Policy & Politics

More than 710,000 people lost their Medicaid or Children’s Health Insurance Program (CHIP) coverage in April, and about 55,000 of those individuals have transitioned to Affordable Care Act marketplace coverage, according to CMS’s first data release on the restarted Medicaid eligibility redeterminations process. Starting April 1, states were permitted to start disenrolling people from Medicaid who no longer qualify after a multiyear pause during the COVID-19 public health emergency.

Of the 2.2 million enrollees due for renewal in April across 18 states, 45.5% had their coverage renewed, with more than 55% receiving automatic renewals. About one-third of the group lost their coverage, and 79% of those coverage losses were due to procedural reasons — meaning individuals didn’t return their renewal form within a specific time frame or the state was unable to reach them.

The Federal Trade Commission doesn’t want to hinder state and federal government efforts to reform pharmacy benefit managers as it continues its investigation of possible anti-competitive business practices in the industry.

With that in mind, the commission unanimously adopted a position statement July 20 that “cautions against reliance on certain of its prior advocacy statements and reports relating to the pharmacy benefit manager market.”

The three commissioners on the panel are Democratic appointees. Whether the vote would have been any different with a Republican presence on the commission is unclear, however. The FTC agreed last year to launch its broad investigation into the PBM industry with the support of two Republican commissioners.

The Dept. of Justice (DOJ) and Federal Trade Commission (FTC) on July 19 released new draft guidance outlining its approach to antitrust enforcement after rescinding decades-old regulations the week before. The moves could further entrench and formalize the Biden administration’s aggressive anti-consolidation agenda. Health care insiders tell AIS Health, a division of MMIT, that the proposed guidance’s impact on health care insurers and providers is far from certain, but they say that the proposal could complicate any or all of data sharing, quality ratings, and value-based contracting — and stymie an active dealmaking environment.

The draft guidance, which is subject to a public comment period and may change, could have profound impacts on the broader economy, not just health care. The Biden administration’s antitrust regulators have evinced much more aggressive legal and economic theories of antitrust enforcement than any administration in decades. The new guidance is further evidence of the administration’s willingness to try and block deals such as acquisitions by health insurers of providers; provider mergers; and insurer deals for other non-insurance assets, such as business services and technology firms.

With the Inflation Reduction Act (IRA) implemented in a relatively short time frame, many uncertainties remain, including the type of information CMS will deem most useful in drug price negotiations and how the law will impact biosimilars. During a June 20 webinar on navigating the IRA, Mark McClellan, M.D., Ph.D., the Robert J. Margolis Professor of Business, Medicine, and Policy, and founding director of the Duke-Margolis Center for Health Policy at Duke University, addressed some of those issues and how he expects them to play out. McClellan, who served as FDA commissioner from 2002 through 2004 and CMS administrator from 2004 through 2006, also offered advice on what he thinks pharma manufacturers should do as the first steps of price negotiation loom.

The event was presented by Innopiphany and moderated by Lisa Kennedy, Ph.D., managing principal at the life sciences consulting company.

As part of a recently introduced health care package, the U.S. House of Representatives’ Committee on Education and the Workforce on July 12 unanimously advanced a bill that would require hospital groups to create individual identifiers for outpatient departments — a major step toward so-called “site neutrality,” a long-held goal of plan sponsors and carriers. The other bills, meanwhile, are mainly focused on PBMs, which have become the hottest health care topic — and for some members, the most notable health care villains — in the current session of Congress.

The overwhelming support from members of both parties for each of the bills bodes well for their eventual passage. So does their alignment with bills currently under consideration in the Senate, according to one D.C. insider.

In a new proposed regulation, the Biden administration seeks to reinstate limits on short-term, limited-duration insurance (STLDI) plans that the Trump administration had loosened — a move that health policy experts predict will have a small but positive effect on the Affordable Care Act-compliant plan market.

But HHS and the Labor and Treasury departments didn’t stop there — they also proposed changes to hospital and fixed indemnity policies and sought comments on whether they should address the proliferation of level-funded plans in future rulemaking.

“I thought that was interesting,” says Katherine Hempstead, senior policy adviser at the Robert Wood Johnson Foundation. “That seems like kind of an effort to, as much as possible, tidy up all those shards of business in the marketplace that are not good for the ACA-compliant market — either the individual or small group [segment].”

Although several PBM reform measures are already circulating in Congress, lawmakers recently added even more legislative proposals to the fray. The Senate Finance Committee released a discussion draft that would introduce a host of financial reporting requirements for PBMs contracted by Medicare Part D plans, and then announced it would mark up a package including that measure and other PBM reforms later this month. And, following a markup, the House Education and Workforce Committee advanced a spate of bills focused on promoting transparency for PBMs, health care providers and insurers.

A Capitol Hill insider tells AIS Health, a division of MMIT, that how exactly these measures will fit into a final package of PBM reform legislation remains to be seen, although a few possible scenarios are beginning to come into view.

In comments submitted to CMS about two new proposals aimed at improving the Medicaid program, health insurers and their lobbying groups told the agency in no uncertain terms that implementing the regulations could require more resources than health plans currently have — especially since they’re also trying to navigate the recently resumed Medicaid redetermination process.

The regulations in question are both notices of proposed rulemaking (NPRM) that CMS introduced in May — the “Medicaid and Children's Health Insurance Program (CHIP) Managed Care Access, Finance, and Quality” NPRM, and the “Ensuring Access to Medicaid Services” NPRM. Together, the two proposals represent the first significant regulatory update to Medicaid managed care since 2020.

CMS on June 9 revealed a list of 43 Medicare Part B drugs that will be sanctioned for having their prices increase faster than the rate of inflation, as part of the Inflation Reduction Act (IRA). The number of drugs affected is almost double the number that made CMS’s initial list, which the agency made public in March. Starting in July, beneficiaries who normally pay 20% coinsurance under Part B for the 43 drugs will see their cost sharing decline based on an inflation-adjusted price. The federal government will invoice manufacturers for 2023 and 2024 Part B inflation rebates no later than fall 2025, and those funds will be deposited into the Medicare Trust Fund.

Seven of Amgen, Inc.’s medications made the list, including its blockbuster bone cancer treatment Prolia, cancer medications Kyprolis, Vectibix and Blincyto, and Nplate for immune thrombocytopenia.

CMS on June 9 revealed a list of 43 Medicare Part B drugs that will be sanctioned for having their prices increase faster than the rate of inflation, as part of the Inflation Reduction Act (IRA). The number of drugs affected is almost double the number that made CMS’s initial list, which the agency made public in March. Starting in July, beneficiaries who normally pay 20% coinsurance under Part B for the 43 drugs will see their cost sharing decline based on an inflation-adjusted price. The federal government will invoice manufacturers for 2023 and 2024 Part B inflation rebates no later than fall 2025, and those funds will be deposited into the Medicare Trust Fund.

Seven of Amgen, Inc.’s medications made the list, including its blockbuster bone cancer treatment Prolia, cancer medications Kyprolis, Vectibix and Blincyto, and Nplate for immune thrombocytopenia.