care had 18.2 visits per user. The study also found that plan characteristics influenced usage patterns, with those in preferred provider organization (PPO) plans receiving more visits per user than those in health maintenance organization (HMO) plans, while provider-sponsored plans were associated with fewer visits. Additionally, cost-sharing played a role—MA plans requiring out-of-pocket payments for home health care saw lower utilization rates. When compared to FFS, MA enrollees were less likely to use home health care following hospitalization and, on average, received fewer visits. Even when controlling for provider differences, these trends remained unchanged. MedPAC staff acknowledged that the study had some limitations, including variations in data completeness across counties and the exclusion of in-home services provided outside the Medicare home health benefit. Moreover, they noted it was not possible to determine the appropriate level of home health use for beneficiaries. Moving forward, MedPAC staff noted these findings will provide insights into post-acute care trends within MA. MedPAC Commissioners raised several key points regarding the analysis of home health care use in MA. Commissioners highlighted the challenge of determining an optimal level of care, noting the common quality issues in home health. Others inquired about the availability of more recent data beyond 2021 and whether the study could explore reasons for home health use. Commissioner Lynn Barr questioned whether costs were being shifted to beneficiaries and whether rural and urban areas were analyzed separately, given the higher costs of care delivery in rural regions. MedPAC staff indicated some uncertainty about whether it was reflected in claims. However, rural and urban areas were examined separately. Others addressed concerns about data completeness, particularly regarding claims records and prior authorization requirements, asking if denials were documented.
Commissioners emphasized the importance of clearly distinguishing the differences between MA and FFS home health use. Commissioner Gina Upchurch built on this by seeking insights into the types of providers delivering home care and the perceived quality of care among MA beneficiaries. Others raised concerns regarding discrepancies in OASIS data and variations at the county level, while others highlighted the distinction between post-acute and home health services, questioning why some required OASIS submissions were missing.
Commissioner Kenny Kan suggested expanding research into long-term care and site neutrality, noting that encounter data remains the least complete. Commissioner Robert Cherry highlighted that MA patients had a 6% higher utilization rate, and findings suggested that those without prior hospital stays might experience greater equity in access to care. Commissioner Scott Sarran said he saw no evidence that MA plans were inappropriately reducing care but acknowledged the complexities of decision-making in the system. Finally, Commissioners expressed support for continuing this research, reinforcing its importance in understanding MA’s role in home health services.
INSTITUTIONAL SPECIAL NEEDS PLANS
The second presentation from MedPAC staff focused on I-SNPs, and how these specialized MA plans for beneficiaries requiring nursing home-level care compare and contrast with other plans. MedPAC Staff noted that Commissioners previously expressed interest in examining the experiences of long-stay nursing home residents and evaluating whether private health plans, like I-SNPs, could provide better care than traditional Medicare. I-SNPs serve a relatively small market, with about 125,000 enrollees in 2024, covering roughly 12% of long-stay nursing home residents.
The presentation highlighted that only 26% of nursing homes participated in an I-SNP in 2023, with participation more common among larger, for-profit, and urban facilities. Payment structures for these plans typically include capitated payments and performance-based incentives. Demographically, I-SNP enrollees tend to have longer stays and have lower mortality rates than residents who did not enroll. Additionally, I-SNP enrollees are more likely to be black, live in urban areas, and be Medicaid-eligible compared with other long-stay residents. MedPAC Staff noted that data on quality suggested that nursing homes with I-SNPs performed better in reducing acute discharges, readmissions, and emergency department visits. However, these findings were subject to limitations in risk adjustment and data exclusions.
MedPAC staff also noted that existing research on I-SNPs is limited but indicates that these plans can reduce inpatient hospital use by shifting care to nursing homes. Compared to other Medicare plan options, MedPAC staff found that I-SNPs have higher costs and bid amounts due to the high medical needs of enrollees, yet they receive lower rebates. The research also reviewed alternative models such as Dual-Eligible Special Needs Plans (D-SNPs), Medicare-Medicaid Plans (MMPs), and the Program of All-Inclusive Care for the Elderly (PACE), noting that each of these plans coordinates with Medicaid, unlike I-SNPs. Looking ahead, MedPAC plans to explore additional Medicare efforts to improve care for long-stay nursing home residents and will include an informational chapter in its June 2025 report to Congress.
MedPAC Commissioners discussed several key aspects of I-SNPs, including enrollment patterns, care quality, and potential improvements to the model. Commissioners raised questions about how patients enroll in I-SNPs compared to other plans. Others highlighted the advantage of having nurse practitioners provide care in nursing homes but expressed concerns about their employment structure and overall care quality.
There was also an emphasis from some Commissioners on the need to improve care for this vulnerable population. Commissioner Stacie Dusetzina requested additional information on the economics of nursing home care, including eligibility criteria and access. Commissioner R. Tamara Konetzka also questioned how to make the I-SNP model more widely adopted. There was common support for the concept of integrated care and exploring alternative models.
Commissioners emphasized the overlap between I-SNPs and skilled nursing facilities, highlighting the need to understand better the services provided. Commissioner Betty Rambur added that while I-SNPs help reduce hospitalizations and turnover, a major challenge lies in training future professionals, as many students do not view this field as a long-term career option. She praised the PACE model, which serves 300 nursing home-eligible individuals, stressing the importance of a team-based approach with pharmacists and nurses, as successfully implemented in Vermont and Minnesota. Commissioner Lynn Barr suggested a comparative analysis of I-SNPs, D-SNPs, and PACE to assess patient experiences and financial structures. Building on this discussion, Chairman Michael Chernew pointed to a broader challenge— determining when and how to separate these programs, given their shared focus on institutionalized beneficiaries.
