TRP Health Policy Report
October 31, 2016The Week in Review
A Friday announcement from the Federal Bureau of Investigation (FBI) over Hillary Clinton’s emails as Secretary of State has shifted the narrative in the presidential campaign, which has spent much of the last month focused on controversies within Donald Trump’s campaign. FBI Director James Comey wrote to inform Congress it had discovered more emails related to its investigation of her use of a private email server, which were discovered in the FBI's separate investigation of former New York Rep. Anthony Weiner, the estranged husband of Clinton aide Huma Abedin. While no information has been released on the content of those emails, the development has allowed Trump to go on the offensive.
Clinton's campaign also continued to face the release by WikiLeaks of private emails from some of the top officials in the Clinton orbit. Some that emerged last week detailed a fundraising scheme at the Clinton Foundation that intersected charity and personal income. Bill Clinton, who was the face of the foundation, has experienced a sharp decline in his popularity over the past month as Trump has upped the criticism of his checkered history with women.
Keep an eye out for our thrice-weekly updates, ‘Today on the Trail,’ for more analysis on what’s happening on the campaign trail.
The Week Ahead
With Congress in recess until the Nov. 8 election, the focus continues to be on the campaign trail. The House reconvenes for the lame duck session on Nov. 14 and the Senate returns on Nov. 15. Congress has until Dec. 9 to come up with a plan to avert a government shutdown. House and Senate GOP leaders will try to strike a deal with Democrats on a spending bill that funds the government through fiscal year 2017. GOP leaders have also said medical innovation legislation, a version of the so-called ‘21st Century Cures Act, could come up when Congress returns.
White House Confirms Premium Hikes for ACA Exchanges
The Obama administration confirmed last Monday that premiums will go up sharply next year under many of the Affordable Care Act’s (ACA) Exchanges, with many consumers down to just one insurer. Before taxpayer-provided subsidies, premiums for a midlevel benchmark plan will increase by an average of 25 percent across 39 states served by the federally run marketplace, according to a report from the Department of Health and Human Services (HHS), and some states will see bigger jumps than others. Due to scaled back roles from major national carriers such as UnitedHealth Group, Humana, and Aetna, about one in five consumers will have only a single insurer to pick from. Republicans used the numbers as a warning that insurance markets created by the 2010 health law are “teetering towards a death spiral.” The GOP has remained committed to a full repeal of the law during the 2016 national election, and Republican nominee Donald Trump has questioned Democratic nominee Hillary Clinton’s ability to mend current concerns with healthcare while lowering costs.
The announcement from HHS essentially confirmed state-by-state reports that have been coming in for months, and window shopping for plans and premiums is already available online ahead of the start of sign-up season, which begins on November 1st. Administration officials are stressing that subsidies provided under the law, which are designed to rise alongside premiums, will insulate most customers from sticker shock, and added that consumers who are willing to switch to cheaper plans will still be able to find affordable coverage. The majority of the more than 10 million customers who purchase through HealthCare.gov and its state-run counterparts receive generous financial assistance, but an estimated 5 million to 7 million people are either not eligible for the income-based assistance, or buy individual policies outside of the health law's markets, where the subsidies are not available. The spike in premiums generally does not affect the employer-provided plans that cover most workers and their families.
Nonetheless, President Obama has asserted the underlying structure of the law is sound, and current problems are only "growing pains." The president has called for a government-sponsored "public option" insurance plan to compete with private companies. Republicans, including Trump, are united in calling for complete repeal, but they have not spelled out how they would address the problems of the uninsured. Clinton has proposed an array of fixes, including enhancing the law's subsidies and allowing more people to qualify for financial assistance.
Senate Finance Leaders Unveil Bipartisan Draft of ‘Chronic Care’ Reform Bill
On Thursday, the Senate Finance Committee’s Committee Chronic Care Working Group unveiled draft legislation to improve chronic disease care for Medicare beneficiaries. The wide-ranging legislation, which follows two years of hearings and policy discussions, calls for the expanded use of home-based health services and telemedicine for senior citizens with chronic diseases such as diabetes. It's unclear how much the chronic care package might cost, and the Senate Finance draft text did not include official estimates from the Congressional Budget Office because they are not yet publicly available. While Chairman Orrin Hatch (R-UT) and Ranking Member Ron Wyden (D-OR) previously asserted that budget neutrality is prerequisite for provisions to be included in the legislation, the discussion draft acknowledges that “offsets to cover any costs associated with this legislation will be supplied.” During a briefing from Committee staff last week, Brett Baker, Health Policy Advisor to Chairman Hatch, added that while “we believe all these policies save money, [the Congressional Budget Office (CBO)] doesn’t always agree.” Mr. Baker suggested that the Committee estimates the bill will require a relatively small cost of “hundreds-of-millions of dollars, not several billion,” which he suggested will be “manageable.” He added that any offsets to the bill will be negotiated in a bipartisan manner.
Among its major provisions, the draft bill would extend the Independence at Home project for an additional two years, keeping it running through September 2019. The program is meant to help keep frail people out of nursing institutions by providing more coordination of care and home visits. The draft bill also would allow for broader enrollment of people suffering from failing kidneys in insurer-run Medicare Advantage, and let these plans offer a wider array of supplemental benefits to people with chronic conditions, including allowing people enrolled in Medicare who undergo the kidney-cleansing home dialysis treatment greater access to telehealth services, starting in 2018.
Additionally, members of Senate Finance sent a letter on Thursday to the Department of Health and Human Services and CMS supporting the Obama administration’s plans to expand Medicare policies addressing chronic conditions. CMS will finalize the 2017 version of its physician fee schedule within days, through which the agency intends to expand its diabetes prevention efforts. The draft CMS rule, which was unveiled in July, also proposes increased pay for additional chronic care management services and bids to promote changes in behavior to improve and protect health, and includes a new payment code to cover assessment and care planning for people facing illnesses classified as cognitive impairment, which include Alzheimer’s disease, the Senate Finance letter said. These policies were all included in a December 2015 Policy Options Document released by the Chronic Care Working Group.
CMS Announces Additional Ways to Enroll in Advanced APMs
The Obama administration, seeking to continue progress achieving its goal of tying half of healthcare spending to alternative payment models (APMs) by the end of 2018, announced it would give providers more opportunities to become involved in Medicare’s new payment schemes. HHS Secretary Sylvia Burwell said the CMS will re-open the Next Generation ACO and Comprehensive Primary Care Plus (CPC+) models to applicants for the 2018 performance year. Both models qualify as an Advanced APM – HHS’ gold standard for risk-based reimbursement – in the new framework for paying physicians established by the Medicare Access and CHIP Reauthorization Act (MACRA)
Patrick Conway, CMS chief medical officer and director of the Center for Medicare and Medicaid Innovation (CMMI), said the agency now wants to work with the private sector. HHS said in March it had already met its goal of tying 30 percent of fee-for-service (FFS) Medicare payments to quality or value by the end of 2016. Much of that, however, reflects models that don't carry enough financial risk to qualify as Advanced APMs. Currently 18 ACOs participate in the Next Generation model, which started in January; three ACOs had dropped out by July. The CPC+ model will launch next January with 57 participants in 14 regions. It has two tracks, one of which relies more heavily on the traditional FFS model.
Unions, Liberal Groups Call for Delay of ‘Cures’ Bill
A major obstacle has been posed for the medical cures bill that leadership had said it hopes to pass in the lame duck session, as a coalition of liberal groups came out last week against a last-minute attempt to pass the bill without including controversial solutions to combat high drug prices. The groups are asking that legislation be held until the 115th Congress, when ample time will allow the addition of provisions that address drug pricing increases. Thirteen groups, including the Center for American Progress (CAP), AFL-CIO, and the American Federation of Teachers, wrote to Democratic leaders in both chambers on Wednesday calling on them to delay the 21st Century Cures Act until next year. The measure is aimed at speeding up the Food and Drug Administration’s (FDAP approval of new drugs and investing new funds in medical research. But the groups argue the measure would benefit the drug industry while doing nothing to address growing concerns over drug pricing.
The coalition's position could be a roadblock for lawmakers who had hoped to pass the legislation in the lame duck session. Senate Majority Leader Mitch McConnell (R-KY) said in September that the measure would be a “top priority” during the brief session, and Speaker Paul Ryan (R-WI) expressed a similar sentiment. Democrats and Republicans have been negotiating on the bill for months, hoping to find a way to pay for billions of dollars in new spending for the National Institutes of Health. House Minority Leader Nancy Pelosi (D-CA) also said at a recent a press conference that while there are divisions within Democratic ranks over the bill, “if leadership takes it up, I think it will pass.”
Slavitt: Tackling Drug Spending Should Be Top Priority for Next CMS Leader
The Centers for Medicare and Medicaid Services (CMS) acting administrator, Andy Slavitt, said Tuesday that the next leader of CMS should make drug prices a top priority. He told attendees of an America’s Health Insurance Plans (AHIP) conference on Medicare that CMS will need a partnership from members of the Medicare Part D community to address drug prices. Mr. Slavitt also stated that the dialogue on prescription drug pricing focuses only on two extremes, “innovative, expensive drugs, or less expensive treatments,” and these choices are “false and unproductive.” He asked that the next leader deliver innovation at practical prices. Mr. Slavitt compared the current debate over pharmaceutical spending to conversations several years ago about rising hospital costs. Now, frameworks exist to help make care more affordable, he said, which can also be done for pharmaceutical costs. Both Hillary Clinton and Donald Trump have said they would support Medicare having the power to negotiate drug prices, and Clinton has also outlined a number of other steps she would consider, including a creating government oversight panel to identify “outlier” price increases.