In the Lede

In a Dear Colleague, House Speaker Nancy Pelosi (D-CA)  indicated that she has requested that the House Rules Committee "explore the possibility of a rule that advances both the budget resolution and the bipartisan infrastructure package" through a single procedural vote that would set up a vote on final passage of the $1 trillion bipartisan infrastructure package, while also paving the way for Congress to consider the $3.5 trillion bill to advance – via the reconciliation process requiring a simple majority – Democratic health, education, and environmental priorities. Speaker Pelosi's efforts follows a letter from nine moderate Democrats who warned that they "will not consider voting for a budget resolution until the bipartisan Infrastructure Investment and Jobs Act passes the House and is signed into law." With a three-seat majority, Democrats cannot afford to lose the support of the moderate Democrats – nor the support of members of the Progressive Caucus, the majority of whom have also warned that they will not support the bipartisan package unless the House acts first on the reconciliation package. The House is returning the week of August 23rd to consider the "Democrats' Build Back Better agenda via reconciliation as soon as possible", according to Rep. Pelosi's Dear Colleague, with the goal of completing a draft of the $3.5 trillion package by September 15. In a joint statement responding to the Dear Colleague from Speaker Pelosi, the nine moderate Democrats stated that "while we appreciate the forward procedural movement on the bipartisan infrastructure agreement, our view remains consistent: We should vote first on the Bipartisan Infrastructure Framework without delay and then move to immediate consideration of the budget resolution."

As part of his Build Back Better agenda, the President released an outline of his plan to reduce the cost of prescription drugs, including calling on Congress to address the crisis and allow Medicare to negotiate drug prices. Specifically, the President's plan includes:

  • Allowing Medicare to negotiate the price for a subset of expensive drugs that don't face any competition in the market. Under the Biden plan, Medicare negotiators would be provided a framework for what constitutes a fair price for each drug, and there would be incentives to make sure drug companies agree to a reasonable price.
  • Making other needed reforms to lower prices, including penalizing drug companies that raise their prices faster than inflation and establishing cap on the amount Medicare beneficiaries – particularly those who take expensive drugs –   have to pay out-of-pocket for drugs each year.
  • Building on existing progress to lower the cost of prescription drugs, which include an executive order last month calling on each agency to improve competition, increase wages, and reduce prices—including for prescription drugs.

In addition, the federal government will be working with states and Tribes to import safe, lower-cost prescription drugs from Canada, while accelerating the development and uptake of generic and biosimilar drugs that give patients the same exact clinical benefit but at a lower cost. The Administration argued that implementing the proposed reforms would lower premiums and copays for millions of Americans – in which insulin prices could fall by hundreds of dollars on average and the price for some arthritis medicines might fall by more than $2,000 every month. According to the Administration, seniors taking an expensive cancer drug could see their out of pocket costs fall by at least $9,000 a year, while others who don't take expensive drugs could also see their premiums cut.  On average, Medicare beneficiaries would save about $200.

On the Hill

Senate Finance Committee Chairman Ron Wyden (D-OR) and Aging Committee Chairman Bob Casey (D-PA) introduced legislation, the Nursing Home Improvement and Accountability Act, to update federal nursing home policy to improve quality of care and oversight. According to the sponsors, the bill would modernize nursing homes by filling gaps in staffing, transparency, accountability, oversight and the structure and culture of facilities. Specifically, the bill would require nursing homes to meet minimum staffing standards, ensure a Registered Nurse (RN) is available 24 hours a day, require a full-time infection control and prevention specialist and provide additional resources through Medicaid to support these care and staffing improvements and raise wages. The bill also includes provisions to increase transparency and accountability by improving data collection, providing better information to residents and their families and enhancing the effectiveness of state surveys. Among the major provisions, the bill would:

  • Require the Secretary of Health and Human Services (HHS) to conduct a study on staffing within three years (and every five years thereafter) to determine minimum staffing levels of Registered Nurses (RNs), Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs), and Certified Nursing Assistants (CNAs) that are needed in nursing homes for purposes of providing quality care; and following completion of the first report, the bill requires the Secretary to use the findings from the report to set minimum staffing requirements (and update, as appropriate) in skilled nursing facilities (SNFs) and nursing facilities (NFs) for RNs, LPNs/LVNs, and CNAs within five years;
  • Provide temporary additional federal resources through Medicaid to increase wages and support the recruitment and retention of staff, as well as support improvements in resident care;
  • Require all nursing homes use the services of an infection prevention and control specialist no less than 40 hours per week;
  • Give the Secretary the authority to issue penalties to nursing homes that submit inaccurate staffing information through the Payroll Based Journal staffing database;
  • Ensure Care Compare – the online tool residents and their families use to select a quality nursing home – reflects only staff hours devoted to direct patient care and adds weekend staffing information (in addition to the current weekday hours);
  • Improve the accuracy and reliability of nursing home data, such as the Minimum Data Set, which reflects quality information vital to the Care Compare website used by residents and their families to select top-quality facilities;
  • Provide administrative funding to the Centers for Medicare & Medicaid Services (CMS) to ensure Medicare cost reports submitted by nursing homes are accurate;
  • Require nursing homes to provide a surety bond of no less than $500,000 to the Secretary of HHS to provide assurances of facility financial viability, ensuring money for patient care remains available in the case of an unexpected facility closure or for other program integrity purposes.
  • Protect seniors' legal rights in nursing homes by ensuring admission to or residence in a facility is not contingent upon signing a pre-dispute binding arbitration agreement;
  • Improve the nursing home survey and oversight process by requiring the Secretary to review the effectiveness of surveys and enforcement in nursing homes, including as it relates to infection control and emergency preparedness; and provides enhanced funding to state agencies to improve oversight processes and hire, train, and retain surveyors;
  • Expand the Special Focus Facility (SFF) program that provides additional oversight to low-performing SNFs or NFs to no fewer than five percent of the lowest rated facilities and establishes a consultation and education program to support these facilities in compliance and quality improvement efforts; and
  • Create a demonstration program to provide funds to nursing homes to invest in the physical infrastructure of facilities, higher workforce standards, and integration of individual resident preferences.

The bill's sponsors noted that the legislation comes amidst the extremely high prevalence of COVID-19 deaths in America's nursing homes. Almost one in three COVID-19 deaths in the United States were connected to nursing homes. 

At the Agencies

The Centers for Medicare and Medicaid Services (CMS) sent a letter to state health official outlining policy changes to better support states as they address the large volume of pending Medicaid eligibility and enrollment actions that will need to be addressed after the end of the COVID-19 public health emergency. In December 2020, CMS released guidance (SHO #20-004) to "support states in planning for the eventual end of the PHE, and to ensure they are able to transition back to normal operations efficiently when the PHE ends in a manner that minimizes burden for both states and beneficiaries as well as limits coverage disruptions." Acknowledging that states have raised concerns that they will need additional time to complete the growing backlog of pending work, CMS updated certain policies to ensure states are able to manage the significantly increased workload and ultimately resume normal operations efficiently, while also ensuring that eligible beneficiaries are not inappropriately terminated when the PHE ends. Specifically, CMS revised the December 2020 SHO guidance in two areas:

  • Extending the timeframe for states to complete pending eligibility and enrollment actions to up to 12 months after the month in which the PHE ends; and
  • Completing an additional redetermination for individuals determined ineligible for Medicaid during the PHE. 

Under the revised policy, states may not terminate coverage for any individual determined ineligible for Medicaid, but not terminated, during the PHE, including individuals who failed to respond to a request for information, until the state has completed a redetermination after the PHE ends. States must complete an additional redetermination prior to taking an adverse action with respect to any beneficiary, including checking available information and data sources to attempt a redetermination without contacting the beneficiary and requesting documentation to obtain reliable information when eligibility cannot be renewed based on available information, as appropriate. CMS indicated that it will provide additional guidance on the updated policies in the coming months. 

According to the March 2021 Medicaid and CHIP Enrollment Data, more than 81.5 million individuals were enrolled in Medicaid and the Children's Health Insurance Programs (CHIP), including almost 75 million who were enrolled in Medicaid. More than 38 million individuals were enrolled in CHIP or were children enrolled in the Medicaid program in the 50 states that reported child enrollment data for March 2021 representing 48.6% of total Medicaid and CHIP program enrollment.

In letters to the states of Ohio, South Carolina, and Utah, CMS formally withdrew each state's section 1115 Medicaid work requirement waivers  approved under the Trump Administration. CMS determined that, on balance, the authorities that permit each state to require community engagement as a condition of continued eligibility are not likely to promote the objectives of the Medicaid statute.

The Centers for Medicare and Medicaid Services (CMS) released new data showing that more than 2.5 million individuals enrolled in health coverage on HealthCare.gov and state Marketplaces during the 2021 Special Enrollment Period (SEP), which closed on August 15. In addition, according to CMS,  families are seeing average savings of $40 per person per month on premiums as a result of premium credits through the American Rescue Plan (ARP) Act. The report also shows that the ARP is also helping lower out of pocket costs for new customers enrolling in coverage since April 1, with the median plan deductible falling by nearly 90%, from $450 to $50. 

In the News

The Hill:  Biden calls on Congress to act on 'outrageously' high drug prices
Roll Call:  Biden sets drug pricing goals as Democrats go to work on reconciliation vehicle to deliver

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