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The Week Ahead

Stay informed with our weekly buzz about what’s going on in Washington, DC.

The Week Ahead 12/18/23: Bah Humbug! The Senate in One More Week – No Real Traction on Supplemental

Good morning from Washington DC, where like much of the east coast we were battered with rainstorms last night.  Fortunately, we woke to sunny skies coupled with forceful winds. The turbulence remined me of the push and pull taking place over the war supplemental request tied to border security measures, as conservatives are angling to slow roll the process and liberals are expressing concerns over actions in Gaza. We continue the conversation below as President Biden is being pulled in both directions, while also battling troubling poll numbers. As we conclude a turbulent political year which saw the ousting of a House Speaker, surprise retirements, and the expulsion of a perpetually lying congressman, we can only hope the administration and a divided congressional body learn to work together to fund the government and pass meaningful legislation in 2024. We can all learn something new – as I read an article last night clarifying the true cause behind the Boston Tea Party. It was caused over a corporate tax decrease (not an increase on tea tax) which would have enticed the colonists to buy lower-cost taxed tea thereby giving up the principle of no taxation without representation. The Senate is in this week and President Biden dodged a car crashing into his motorcade!  Welcome to the Week Ahead!

The Administration

What a past few days President Biden experienced.  Last night, a car crashed into a SUV in his motorcade right after he answered questions from reporters about why he is trailing Trump in the polls.  Fortunately, the President and First Lady were fine.  In addition to polling headaches, the President continues to face an uphill battle in terms of his war supplemental request. As we’ve mentioned in past weeks, the administration wants to provide funding to Israel, Ukraine, and Taiwan, but the House wants to link any funding request to changes in border security measures. The President, feeling much like the Stealers Wheel Song – Stuck in the Middle With You, is feeling clowns to the left of him and jokers to the right. Conservative opposition to funding Ukraine without reforming border security measures continues to mount and stall the process, while members of the Congressional Hispanic Caucus voiced concerns about the Biden Administration not communicating with them regarding negotiations which took place this weekend.

In healthcare news, the Center for Medicare and Medicaid Services released a voluntary payment model to improve maternal health in the US, a pillar of the Biden Administration’s goals in healthcare. The Transforming Maternal Health Model (TMaH) plans to partner with state Medicaid agencies to lower maternal mortality rates while reducing associated health disparities. The initiative will develop a value-based alterative payment model which will improve health outcomes and quality.  TMaH will focus on three main pillars: 1. Access to care, infrastructure, workforce capacity; 2. Quality and safety, 3. Whole-person delivery.  The program aims to work with participating states to address gaps in maternal health care by supporting access to midwives and doulas, improving perinatal care for chronic conditions like diabetes and hypertension, and reducing c-sections for low-risk mothers.

 

The Senate

Senate Majority Leader Schumer made sure he received less holiday cards this season as he called the Senate in session this week.  Senator Schumer hoped this week would allow for a negotiated package to come to the floor this week.  However, negotiators on the supplemental request, while making progress, failed to come to agreement on a package.  The White House was directly involved, and it is reported that some provisions were agreed to but that large hurdles remain.  Senate Republicans are in no rush to have a vote, and Senator Chris Murphy stated no legislative text exists for members to vote on at this time.  Senator Ron Johnson led a group letter of conservatives requesting a conference-wide meeting to discuss what they felt were “secret” negotiations with Democrats. All this to say, it is unlikely a floor vote on a supplemental request without legislative text will pass this week.  This sets up a particularly busy early part of January which also runs into the first tranche of government funding.  The Senate is also moving on stalled military nominations this week.

Senators are moving in a bipartisan work on health transparency with new legislation that requires insurers, hospitals, and other health facilities to disclose more pricing information.  The legislation entitled, The Health Care Price Transparency Act, 2.0, aims to be more stringent than its House counterpart by requiring hospitals to post the actual price for a service, rather than the median price. Like the House passed Lower Costs More Transparency Act, the measure extends transparency requirements to imaging centers and clinical labs, among others.

The House

The House finished its business last week and is out until next year.

Things will pick up quickly come January 8 as the House will only have eight legislative days before the first set of appropriations and health extender deadlines hit on January 19.  The House will only have an additional 4 legislative days before the second set of appropriations deadlines hits on February 2.  Rumors have started to percolate the House could extend the appropriations bills set to expire on January 19 to February 2, and a very likely scenario is a year-long continuing resolution to fund the government at current levels through Fiscal Year 2024 will be the result in February.

With multiple health extender deadlines hitting on either January 19 or 20, whatever government funding package is passed to fund the government past January 19 is expected to include health extenders. With the House having passed the Support for Patients and Communities Reauthorization Act last week with broad bipartisan support, it is rumored that the legislation could be packaged and passed along with provisions to provide partial relief from a scheduled 3.37% cut in Medicare physician payments and extend incentive payments for alternative payment models that would closely align with provisions passed the House Energy and Commerce Committee and by the Senate Finance Committee. Other provisions to be included would extend payments under the Medicaid Disproportionate Share Hospitals (DSH) Program, an extension of the Work Geographic Practice Cost Index (GPCI) Floor, and extensions of funding for Teaching Health Center Graduate Medical Education (THC GME), Community Health Centers (CHCs), and the National Health Service Corps (NHSC).

While the House did also pass the Lower Costs, More Transparency Act with bipartisan support last week, it seems less likely that the pharmacy benefit manager reforms and other measures, including site neutral payments for certain services, will be in play for moving in a January package because why include things to which everyone agrees?

As always, we value your insights and look forward to hearing from you!  This will most likely be the last Week Ahead for 2023.  Thank you for making this a wonderful year, and from all of us at Chamber Hill Strategies we wish you happy holidays and a fantastic New Year!

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A Whirlwind Week in Washington D.C. – From Political Storms to Legislative Waves

Good morning from Washington DC where the weather changed from rain, to snow, to warmer temperatures and sun in a matter of 36 hours.  The dramatic shift in weather cycles reminds us of the recently announced retirement of former House Speaker Kevin McCarthy.  Where else can you go from being Speaker, to being removed by your own party, to retiring all in one year?  Here in Washington of course!  Rep. McCarthy is not the only one to announce retirement for this term, and we do expect many more to leave before filing for another term.  With the slight majority Republicans hold in the House, each retirement and expulsion (Santos) makes the holiday season more enjoyable for House Democrats looking to take control next session.  In addition, we only have one week left of legislative business, and we still have no agreement reached on aid for Ukraine and Israel.  Congress returns this week to what could be a very busy time! Welcome to the Week Ahead!

The Administration

President Biden continues to work behind the scenes with Senate negotiators on the White House supplemental request for funding to Israel, Ukraine, and Taiwan.  As previously mentioned, Republicans in Congress want to tie any aid for these countries to increased border security measures.  The administration publicly stated reforms are needed at the border, but at this time, no agreement has been reached for foreign aid. President Biden will host Ukrainian President Zelensky this week.  With time running out and House Republicans becoming increasingly skeptical of funding Ukraine, President Zelensky returns to Congress for a last-minute plea to the Senate.

In health care news, and in line with its priorities, the White House celebrated the announcement that the FDA announced the approval of gene therapies to treat sickle-cell disease via its statement.  To address health inequities and improve on treatment of sickle-cell disease which disproportionately impacts African Americans and Hispanic Americans, the Biden Administration believes this breakthrough can save and improve the lives of millions.

The Senate

The Senate will welcome Ukrainian President Zelensky for a speech on the importance of funding to Ukraine.  The invite was extended by both Majority Leader Schumer and Minority Leader McConnell.  Behind the scenes negotiations will need to resume on border security measures to couple with potential funding on the war supplemental.

With an eye on health care for moving into 2024, the Senate will look to the following this week:

The upper chamber will look to conclude the year by finishing off its health care priorities, although they lack a bipartisan larger “package” which Leader Schumer expressed desire to complete this year.

The House

Retirement season has officially kicked off on Capitol Hill. Former Speaker McCarthy is leaving at the end of the year, Chairman Patrick Mc Henry (R-NC) is in his final term, and we expect several more are going to leave before they must file to run for another term. Many members are citing (shocker) dysfunction and just want to go back to their private lives.  With one week remaining, major fireworks remain on emergency packages for Ukraine, Israel, Taiwan, and the border wall. The Senate continues to negotiate, but the Senate package still must pass the House and must include border security.

In the area of artificial intelligence, the House Energy and Commerce Committee will hold a hearing on Wednesday leveraging agency expertise across the economy to position America as a leader in AI.

Health Care

As Congress looks to close its work for 2023, the House will be taking steps to move health legislation forward with an eye to positioning themselves going into 2024.

  • The House will consider 14 bills, including:
    • Lower Costs, More Transparency Act (H.R. 5378), which would establish increased transparency for insurers hospitals and PBMs.
    • Support for Patients and Communities Reauthorization Act (H.R. 4531)
    • PREEMIE Reauthorization Act of 2023 (H.R. 3226).

Each of the bills will be considered under the suspension of the rules signaling House leadership’s belief that the bipartisan bills will garner enough support to pass with the required two-thirds majority needed under the procedure. By moving the legislation with strong bipartisan support, the House leadership will be asserting a strong position on several health issues, including pharmacy benefit manager reforms and provider payments, as House and Senate are expected to work to reach an agreement on health legislation in 2024.

Beyond this public work on health care, we also expect work and conversations to continue behind the scenes, as leadership and committee staff on both sides of the Capitol work with an eye toward drafting legislation to address several expiring health care provisions and programs in January. As readers are likely aware, the House Energy & Commerce Committee moved 19 pieces of health-related legislation last week, including measures to extend the work Geographic Practice Cost Index floor, to revise the phase in of certain payment changes for lab services, an extension of expiring incentive payments for alternative payment models, and additional relief to help mitigate the 3.4% cuts in Medicare physician payments scheduled for January 1, 2024. At this time, we do not anticipate seeing a final agreement on these provisions before Congress adjourns in 2023, but it is expected that these other health provisions could be included in a legislative package in January.

Your insights are valuable, so please reach out with any questions or information.  Please create a great week!

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Navigating the Capitol: A Look Ahead at Congress’s December Agenda

Good morning and welcome from Washington, DC where Members of Congress return to work this week to face a few weeks of varying agendas depending on whether they sit in the Senate or the House. We hope our readers enjoyed a restful week and are back energized and ready to go!  Your author was able to avoid any travel this past week but unfortunately experienced his first taste of Disney princess fatigue, as I took my young daughter to see the movie Wish.  As the movie has a nice premise of free will and establishing one’s own destiny while not falling victim to a charismatic and selfish leader, I was reminded at times, however, it is good to have a collective group think – and we can only aspire that Congress exhibit this ethos to work together this month to avoid a government shutdown come January 19th.  Now that the holiday meals have settled, it is time to get to work!  Welcome to the Week Ahead!

The Administration

The Biden administration is moving forward to work with the Senate on its supplemental funding strategy which includes funding for Ukraine, Taiwan, and Israel.  The administration sees this as imperative to remaining a trusted leader on the world stage with America’s allies and must work this week to make it happen.  Timing is of the essence as only a few weeks remain until the end of the legislative calendar for 2023.  The deal will basically hinge on border security measure and asylum policies to address migrant issues at our shared border with Mexico.

It was announced this weekend that President Biden will not be attending the upcoming United Nations Climate Summit known as COP28.  The President attended the summit over past two years, but the ongoing war between Israel and Hamas has taken much of the President’s time, as he continues to pursue a ceasefire and the release of hostages.  John Kerry, President Biden’s special envoy for climate change will attend the summit in his place.

The Senate

Majority Leader Chuck Schumer issued a Dear Colleague letter outlining the Senate’s ambitious agenda for the remainder of the calendar year.  The Senate will aim to tackle a variety of challenging policy areas to include leading with President Biden’s supplemental funding request as early as next week.  Several Senate offices have stated that a deal must be worked out this week to successfully place the request on the Senate floor during the week of December 4th.  Again, any funding request would most likely be paired with border policy changes.  Senate Democrats realize that some policy changes are required to get a deal completed in time.  In addition to the funding request, the Senate will work with the House on the first set of appropriations bills to keep the government funded past the January 19th deadline.  The Senate will also look to pass the NDAA, confirm further judicial nominations, and work to overcome the legislative blockade of Senator Tuberville on military promotions.  With all that is happening on the national stage this month, what passes with regards to health care remains to be seen.

The House

As the House shifts focus to holiday parties and fundraisers, there is still plenty of drama remaining in the lower chamber.  With the potential ousting of Rep. George Santos, it will be interesting to see who else retires and how the battle for the House heats up.  Since Speaker Johnson cut a deal on the budget, it is holiday season around Washington D.C.!!! Christmas and holiday parties begin this week with a slew of fundraising before the final quarter of this year’s fundraising cycle. Congress has punted the budget to next year, and the town will feel the pressure start to cook once they get back from break.

The House will need to work with the Senate to come to a consensus before recess on the President’s supplemental request. This will be quite tricky as the House has already passed Israeli aide with a pay-for. The House may adjourn by December 8th, pending an agreement with the Senate on this request.

With Congress coming back from the Thanksgiving break, we expect a light week in Washington with few hearings and a focus on legislation largely related to issues other than health care. That said, the House Energy and Commerce Committee will hold two separate health-related topics. First, on Wednesday, the E&C Health Subcommittee will hold a hearing titled “Understanding How AI is Changing Health Care,” which is expected to be a broad hearing covering the potential and concerns surrounding AI in health care delivery. On Thursday, the E&C Subcommittee on Oversight and Investigations hearing will hold a hearing titled “Unmasking Challenges CDC Faces in Rebuilding Public Trust Amid Respiratory Illness Season,” where the Subcommittee will hear from Mandy Cohen, M.D., Director, Centers for Disease Control and Prevention and is expected to pursue questioning regarding the origins of COVID-19 and communications during the pandemic.

Also, with the passage of the continuing resolution to fund the government into next year, Congress also extended several health programs and provided protections from potential cuts into January as well. By taking action to prevent pending cuts under the Medicaid Disproportionate Share Hospital (DSH) program, extending the Work Geographic Practice Cost Index floor, and providing an extension of the Teaching Health Center Graduate Medical Education (THC GME), Community Health Centers (CHCs), and National Health Service Corps (NHSC) programs to January 19, Congress effectively punted on addressing larger health-related legislation until at least January—if not later in 2024.

In addition to pushing off the likelihood of any action on legislation targeted at pharmacy benefit managers, mental health or opioids, the extensions of these programs into January also means that Congress is unlikely to take any action to address a scheduled cut of 3.4% in Medicare payments to physicians that is set to take effect on January 1 as well. Readers may recall that in late 2022, Congress passed legislation to provide relief from projected physician payment cuts in 2023 and 2024. While the Senate Finance Committee included a provision to mitigate the cuts in the Better Mental Health Care, Lower-Cost Drugs, and Extenders Act, which it cleared earlier this month, the House seems to have little appetite to provide additional relief to physicians in Medicare and the 3.4% cut is likely to take effect in January.

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Heating Up the Debate: The Latest on Medicare Advantage Plans from Washington, D.C.

Greetings from Washington,  

While temperatures are dropping here in D.C., the Administration and some members of Congress are doing their best to heat it right back up by putting Medicare Advantage (MA) plans on blast. However, the Medicare Payment Advisory Commission (MedPAC) must’ve thought those changes weren’t enough as they thoroughly fanned the flames during their meeting earlier this month. 

MedPAC & MACPAC 

During the second day of its November Meeting, MedPAC held two sessions related to MA. During these sessions, MedPAC staff shared findings that show MA payments being consistently higher than expected because of coding and favorable selection. Specifically, in September, MedPAC estimated that coding differences alone led to more than eight percent higher MA plans than fee-for-service (FFS) plans in 2021, even after accounting for CMS’s 5.9 percent adjustment. In June, MedPAC estimated that favorable selection alone led to eleven percent higher payments than FFS in 2019. MedPAC staff also shared that a large collection of research points to MA plans experiencing favorable selection, both indirectly and directly.  

Furthermore, staff shared updates they made to the analysis from the 2023 MedPAC June Report to Congress. Two of these updates increased the selection effect by less than one percent and one of them decreased the selection effect by two to three percent. The estimated cumulative selection effect in this analysis went from 5.9 percent in 2017 to 12.8 percent in 2021. Based on this analysis, MedPAC staff estimates the combined effects of selection and coding to have caused $50.8 billion in increased payments to MA Plans in 2021. MedPAC plans to continue looking at the effects of selection into MA and will include estimates in the annual March MA status report. When it comes to networks in MA, MedPAC staff has found that choice of provider is important for beneficiaries and that many beneficiaries are willing to trade choice for reduced cost sharing, out-of-pocket spending caps, and additional benefits. When it comes to prior authorization in MA plans, MedPAC has found most MA PA determinations and reconsiderations were eventually approved.  

Commissioners raised many concerns about the Advantage plans including how plans are reimbursed, how the plans use rebates they are issued, and how CMS ensures network directories are accurate. They also expressed concerns about the potential barriers to care and burdens to providers caused by prior authorization requirements. 

Likewise, the November meeting of the Medicaid and CHIP Payment and Access Commission (MACPAC) included a session on the use of State Medicaid agency contracts (SMACs). MACPAC staff concluded that states are using contracted strategies in their SMACs to improve integration with varying frequency. Additionally, they found certain provisions are more widely used while others had relatively limited use. As for next steps, MACPAC will start conducting interviews with state and federal officials and health plans representatives to explore challenges to optimizing SMACs.  

Overall, commissioners were disappointed with the use of SMACs. Chair, Melanie Bella, MBA, underscored a gap exists between what they might see on paper and how these tools are used to ensure everyone who needs it, has access to integrated care. Commissioners expressed a desire to see researchers investigate what prevents states that have D-SNPs and SMACs from effectively using SMACs. MACPAC staff said they could look into this subject.  

On The Hill  

Democratic leaders on the Energy and Commerce Committee have called for increased oversight of the MA program. On the Senate side, Finance Committee Chair Ron Wyden (D-OR) held a hearing on MA marketing and enrollment practices and has commented on the need to address some of those practices.   

CMS Proposed Rule 

The Centers for Medicare and Medicaid Services (CMS) tried to stabilize the climate and keep our lawmakers’ heads cool by publishing a proposed rule to revise the MA program. They outline this ruling in a 2,500-word fact sheet, but we’ll try to give you all an overview in fewer words. Regarding broker/agent compensation, this rule would change the cap so it combines the additional fees at a flat rate (the new cap would be $632/beneficiary instead of $601/beneficiary). The rule would also require plans to provide enrollees with a mid-year notification about supplemental benefits to ensure they are taking advantage of the benefits. CMS also decided to address concerns about the use of prior authorization within MA. To improve the experiences and outcomes for dually eligible individuals the proposed rule would increase the frequency of special enrollment periods for enrollees eligible for both Medicare and Medicaid. And lastly, the ruling would limit out-of-network cost-sharing for dual eligible special needs plans (D-SNP) preferred provider organizations (PPOs) beginning in 2026. 

In accordance with federal law, this proposed rule will be published and subject to a public comment period. To ensure consideration, comments must be submitted by no later than 5 PM on January 5, 2024. 

Between the Administration, Congress, MedPAC, and MACPAC, it seems as though everyone has been trying to cook over the fire that are Medicare Advantage plans. We expect the oversight to continue, and you can be sure we will be watching the thermometer to ensure our clients’ voices are heard in Washington.  

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The Weekly Update: Congress’s Last-Minute Save

Good morning and welcome from Washington, DC where Congress averted a government shutdown just in time for government employees to return to work today (and actually get paid for it).  Only in Washington can you meet the minimum standards of your basic job and somehow attempt to take credit for it. In other developments, today former President Trump begins his civil trial in New York for fraud as a judge last week determined he is liable for inflating the value of his properties to secure and obtain business loans.  You know what is not overinflated? The 400% increase in jersey sales for the Kansas City Chiefs tight end, Travis Kelce, since Taylor Swift appeared at Arrowhead Stadium a little over a week ago.  Last night Swiftie was in the Meadowlands as the Chiefs beat the Jets and all remained well in the football world. Other celebs filled the owner’s box to include Ryan Reynolds and Blake Lively which probably worked in their schedules since actors remain on strike in Hollywood.  Other strikes remain to include the United Auto Workers, and a potential upcoming three-day strike by 75,000 workers from Kaiser Permanente which will begin Wednesday. The workers demand a resolution to the staffing shortage in the health system. Speaking of resolutions, now that the continuing resolution was passed, we only have until November 17th to fund the government – as my four-year-old daughter would say – “for real life” this time.  Welcome to the Week Ahead!

The Administration

President Biden signed the continuing resolution this weekend to fund the government for 45 days. The CR included disaster relief funding, FAA reauthorization, and an extension of the federal flood insurance program.  One priority for the Biden administration which was not included was additional funding for Ukraine. President Biden spoke on Saturday and blasted “extreme House Republicans” for wanting drastic funding cuts and not supporting funding efforts for Ukraine. He wants Speaker McCarthy to secure a commitment from the House to provide funding for Ukraine moving forward – something to watch as the next rounds of negotiations continue.

The Senate

The Senate played its part this past weekend in helping to avert the government shutdown.  As we previously reported, the Senate was looking to take the lead in the government funding drama by attempting to pass its own bipartisan package. Both the House and Senate were in a race for a collision course, until the House passed their package (details below). However, the proposed CR drama did reveal that Minority Leader Mitch McConnell experienced a slight setback as Republican senators refused to include additional funding for Ukraine in their version of the CR.

With the passing of Senator Feinstein last week, California Governor Newsom appointed Laphonza Butler to fill her seat. Butler is the head of EMILY’s List, and she will not work for the organization now that she will fill the vacant seat. This of course is not the end of the story, with a series of special elections schedule to take place next year in the Golden State.

The Senate Committee on Veterans Affairs will hold a [hearing]hearing entitled, “VA Accountability and Transparency: A Cornerstone of Quality Care and Benefits for Veterans” this Wednesday at 3pm. Last week, the Senate Finance Committee leaders introduced bipartisan legislation entitled the Modernizing and Ensuring PBM Accountability Act (MEPA) which largely reflects the Chairman’s Mark from July.

The House

Over the weekend Speaker McCarthy cut a deal with House Democrats to avert government shutdown.  The continuing resolution (CR) passed both the House and Senate on Saturday and funded the government for the next 45 days. The measure was passed, 334-92, with 200 Democrats supporting the bill 334-92. The legislation did not include funding for Ukraine. The CR Includes funding to keep community health centers, teaching health centers, and the National Health Service Corps open through November 17th. Additionally, the bill would maintain funding for health centers that offer services to underrepresented communities.

Oh – but the fun continues. Speaker McCarthy is in hot water with the Freedom Caucus as threatening Matt Gaetz aims to bring up the motion to vacate the Chair along with four or five other members of the far-right wing of the Republican party. This is going to be interesting politics as Speaker McCarthy is the number one fundraiser and Gaetz would need Democrat support to overthrow the Speaker. Democrats have yet to signal how they will move in this House Republican civil war.

Additionally, Congress will continue the same fight for the next forty-five days as the government shutdown will be threatened again on November 17th. This will be the ultimate title fight as McCarthy tries to hang on to his Speakership along with avoiding another possible shutdown.

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