This is an unedited transcript.
0:04
Hello, everyone. Thank you for joining today’s briefing on implications of the midterm Elections for Health Care. My name is Christopher Holt, I serve as the Vice President of Policy here at the Alliance for Health Policy.
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For those of you who are not familiar with the Alliance, I wanna welcome you. We’re glad you’re here. We are a non partisan resource policy community. We’re dedicated to advancing knowledge and understanding of health policy issues and doing so in a collaborative way that brings all voices to the table.
0:35
Today’s briefing is brought to you with generous support from Nigam, the National Institutes of Health Care Management. So we thank them for that support.
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0:52
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1:02
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1:31
And so it’ll be passing them along to me during the broadcast.
1:35
Throughout the webinar, if you have any technical difficulties, use the chat feature and someone should be able to help you.
1:42
So, with that out of the way, I would like to introduce our panelists for today’s discussion. Their full bios are available in the webinar materials on our website, so I encourage you to check that out. But briefly, let me start by introducing suddenly Nesbit, who serves as a senior policy advisor at Arnold Porter.
2:02
She has over 20 years of experience working with Members of Congress and their senior staff.
2:07
She was previously appointed by President Obama to serve as HHS Deputy Secretary for Legislation where she oversaw legislative portfolios for multiple government agencies.
2:18
She is also a longtime former Ways and Means Stafford’s.
2:22
So I wanted to fly back.
2:25
Next, we have Josh …, who serves as a principal at Levitt Partners. Josh manages multi sector alliances and advises clients across the healthcare sector on federal health policy. He’s worked at the White House, at HHS in the Senate, and the House Energy and Commerce Committee.
2:41
Josh specializes in public insurance under Medicare and Medicaid and chip, as well as the Commercial Health Market and the Affordable Care Act.
2:49
Finally, we have at Cetus Malinowski, founder and managing Director of Capital Street.
2:54
… is an expert on legislative and regulatory process. She provides research and policy consulting on a diverse set of topics from insurance to life sciences, and biopharmaceuticals, and she is a frequent contributor and expert source for media outlets such as The New York Times and the Wall Street Journal.
3:13
So today, we’re going to start our conversation with some level setting, that Josh is going to walk us through some slides, just to kind of understand the framework post midterms.
3:25
After that, we’re going to turn to the remainder of the 117, we’re gonna think about what the midterms mean to the lame duck, and then we will move on and look at the 118th Congress.
3:36
So, Josh, if you would like to get us started, that would be great.
3:43
Great. Chris, Thanks. Great to be with you.
3:46
Let’s go to the next slide.
3:48
We just wanted to do a quick level set on the leadership and the outcomes from the election. Let’s go to the next slide.
3:56
We have clarity from early November. a few weeks ago. We were all wondering what would happen. Now we know the results. Republicans have won the House. We have a few races, just two races, that have yet to be called.
4:10
That could give a few more to the Republicans, or a few more to the Democrats in the Senate.
4:16
We have a very closely divided chamber Still. Let’s go to the next slide.
4:21
We have a runoff race in Georgia.
4:25
As folks will know, on December six, that will determine whether or not the Chamber remains 50 50 as we’ve seen this, Congress, or if it actually flips into democratic control.
4:38
With the official 51, we’ll talk about some of the implications for that.
4:42
Let’s go to the next slide.
4:46
For Republicans, House, Republicans are being led by speaker, it well speaker to be speaker elect.
4:54
Potentially, Kevin McCarthy, who has not yet secured that vote, but is on his way equally kind of perfect, pursuing that we’ve no, these members, and they’ve been members of leadership in different capacities before.
5:12
That speaker vote will be scheduled at some point in the future, and there’s a lot of interest in what happens there.
5:19
I think what we’ve seen, historically, for other speaker votes, is that they eventually gain the confidence of their members, and where they are at this point. Historically, and in a conference, excuse me, in a Congress, often evolves to get support as time moves forward.
5:37
Let’s look at the Democratic leadership on the next slide.
5:40
On the House Democratic side. They actually have deliberations underway today, where Representative Hakeem Jeffries was just elected the next Democratic House leader.
5:51
Seeing kind of a new cast of characters from the current leadership with the exception of Representative Clayburn, representing as folks are saying a little bit of a generational change.
6:03
Certainly, new leaders who are not new to leadership, but new to these positions, looking at how to navigate a closely divided Congress moving forward.
6:11
Let’s go to the next slide.
6:14
In the Senate, it looks relatively similar to what we’ve seen before. With leader Schumer staying in as majority leader. There’s still some decisions to be made about, potential assistant, democratic leader in leadership loads. There will be coming in the next week or so. So we’ll know more about what those roles look like and use officially occupies those seats when the final deliberations are made. Let’s go to the next slide.
6:46
And the Senate Republicans, it’s largely status quo.
6:51
Leader McConnell was challenged briefly and retain his control, the Republican Conference. And that looks to be fairly predictable for the foreseeable future. Let’s go to the next slide.
7:08
And then just as a quick highlight, there are Democratic and Republican Campaign Committee leads.
7:14
These are important just to highlight, because the policy gets done in the context of the politics, and these members and their views in their opinions will be important in shaping the political environment and the policy agenda for the next Congress as well.
7:29
With that, I think that’s all of the slides.
7:35
Great. Thank you, Josh and Sonya and I see that if you want to join us on camera.
7:41
Appreciate that. level setting Josh.
7:44
Sonya um, one of the things Josh mentioned was the upcoming Senate Georgia Runoff and I think that there might be a sense that, you know, look, Democrats have the chamber control, regardless of what happens, thanks to Vice President Harris. And so this may not be as significant a race, but I wonder if you could speak to the implications of that race or how the Senate operates. Thanks so much for it. Refer for having me.
8:10
I gotta tell you, I think, I know our, my fellow panelists are old enough to remember when H one, There are complaining that 56, or 54 members in the majority wasn’t enough. And here we are, now today, going over to get 50, really, 51.
8:26
Definitely do, and it matters for committee ratio sake, right, I mean, that’s going to determine how many people are sitting on a committee, how much are how aggressive, I would think Democrats can be, in terms of moving legislation, through committee and on to the floor.
8:44
Keep in mind, with all due respect, we do the Democratic side. I am a member, that party, still have Senator Imagine, Incident, Imagine sinners Center, send them out to deal with as well, interests. It’s something that their thoughts on what should move forward and have an extra seat. Obviously, it’d be helpful if you should lose one of those of your judge. So, you know, I think it matters a great deal. Frankly, again, because it’s going to dictate just how aggressive, if you will, decide, the majority leader might be as well as a committee.
9:15
Chairman and Chairwoman might be in terms of events.
9:19
Yeah.
9:21
There are also, as part of the power sharing in 15, 50, right, there are also limitations on what can get to the floor easily because of that, right. That would be Absolutely. That’s exactly right. And now, we’ve been in scenario, where the committees have been under the 50, 50 ratio, depending for a number of members. So, each side of the aisle.
9:41
So, again, committee votes have been impacted by, that impacts what can get to the floor.
9:46
But, again, that gets back to the, how aggressive can, can the Democratic leadership be, in terms of advancing their priorities and priorities that they want to advance, will be half of the administration.
9:57
Thank you. Um, if see that, I can’t see you right now, but hopefully you can hear me.
10:03
Can you hear me?
10:05
I can hear you, all right. We’ll just, we’ll just go with that.
10:09
So, um, so there’s, there’s also going to be, above they are. There’s gonna be a lot of shifting on the committees. Obviously, in the house, it’s just, you’ve got ranking members and chairs flipping, but there’s also some new members coming in at chair and ranking member on both the house, the senate side. I don’t think we know yet new ways and means chair is going to be.
10:29
There’s also going to be new members coming onto the committee. So, I just wondered if you could speak a little bit to kind of wait where you think some of the most significant shifts are.
10:37
And, yeah.
10:39
Awesome. Sure. And by the way, thanks for having me.
10:43
So, let’s see, I would say, thinking about, of course, the committees of jurisdiction, we know what the entity are, of course, in finance. Ron Wyden, like, great, though.
10:57
You know, I would say on the Help committee, we’ve got Ernie. Know somebody who wants at one time, Medicare for all. So that’ll be a big shift. I don’t think that’ll happen anytime soon.
11:08
But, of course, we know Bernie also is a proponent of drug.
11:13
We importation, so on the health policy side, I think those are two things I think about you have doctor Cassidy, who, you know, is a proponent of dual eligibles, managing those very vulnerable.
11:28
Medicare and Medicaid enrollees.
11:30
You know, we’ve got a big redetermination event that’s going to be happening after the BHCS. You know, what happens to those folks?
11:37
I think he wants to see a bit of a more streamlined care management plan for the duals about 6 7 years ago. A dual eligible plan was was kind of thought and I will say like several years and everyone thought, Well, gosh, what happened, a few states dabbled.
11:53
Did some demonstrations with CMS but I would say that more can be done with about the nine million dual eligibles in our in our country big opportunity financially as well for the health plans. And then as you mentioned, there’s a bit of a fight for ways and means.
12:09
And, you know, energy and commerce.
12:11
You know, I think that a couple of areas I’ll just briefly mention of bipartisan interest that we think could see some airtime, and even with the passage of a few bills over the next 1 or 2 years kind of taking the longer view mental health, behavioral health.
12:27
We think that certain packages and ideas or will cross the finish line again perhaps in chunks 2 or 3 bills over the next couple of years. Telehealth, of course, is something that the genie is out of that model. We learned so much of what we can do during public health emergency can be done with, with an i-phone, with a smart phone. So that will certainly continue in some form or shape as well. I know we have a section on the lame duck and a little bit less bullish on a big package of health care policies passing in that December late December timeframe, But that’ll be an interesting package to watch as, as well.
13:07
Yeah, so, So you brought it up, so I think maybe we can shift to, to that, and I’m gonna ask a relatively broad question and I’m gonna let the three of you kinda take it where, where you think is most useful. But yesterday, before congressional leaders met with president, they discuss the end of your priorities. Obviously, I think the President wants some … funding. See how likely that is. We’ve got RCR running out in a couple of weeks.
13:35
So as we think about the lame duck, particularly with an eye toward health policy, what has to happen?
13:41
What can happen and what just isn’t going to happen and how have those categories shifted as a result of November?
13:50
Maybe we’ll start with Josh and, and then we can just kind of go around the table.
13:57
So, let me tackle that what has to happen. We have a couple of Medicare extenders that are typically bipartisan and to have to happen category Medicare physician fee, schedule payment issues that there’s a lot of interest. On a bipartisan basis that I’ve heard staff put into It has to happen category.
14:16
There’s a lot of interest in Medicare telehealth. And I would also put that in. That probably has to happen. As Congress threw themselves a little bit of a Boomerang.
14:25
They did an extension and it’s come back to, you know, the point where they need to be able to deal with that.
14:31
It’s certainly up to your point, Chris, on the appropriations front.
14:35
That the appropriations are always important.
14:37
We often focus in the kind of popular press on, and keeping the government open, and what the horse race, it looks like in terms of the political imaginations and the deal.
14:46
I think all the Appropriators have been telling you, and all their staff would tell you, it really matters for a lot of very bipartisan healthcare priority. So what’s the level of funding And what is the conference report look like? or, excuse me, committee report?
15:00
Language kind of look like that instructs NIH and CDC and HHS around so many priorities that are important to the appropriators, that the appropriate or support that they monitor.
15:12
There’s a lot of oversight to the power of the purse there. And I think that is something that often gets a little bit overlooked, but will be very important in the Medicare kind of sequester PAYGo issue to deal with as well.
15:23
So, I would put all of those in the have to happen, and then we can talk about, you know, what might, could, should, will happen.
15:32
I can, I can hop in on kind of the sum up, no, I guess it’s sort of in flux, but, um, I would agree with everything that was said by Josh, of course, in the kind of must address category.
15:47
I think that, you know, look, there’s always the bits and Bobs the policies that are getting asked to be added, know, the dialysis providers, …, were dealt a blow with a Supreme Court decision in June, and have some legislation, where they’re trying to get that included. The CBO has not been very kind on some of these provisions. So, if that hasn’t been price tag, thinking it probably won’t go telehealth.
16:14
I think we just talked about that, but I think a one year, it seems to be, like the consensus is about extending that telehealth benefit for about a year. Again, post P H E.
16:25
Um, gosh, what else, Hospital at home, I believe that has a very favorable score of zero, which, you know, helps when you’re trying to get something touched in. Specialist physicians were dealt a bit of a blow in the final CMS rule. I don’t think this was a surprise to anyone from the regulatory side, but perhaps, I would put that in the maybe category things that go in the lame duck, and maybe not a full restoration of payments. but like, a little bit.
16:55
Um, and I guess, I’ll just end with that, clinical labs, actually, is something, you know, there’s a bill called the sulfa Act, Catchy Acronym.
17:06
Um, that also, I believe, has a decent score on it, so unlikely to get attached to that, ended your package, but perhaps a delay, and this is Diploma Act of 2014.
17:17
The labs have been pretty successful of getting delays, at least on data collection in the past, so we can see that happen again.
17:26
Suddenly, you’re nodding a lot. You want to jump in? Yeah, I think on that dialysis perhaps just want to point out to them. There’s still some stuff on a user fee authorization side, that is it likely to happen? Who knows? But there’s certainly a great deal of interest to get it done.
17:41
Particularly related to our approval, clinical trial diversity, and all the other riders that people will like to add on to the things that didn’t get done, that’s part of your earlier building, this area.
17:50
So just adding that into the mix, now granted, as people said, that’s a long list of things, and the window to get it done as narrow it out, you know, each hour as we go along.
17:59
So we’ll see, we’ll see what happens.
18:04
I think we touched on this a little bit, but what, what, maybe, you know, I remember talking to a few folks on the Hill in a month ago, and right, that the number of asked, the number of things that people were hoping to see missing of your package was, was pretty extraordinary.
18:20
Kind of what has definitely fallen off the table because of the midterms or have the midterms not really had much of an impact?
18:30
Sorry, I’ll jump in, I mean, I’ll test this theory, test that, you know, I don’t.
18:37
The midterms, obviously, the Democrats exceeded expectations.
18:44
I don’t, given a narrow majority of the house without the Republicans could go in with, I don’t think that has abated any desire for our members, on the democratic side, to get things done As you move things for. We still have members who are retiring members who are leaving and who want to see if we want to get things done a good house. Democrat, you have the gavel Now. Now’s the time to get anything done, particularly if, it hasn’t costs.
19:09
I’m not going to speculate about whether or not your House Republicans are going to turn a blind eye on getting some of this stuff done.
19:15
You know, clearing the plate, if you will, for things that they probably are amenable to, but don’t want to do on their watch, but I don’t think the elections change the desire to want to add a ton of policy riders to appropriations bill. Again, we still have leahy and shall be retiring in the Senate that Appropriator Cardinals on that side there one-on-one. See things that.
19:39
You’re just going I think continue to see a lot of appetite from folks, just 16 and move forward.
19:45
The question becomes: How big of a package and I think that’s dictated about how much time they have.
19:52
And if they can get to the agreement even on the top line number of an appropriation, patch which hasn’t happened yet.
19:59
So we have a question from the audience.
20:02
And that question is, basically, what, what about the mental health bill that passed in the house that one wants to do? What are the, what are the likelihood of that moving as part of either single owner part of the omnibus?
20:17
I can start here. I think a lot of the workforce authorizations have a pretty good shot at and, again, getting passed by the end of the year, SAMHSA, HRSA, et cetera. I think what the questioner is asking about, perhaps, the bill that just got a CBO score, I think, right ahead of Thanksgiving.
20:35
I mean, those seem like relatively non no access to more outpatient care. I think there was about $10 million for CMS to re take a look at the prospective payment system for inpatient psychiatric facilities, which is something that Medpac is talking about too. So, you know, I’m not a Republican, I’m not a Democrat. I’m pretty much squarely in the middle.
20:58
And certainly a capitalist those seemed like policies that could go at some point perhaps not by December 16th or if they do a CR to the 23rd by the 23rd.
21:11
But, I guess, you know, we do a lot of mental health, behavioral health work, and value based care work, and we can see some of those things going, but, again, if you put a gun to the head, I don’t know whether it goes by the 16th or the end of the year.
21:26
I think I’ll just flag one other dynamic, to build them, but I see that said, you know, part of, the way to think about what gets attached is, the appropriations pieces, obviously count on the top line.
21:38
You have some discretionary policies, which may or may not cost. And that’s typically millions now billions, maybe cumulatively billions.
21:47
Some of the Medicare, Medicaid policies are very substantial.
21:50
So, that really often depends on bipartisan agreement, on offsets, which the committee’s work on and worked with leadership on.
22:00
So part of, I think what you’re hearing is safe grasses.
22:03
You know, it’s it sounds like an out, but it depends. It depends on the agreement that the members have that the leaders have. It depends on when these, some of these decisions get made, because, as we all know, you need time for the committees to work any language to be written in a CBO scores. And a lot of that is done at this point.
22:24
But you still have to have time to stitch bills together and put language together and get CBOs, blessing that the math works. So the timing piece is really important.
22:33
And if Congress gives itself more time, as, you know, some have suggested, that might be a signal that, to Sonia’s point, there’s still willingness to get some interesting, getting something bigger, done, and there’s still time in the clock to get get something done.
22:48
Great, Thank you. I think we should probably start to move towards next Congressman with one more question from the audience on the lame duck and so this is specifically about the, the provisioning cares that allows employers to offer telehealth services prior to the deductible that’s ending at the end of the year? What is the chances that that gets extended time?
23:14
Anyone wants to take that?
23:21
That’s a good question. I’ll defer to Sonia and Josh, if they have thoughts.
23:25
Listen that potato to Josh as well because that is a really great question.
23:29
That, I just don’t have that sense of.
23:33
Yeah, it’s a good It is a good question.
23:35
And the reason I was quiet is, I think, what’s interesting about tears is members voted for a lot of things In Cares in the cares Act that was It was extremely bipartisan over time.
23:49
There have been different ways to think about some of those provisions of policies.
23:54
So, one rubric, to often think through, as does something start bipartisan, it’s usually stays bipartisan.
24:01
Cares, I think, is a little bit of an exception to that rule, and I don’t have a good sense of how committees are thinking about that, and where members are in it.
24:09
I think there’ll be a lot of support. Does that support actually translate into, kind of, deep, broad, bipartisan support? So when committees are working with leadership on cutting a final deal, it gets done.
24:20
I don’t have a great sense of that yet, and maybe what?
24:23
What this all suggests is that individuals interested in that provision should make sure they’re in touch with, you know, their members that are working on it.
24:32
Josh, I’m going to jump if a question or an ask a follow-up. So I agree with everything related to the Keras Hack.
24:39
But given the brought popularity of Telehealth, do you think that would not make it an exception to that rule, which I think is the right rule?
24:47
I mean, the right, you’re right.
24:50
Sonya. It’s a great point. Yeah, if we put our thumb on the scale telehealth is got and then winds at its back and so maybe that means look, it’s a telehealth extension. It started bipartisan. The general climate is towards more telehealth.
25:03
Seems more likely than not, and maybe the fact that we haven’t heard a lot of noise on it means there’s not a lot of opposition. That’s it, probably a very good interpretation.
25:15
Sounds good, let’s pivot to the 118.
25:18
So we’ve got very slim majorities in both chambers to the point that Sonya was making earlier, that uh, almost unthinkably than majorities. And in terms of kind of store, where some of us have been in the past, it’s a divided congress.
25:33
We have a president who has had somewhat lower popularity, who says he’s running for re-election, he’s heading into a presidential cycle.
25:42
So as we move into next year, what are you watching for in the new congress?
25:47
What are sort of your big, big ticket items?
25:52
Josh, maybe you could start.
25:55
Yeah, So I think there’s a lot to watch.
25:59
I think some of the early statements in by committee leaders will be really important to get a sense of: where do they want to go, their hiring decisions, their policy agendas.
26:12
We’ve seen some of that forecasted from where committee leadership is not turning over, but I think it’d be really important to get a sense from some of those early steps for committees on what do you want to work on.
26:25
Um, I’ve been thinking about the shifts as you control of Chamber as one Committee changes or another? I think this hundred and 17, Congress is the last Congress that we’ve seen, that’s probably likely to do major covert legislation.
26:41
Now, we could put it through a big asterisk on that.
26:45
Maybe we see another variant in, we’re back into kind of the acute phase of the pandemic at some point.
26:50
But I think barring that, we’re probably at a point where most of the major coven legislation is in the rearview mirror.
26:57
So that, that means that there’s going to be a lot of focus on some of the items that Sonya Exceeded talked about around mental health. and some of the Medicare policies, which are very partisan substance use disorder, brought behavioral health very broadly.
27:12
But how members tackle that will be really important.
27:17
Start to watch what their decisions are. I think in the House Republicans, you will see a lot of oversight in.
27:25
That is one way in narrow majorities where they can drive a lot of attention, harness a lot of energy. And it informs policy, you know, that it’s often seen sometimes in a vacuum, but I think what folks Smith’s sometimes is that the stones that are uncovered in policy and oversight often inform more policy goes And sometimes you don’t know what is under every rock until you look at it.
27:51
So I think the oversight committees and subcommittees will be active on the Republican side of the House.
28:00
All right. Thanks, so many of you when you want to jump in.
28:03
Yeah, I do.
28:05
First as Josh, I think you’re right in terms of covert legislation and over every mirror, but I will put an emphasis on brought covert legislation.
28:13
I do know that I think all of us have folks who we work with.
28:17
Am I doing individual things related to trying to get therapies and other treatments? In the stockpile, we’re trying to get them authorized and available whether it brought a diagnostic source, code that, and other things. But, I think just putting a finer point on that, I think you’re right, the big on cares, Act.
28:36
All that type of broad base, large legislation’s done, but I don’t want us, and I know you did leave anyone with the impression that there’s no more, get our diagnostic support out there. I think there is, it’s just going to have to be done in a very fine tooth way, called way. Everything, he said, I think it’s particularly oversight side, one thing I’ll throw in, and I know it might head there anyway.
29:01
But, you know, the Inflation Reduction Act, the IRA, obviously, the implementation of that’s going to be a very big deal, in terms of next year for health on the Health Committee.
29:11
A lot of work that’s going to be done, loves what happened by the administration.
29:15
On the regulatory side, to Josh’s point.
29:18
Not only do I think we’re gonna see oversight of general health care matters, the Republicans have long had on their lists related to a variety of things.
29:26
Kovac Clovis origins, the administration’s response to it.
29:31
But I also think you’re gonna see a critical eye towards the implementation of the official reduction act as well.
29:39
And, you know, the one thing I would throw out there and I’m not to be too provocative, but you know, 2020 for the presidential race and that type house competitively salaries are gone, right?
29:48
And so if you are leading a health committee, or anyone else, and the leadership on either side of the aisle in the Chamber, you know, you’re thinking about how to position your agenda.
30:00
Your Members, your caucus, in a way that’s going to be competitive.
30:05
Not only at the top of the ticket, but also really get an eye for the competitive house.
30:10
Where we get Mercy in that narrow Republican majority of, Democrats are, I think we get it back in two years.
30:15
How do we position ourselves to be able to do just that?
30:20
Great, great points. Sita, let me, let me turn to you. And I do want to flag, I definitely want to come back to you on Waste Reduction Act of, I don’t wanna get too far down that rabbit hole just yet.
30:32
Sure.
30:33
So, then, I will know, 100% agree on the oversight, you know, bringing in Chiquita at CMS, Doctor Kayla FDA, …, who will be a regular old citizen, know, that takes a lot. That sets up a lot of energy and resources I would add for the agencies, preparing for these things, Responding to requests. So that’s just one thing to keep in mind.
30:55
Some other things that we’re looking out for, again, the regulatory agencies, we can pause on, inflation reduction edge, but Medicare Advantage, we’ve got some risk audit regulations coming due by February first.
31:10
Those are regulations that have been in the works for over 10 years, 12 years.
31:15
This has to do with potential up coding of beneficiaries to garner that additional risk adjusted payment from the government. So grad V is affectionately, what it’s called, and then the 2024 rates. In the first quarter, finalized typically around April, again, that’s for 2024, could be some interesting surprises in those.
31:34
Certainly, there’s a lot of interest in MA with 50%, five, 0% of Medicare folks are in an MA plan. So it’s pretty popular.
31:42
And, you know, 10 years ago, the grass roots group go to the hill and say, don’t take away my Medicare. Now, it really is, don’t touch my Medicare Advantage. You get the vision, you get the dental, you get the silver sneakers.
31:55
So it’s very, very popular other things in no particular order, we talked about pandemic preparedness, valid at some of these issues. There is a must pass vehicle in September of 2003 for the Animal Drug User Fee Act. So you could have some of those policies that are being worked out, refined, et cetera, with stakeholders, potentially pass in the summer or fall of 2023.
32:22
So, I would keep an eye on that.
32:25
And then the last thing I’ll just mention is deficit reduction.
32:28
Typically, about once in a decade, there is a come to Jesus moment about getting the fiscal house in order. We’ve spent what 7000 billion with a T … relief vaccines, additional payments to providers. So I would look out for that, again, that is something, and perhaps the next quarter or two, But something that potentially Congress can can agree upon some sort of framework.
32:53
I was gonna say supercommittee, but some kind of mechanism to trigger warning bending, I’ve had to, is that not an entitlement reform? You’re thinking that you’re thinking more in terms of deficit release, because we don’t just think about it in the context of health care.
33:11
I agree, I think, I mean, look, as long as I’ve been doing this work, which is a longtime military, never seems to get cut, but, you know, put providing a 2% haircut to providers across the board.
33:22
You know, why not Sequestration happened and, you know, nobody seemed to lose their shirts. So no. I think there’d be no sacred cows, and again, you’d hit physicians, potentially hospitals, plans.
33:34
I mean, everyone, and again, that’s evolutionary down the road.
33:38
Nothing that potentially takes place in the next few months, but I think those discussions will come up.
33:45
Tipsy this point that I do think you’re going to start to see more Republicans talking a lot about the Medicare Hospital Insurance Trust Fund where where we have an insolvency projection of 2028 from.
33:58
The actuaries will have the actuary’s report next May June and July and that number could bounce around a little bit depending on what happens with payroll tax collections and our economic outlook. So I actually think it’s a good issue spot that that will be something we’ll hear a little bit more about.
34:13
And just to build on the point made on animal drug user fee, think about some of the mess past vehicles for, for next Congress.
34:21
We do have the exploration of the Community Health Center Fund that will drive a lot of work in the help committee and energy and commerce. So, as we think about, you know, what will Chairman Sanders, who what will ranking member Cassidy to help committee?
34:38
A lot of what they’re going to work on is must pass legislation for reauthorization.
34:45
Great.
34:46
Um, I just, I can’t let it, because, you’re right, Josh, Community Health Center, please keep in mind both Sanders as well as Kathy, are really big fans of that.
34:57
Lead cassady even has some sort of your personal ties to community health centers.
35:02
So that really would be an area where it would be interesting to see how the dynamics come together and move forth in that respect.
35:10
Oh, sorry, I’m sorry say before my coffee and so one other is the pandemic all hazard is preparedness. So, there will be a number of, you know, HRSA programs as well.
35:22
The public health piece, Community Health Center funds, so that that’s a lot.
35:25
And then there’s some provisions that support act, as well, that will be up for extended, and some of that will fall on the finance side.
35:31
And some of that will be on the help site as well.
35:36
Its paws, Anyone else I was going to ask about must pass pass legislation. You guys went right to it. So that’s great.
35:44
Josh, I wanted to ask you, and we’ve had a couple questions along this line, Specifically, as we’re thinking next next Congress, What are kind of, how are Republicans approaching health policy? What are their priorities, what are they thinking about? And maybe I’ll caveat it with a comment that someone maybe on here, so I won’t quote them by name, has made me a few times, which is, If Republicans are talking about health policy, they’re doing it wrong. But nonetheless, that, Well, it might not be of a politically, as one of their focus points. What are their priorities, and in particular, some of the incoming chairman?
36:23
Yeah.
36:24
So, I think it depends on what do you, what, what Republicans you’re talking to, right, so broadly for the House GOP Conference. They’ll look at the Healthy Futures Task Force.
36:36
The, the, we’ve seen this kind of mechanism used by Republican leadership, at least in the House before with Speaker Ryan, and the kind of better way plan in 20 16. That became a bit of a governing document in 20 17.
36:51
And there were some very big differences between that and I think where leader McCarthy and his team are right now.
37:00
But, I do think, when you think about some of the priorities, you know, they went through a very deliberative process, where they worked with the committees. They also told members off community had listening sessions, a lot of feedback.
37:12
And that is designed to bhagavat recommendations and policy ideas, and then put that together in a coherent framework that’s built out by specific domains, or an innovation and coverage and access.
37:25
Um, I think what you’ll see is a lot of that document get translated forward into bills that will move through the committees.
37:35
And you start to see that, kind of as a, as a reference point in.
37:41
So, I think that’s incumbent on stakeholders to kind of familiarize themselves with some of the policy ideas and the recommendations.
37:47
And, to the extent that they’re engaging on those topics, I think that’s important.
37:52
From the committee perspective, I think, on the house side, you know, we don’t yet know the ways and means neater.
38:01
I think for Mcmorris Rodgers, some of the things we’ve heard her talk about as than interest in authorization of NIH and CDC.
38:12
So, not just the oversight of those agencies is covered that Sonya mentioned earlier, but I think also authorizing those, certainly, a lot of interest in covert an understanding of the Government’s response and impact, a lot of interest in telehealth.
38:26
So if you think about a, there’s a one-year extension at the end of this year, we could easily be seeing another extension next year.
38:35
Um, I think Sonya was dead on. There’ll be a lot of oversight of the Inflation Reduction Act.
38:41
And, I think another issue that may be less well appreciated, but a big area of focus for Mcmorris Rodgers, would be helping individuals with disabilities live to their fullest potential, Very active in soliciting ideas from the Medicaid policy community, interest in ideas of home and community based services, personal care services.
39:00
A lot of these issues that I think we’re very bipartisan and really interested in understanding where stakeholders are. I think that’ll be a major focus as well.
39:09
And I’ll just finally say, Sanyo is a great point about, to help clarify my comments, that the major things and covert are done, but there’s a lot of important work to harvest the lessons from Covert, And we’ve seen it and to prevent pandemics Act in the Senate.
39:24
And I think you’re You’re exactly right.
39:27
That there are there are some things that we’ve learned from cover that are really important.
39:32
and it’s time to continue to carry those through. And I think they’ll still be a bipartisan support for those.
39:39
Great. Thanks, Josh. Sonya, you know, if you think back to the start at 117, Congress, I think, you know, the President, I think Congressional Democrats came in with a very ambitious set of healthcare priorities, And hopefully at the end, we can kind of circle back a bit on on that and kind of how that played out.
39:55
But as Democrats are now entering the 110th Congress, what are they prioritizing? And where do they focus? Just given the reality of a Republican house?
40:05
Yep, from the, like we talk specifically, the Congressional Democrats are still thinking about Congressional Democrats. I think then we’ll pivot over to Sure.
40:15
No, I think, you know, there are a number of things that, you know, that’s why I think this lame duck is going to be so intriguing to see what doesn’t get done on their agenda that they’re hoping to do that could be pushed into next year, you know, and keep in mind, you know, again, they have to send it as well. But you’re right, things get into the house, so we’ve already talked about sort of the mental health stuff, that Telehealth stuff.
40:38
things that are particularly interesting of interest to them there.
40:42
Um, there are a number of smaller cats and dogs around some of the things I’ve done in the ACA. I’m even thinking about premium tax credits, that something this administration has been pushing for an advocate, or for a very long time. Those were things that I think this will be top of mind.
41:00
That’s why I think it’s gonna be brilliant for supper, instructed to see what does and doesn’t get done in terms of Lambda, C, where they head into moving for it.
41:10
But, you know, I think for the committees themselves, it’s good, too.
41:16
The kind of interesting to watch. Yeah, you’re right, Josh, in that fee.
41:20
This task force that republics have put together that has there broad framework on where they want to lead on the health care piece, I think, has, from a policy matter, hasn’t been very strong on a specific instructions about where they’re going to go. So, I think, particularly for Palone or whomever, from Richie Neil, and certainly they will take the signals from Catherine Morris projection map. It takes some of the ways, it means how to figure out where they want to go on health.
41:45
But I continue to believe and know from conversations that, they tend to be to be in a position where they’re going to be aggressive.
41:53
Moving forward on not only advance the things they want to get done, but obviously moving forward by priorities as well in this area.
42:01
And I’ll get back to expansion.
42:04
access, affordability, coverage, and health equity.
42:09
Thank you. Um, he’s Sonya Sita. I, actually, I’m thinking I’m going to move more quickly to the administration side, because I think we have a lot of good audience questions. But, I think we’re just kinda a little tight on time. But, one last question on this point Before we move on. And maybe you can start here. Josh alluded to some of this, Sonia a little bit.
42:30
Where do you Where do you see, given the fact that it is a divided Congress, where do you see opportunity for bipartisan, legislating, ex Congress?
42:40
Sure.
42:41
So I think I touched a little bit before on a few things, but I guess, just to put a finer point on it, mental health, behavioral health, substance abuse, I think that’s certainly something that we’ll see over the next couple of years with some concrete legislation, I think, that could pass in chunks. So, that’s number one, Telehealth. Of course, we learned the benefits of telehealth during during the pandemic and I think that will continue in some form or shape. Certainly bipartisan interest in that.
43:12
Um, what else? I think value based Care. We haven’t really talked about it yet. There’s a demonstration out of CMMI called ACO reagent. Was Rebranded earlier in the year.
43:24
Had been Direct Contracting.
43:27
You know, this is a program that kind of survived the darkness with a rebrand.
43:30
There are some health equity components of the program and then also some other refinements. But, you know, that, that program, I think, has some staying power. The Center for Medicare and Medicaid Innovation has a real desire to promote value based arrangements.
43:47
It’s something that, you know, in health policy circles, we’ve been talking about for, you know, 20 years, moving from fee for service to value.
43:55
A lot of the stakeholders, you know, some preliminary results were released last week. They’re doing pretty well.
44:01
Um, and so I think that’s a theme we can see going forward and with support, Again, that’s from the agency. But bipartisan support for, you know, Downes upside and downside risk, two sided risk.
44:16
Value based care, more generally. A lot of the companies, by the way, are kind of leading the way here to Agile on Oak Street.
44:22
A lot of these companies have gone public during the endemic, and really are providing a great service.
44:28
Finally, incentivising primary care, um, by partisanship, I think deficit reduction, you know, is something a conversation that’s going to have to be had. You know, somebody on my team a couple of weeks ago was saying that, you know, typically deficit reduction does happen about once a decade.
44:44
And with what wasn’t a Democratic president and a Republican Congress?
44:49
No, we’re in a mixed divided Washington situation, but I would just keep an eye on those discussions longer term.
44:57
And then one other thing I would mention is don’t forget about surprises. We always call the courts. The third swimmingly. You got Congress of course. You’ve got the Agencies with orders and of course, regulations, but we’ve got a preventive health ruling coming out.
45:15
Look, again, remember Justice Read I just called them Justice Judge.
45:19
Read O’Connor in Fort Worth, Texas who has really challenged the idea that the USPS should be making. recommendations about preventive services. And Americans, of course, have enjoyed zero dollar cost sharing and co-pays for those services will that could go away, impacts about 150 million Americans. So that’s just a court case, the decision that that we would watch over the next few months.
45:45
Thank you so much. I think just given time, I’m going to truncate this part of our conversation and pivot to the administration. Maybe, start with you, Sonya, and then, Josh and then I’m gonna see that I do have some questions for you.
46:03
But you know, we’ve talked a lot about Congress as as we think about the administration, as President Biden goes into re-election Cycle.
46:13
What are his healthcare priorities?
46:16
How are they tempered or not by by what we’ve seen in the midterms and the reality of the House? And where do you expect to see the most action?
46:25
Yeah, I think, yeah.
46:27
I think there’s a, a hope that we’re gonna see a lot of the action on health care company. Actually, out of the administration, given the divisions that we’re going to see.
46:37
And do we have a Congress, and the lack of appetite, obviously, for Republicans in the house, to be able to advance any of the key priorities that they don’t agree with coming out of the administration? So I think we’re going to continue to see a very aggressive posture. Again, a lot of it relates to implementation things, pass.
46:58
It’s also going to be obviously focused on expansion expansion expansion up there for the ACA.
47:04
The exchanges, Again, it gets back to our competition in their equity issues when I talk by RA, but, again, I think that you see them But there’s no surprises Act, opposite implementation of that. Sort of coming to a final.
47:17
And so, I do Cattails think that you’re gonna see aggressive posturing, particularly in 20 24, with the idea being, look it up.
47:27
Pandemic. We’re not really, right, you know.
47:28
We had these set up, door heads are happy, but coming up in the fall, and whenever related to pandemic.
47:35
Let’s see some code that flu RSV, um, in parks and that we recently renamed Monkeypox anything else. I can come up there, obviously, it’d be reactor towards that. But also trying to advance their idea of creating as much opportunity for people to get coverage as possible. Obviously, for the redetermination.
47:56
So, going to happen statement a public health emergency and this can be a lot of work around making sure from that, from this administration that folks are able to transition from Medicaid to either, you know, the exchange or somewhere else.
48:10
So, I think you can see a lot of aggressive activity outside of imputation of loss And making sure people have coverage.
48:17
And access to coverage isn’t affordable and obviously we talked about CMS administrator, I know others as well.
48:25
Clearly the HHS secretary very passionate.
48:27
as I said before and about health equity, it’s been a longstanding issue obviously exacerbated during the pandemic and now that all eyes particularly in Congress on the Democratic side and other folks are really thinking about this, now I think it’s time for them to be able to act on it as well. So those are some, I think the general areas where they’re going ahead.
48:48
Great, thank you. Josh, sort of similar, similar question. Where do you, kind of what is the regulatory outlook?
48:55
What are you watching? Where is most significant action is likely to be?
49:01
Yeah. Exceeded flagged earlier the Medicare Advantage. Both the reg and the rate notice. I think those will be very significant. We’ve seen them in a potentially significant.
49:12
There’s certainly significant to watch.
49:13
We’ve seen the administration two different times, kind of think about ideas for Medicare Advantage related to plans being more accountable for social determinants and other kind of factors that are challenging for beneficiaries. If something there is finalized, I think there’ll be a lot of interest there.
49:34
You know, we, we have been watching the Medicaid eligibility and enrollment legislation. It’s, excuse me, regulation, the proposed regulation.
49:45
It’s surprisingly, probably not gotten as much attention outside of Medicaid circles as it probably merits, but it’s a very significant, um, reg which would have significant implications on enrollment eligibility processes in many cases, making enrollment much more streamlined and consumer centered.
50:06
And that includes just a lot of changes that stakeholders feel strongly about passionately about.
50:12
And I think in some cases, wanted to, you know, you’ve seen the leaders of the House and Senate Committees for Finance and Energy and Commerce, send an oversight letter to ask CMS a bunch of questions about some of their legal authorities in the rule and how they’re implementing it and what they’re proposing to do, how they think about the kind of multi-billion dollar costs it would be for states to bear.
50:40
So, you know, the power of the pen that the Administration holds for regulations is very, very powerful.
50:47
And, I think, Medicare rules, Medicaid rules, they can be very significant.
50:51
And it’s an area where, too, Sonia’s point around kind of coverage, expansion, access, and affordability, They can do a lot, and stakeholders will challenge some areas where they think they’ve gone too far.
51:03
And I think that points to see this great point about there’ll be surprises, you know, courts will have to surprise surprises.
51:10
And I think also, we all know Congress is very fluid. We’ve seen them react to issues that suddenly become issues du jour.
51:19
You know, whether we, that’s something that has been building awhile that we know is an issue, or just becomes a novel issue.
51:26
And if you think about insulin became an issue, has been an issue for a long time, but kind of became a very hot issue, where a bunch of people were working on it, there’s five partisan interests.
51:37
We saw the legislation earlier this year around firearms, safety, and mental health, where it’s some of those issues have persisted for a long time, but with public events kind of drove Congress. And there was action to happen. So keeping a category in our brains, for surprises of things that can bubble up, I think, is really healthy.
51:57
Can I just add one more thing? I know Josh and I both talked about MA Rebby.
52:02
The Rates, Marketing, there’s third party marketing organizations. The Finance Committee is very interested in this topic and launch an investigation. We can also see some more parameters, I think, around, again, these third party marketers which are a little bit nebulous. Some of them are, you know, calls originating outside of the United States.
52:23
And, um, seniors are getting called 20 times a day at times. Getting approached the grocery store. I mean, things you wouldn’t even imagine. So I think we could see more around marketing guidelines and impacting star ratings, eventually.
52:38
Then Josh, as Josh was talking earlier about this idea of oversight, right? Like you, you kinda start looking under the hood and you think you’re gonna go there. But then you end up here know that there are some members who want to look at 3 40 B.
52:52
You know, we can see some oversight on the 3 40 B program, which many would argue is, in need of some updates, MLR. You know, what happens if we get rid of medical loss ratios? Again, not saying these things will happen, but at least kind of asking that question. Gathering the information to understand the flow of funds and just provide some transparency at the very least and then maybe figure out policy later.
53:18
I would add PBMs to that list too.
53:22
Again, I think that’s an area if you’re gonna go, and think broader drug policy, particularly it, And this is probably more and Josh ground, but where do Congressional Republicans go in terms of coming up with an alternative, the policy, or reduce a prescription drug pricing and address an issue that they want to seem responsive to?
53:43
I think for eps, and I think that’s the scenario to keep an eye on.
53:48
So, you guys have done a really good job of touching on a number of audience questions without me, team them up. So we’ve got five minutes.
53:56
I promise to see that I was going to ask her about, on the IRA, and I have 1, 1 sort of question for Josh and Sonia.
54:05
So let will try to combine them and go fast, but the, the, the biggest, I guess the way I wanna do this is particularly on IRA, you know, does it does the house?
54:18
How does the house flip impact implementation?
54:22
And then kind of to Josh and Sonya, having been on the agency side, how does, more broadly, the, the increase, in oversight impact the ability to do all of this regulatory work that we just talked about?
54:37
And we’re on the clock, go …, OK, so sorry, what was the question I’m talking about, IRA?
54:45
Yes, you talked about how the midterms have have impacted how that administration is likely to go about implementation.
54:52
We can start with, all right, OK, sure. So IRA, yep. Let’s see, this year coming up, 2023, we’ll have the Inflationary rebates kick in.
55:05
And then, on September, first of 2023, per the IRA, we will see the list of drugs to be negotiated in 20 26.
55:14
So I think the sort of common thinking is that it’s really the Drug Negotiation and B And indeed, that are probably the most onerous to industry, and we’ll see a list of those drugs September first of 2023.
55:26
So just kinda pointing out some some catalysts in the year ahead. And then, you know, to your point, the agencies are stepping up. And, you know, this is a huge effort for them to reform Project restructured Part D.
55:40
Of course, there’s new liabilities in the initial and catastrophic phases, $2000 out of pocket cap, that kicks in in 20 25 versus 2024, which is when the restructuring takes place. So there’s a lot going on there as far as the congressional makeup.
55:58
I don’t know how that really, if at all impacts the IRA, truthfully, I think pre midterms when there was a prediction of a red wave.
56:07
And, by the way, we didn’t really pay attention to a lot of the polling, but I will say that the question did come in. That was, OK. Can, you know, can the IRA be repealed and, you know, my quick, you know, gut reaction was, Well, I don’t see that both for an A but B, remember, the IRA saves the government dollars. So, if you’re going to change it repeal it, you need to offset that.
56:28
Um, maybe, I think industry has a decent argument with the 9 and 13 years around exclusivity and bringing that to parity.
56:38
Again, that change might also have a cost associated with it and might be difficult to, to pass.
56:49
Thanks Josh and Sonya.
56:51
Kind of thinking about, and we’ll make, these are our closing remarks, we’re just about at time, but thinking about the impact of that oversight on, on the regulatory agenda.
57:02
I go first, Josh, and just thinking about and see, the did a great job of. Sort of Highlighting when things are happening and how the administration really has stepped up to be able to meet these goals. You know, I don’t think you, I think, let me be clear, you’re asking how the input the ratios, have changed the ability to be aggressive.
57:28
So, as as you have House Republicans take over, they’re going to be pretty aggressive on oversight. Coming from the agency perspective, there’s a lot of different regulatory initiatives that are ongoing.
57:38
How does that oversight impact the ability to exercise the regulatory? Sorry, Chris.
57:44
I heard the question that somebody thoughts going at once there, I don’t think it impacts it.
57:50
I mean, look, this is for the Democrats, in particularly Abide administration, a very big deal, if they see it as a transformative deal, particularly on the drug pricing pieces, this is not going to impact how they move forward.
58:07
And in fact, if you really want to be, um, little Darien in terms of how some people might view this, you might say if you’re in a Democrat, progressive Democrats that by the administration, we pass this momentous bill I’m going to talk off from their perspective right before the elections we over perform Perhaps this validation that people like what we’re doing.
58:30
Battling just on, yeah, this particular building in other ways, as well.
58:34
So, I don’t think people are going to be at all concerned now, obviously, from a mechanical standpoint with additional oversight. And perhaps even a much more aggressive posture coming from House Republicans, an oversight about how they look at things.
58:47
about how they’re looking to make sure that the administration is being a key date.
58:52
And I hear from your stakeholders who are helping to influence the process and agitate the process along the way they will need to respond to that. And I haven’t been into building, and Josh may have similar purview, that does impact the ability, your ability to be a little bit more aggressive, in some respects than others. But I think on the policy side, from a policy angle, they don’t walk away from that. Perhaps instead, they go a little bit more into the more that’s more very communicative, sort of you are how we talk about what we’re doing, why we’re doing it.
59:22
And just, you know, can create it, I think much more favorable environment for the public to understand what they’re doing, and why they’re doing to help kind of balance oversight questions and concerns that are going to come from House Republicans.
59:40
John, do you want to add?
59:42
I think it’s a great, very, I’d say. I’ll just say, you know, sometimes, we think of oversight as red meat. And there will be some of that, I would expect.
59:49
But I think there’s also you would expect, as you were saying, these are big changes, transformative things that CMS has never done before for Part D or drug pricing.
59:58
So, a lot of kind of policy, legal, mechanical, operational questions, are just understanding, how does it actually work?
1:00:05
And oversight will have both some of those kind of maybe more political questions, but a lot of the policy questions, too.
1:00:14
All right. Well, thank you, all. Thank you for your insights. We are at time, so I think we will, we will need to end it there.
1:00:22
But, I really appreciate your time for the audience. Let me just encourage you to complete the brief evaluation survey that you’ll be receiving as soon as the broadcast, and you’ll also get an e-mail later today. It’s really helpful to us when we, when we are putting these programs together, to, to know kinda what’s worked for you, what’s been beneficial, So please do fill that out.
1:00:46
And then let me also flag for you all that what I believe will end up being our last webinar of the year, is scheduled for February, December ninth, That briefing examining the social determinants of health and measure, how, sorry, examining the social determinants of health measures, evidence, and policy solutions.
1:01:04
Again, will be February, I sorry, pride in December nine, so please do tune in for that recording of this webinar, and all of the additional materials is available on our website.
1:01:16
And so that concludes today’s webinar, Sonya. Josh, Cedar, Thank you so much.