Congress has concluded a flurry of activity ahead of the August recess, which includes considering dozens of key public health programs that expire on Sept. 30, including Community Health Centers, the Pandemic Preparedness Office, Global AIDS Funding, Programs to Address Opioid Use Disorder, and Health Workforce Training. Congressional committees have also voted on a framework of PBM reform bills, which may result in a larger reform package this fall. This article will discuss the landscape as Congress enters its recess period and preview our expectations for the fall.
Pharmacy Benefit Managers (PBM) Legislation
Over the last six months, seven congressional committees have considered legislation that reforms PBMs. Legislation considered to date largely focuses on greater oversight and transparency of PBMs, but a few bills also include policy changes such as banning PBM spread pricing in the Medicaid program and delinking PBM income from prescription drug prices.
Both chambers have distinctively different takes on how to address PBMs, with the Senate provisions largely being more aggressive than the House provisions. PBM legislation from the Senate committees included robust provisions that limit PBM practices pertaining to Medicare, Medicaid and the commercial market, and expanding FTC authority. In contrast, the House committee’s PBM legislation does not touch the commercial market and focuses more on greater transparency of PBM’s practices.
Based on these differences from both chambers, any PBM reform could be limited to watered-down policies that focus on transparency and increased PBM-related disclosures and rein in PBM practices in the federal channels, not commercial. As there are some federal savings associated with PBM reform, Congress may look to these provisions to use as an offset to pay for expiring federal health care programs. We anticipate that staff will utilize the August recess to determine the feasibility of packaging the legislation and moving through the two chambers in the fall given Congress’ long list of legislative priorities. If Congress does not address PBM legislation in the fall, it remains possible for some provisions to be included in either an end-of-the-year package or carried over for consideration in 2024.
Health care reauthorization programs
Pandemic and All-Hazards Preparedness Act Reauthorization
The reauthorization of the Pandemic and All-Hazards Preparedness Act (PAHPA) will reauthorize critical institutions and infrastructures that strengthen America’s national biosecurity response such as the Administration for Strategic Preparedness and Response (ASPR), the Biomedical Advanced Research and Development Authority (BARDA) and the Strategic National Stockpile (SNS).
Both chambers have marked up and advanced their versions of reauthorizing PAHPA during the July work period. At the last minute, during the House and Energy Subcommittee markup of the legislation, Rep. Anna Eshoo (D-CA) pulled her support from the bill as Democrats argued that PAHPA is the appropriate vehicle to address drug shortages by providing FDA with more authorities. The legislation passed out of the full committee on a partisan basis. The Senate committee passed their version of PAHPA, which includes drug shortage provisions such as to ensure manufacturers communicate circumstances that may result in drug shortages and provide information to FDA in order to avoid potential shortages, and reauthorizes the medical countermeasure priority review program.
We anticipate staff to start discussions on how to rectify the different versions of the PAHPA legislation over the August recess and that House Republicans are still open to continue conversations with House Democrats to add drug shortage provisions to ensure the bill receives bipartisan support. House Republicans have released their own proposal to address drug shortages and are seeking feedback from stakeholders over the recess period.
Community Health Centers
The Community Health Center Fund (CHCF), which was established by the Affordable Care Act (ACA), is due to expire on Sept. 30 unless Congress extends it. The CHCF accounts for roughly 70% of all federal health center grant funds.
The House Energy and Commerce Committee advanced a two-year extension of the program with a 5% increase in funding. The Senate has yet to act on CHCFs, but Senate Health, Education, Labor and Pensions (HELP) Committee Chair Bernie Sanders (I-VT) pitched a five-year extension with a larger annual increase than the House version. Senate HELP Committee Ranking Member Bill Cassidy (R-LA) introduced legislation that mirrors the House Energy and Commerce Committee policy.
Children’s Hospitals Graduate Medical Education Payment
The Children’s Hospital Graduate Medical Education (CHGME) program, which funds medical residents and fellows studying pediatrics, is set to expire on Sept. 30. Congress has reauthorized the program five times since it was initiated in 1999 with strong bipartisan support. However, this year Republicans in the House have added a provision to the bill that would prevent hospitals from receiving funds if they provide gender-affirming hormone therapies or surgical care for minors.
The House Energy and Commerce Committee passed their CHGME legislation out of committee without any Democratic support in July. The Senate has yet to act on any CHGME legislation; however, Senate HELP Chair Sanders released a proposal to extend CHGME funding through 2028 without any modifications.
U.S. President’s Emergency Plan for AIDS Relief
The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) provides funding to address the global AIDS crisis. PEPFAR has been reauthorized three times on a bipartisan base; although in 2008 there was an attempt to lift restrictions on funding to groups working with sex workers.
Republicans this year are pushing for the addition of language that would make it so no AIDS prevention funding would go to an organization that performs or advocates for abortions and have yet to release a reauthorization bill. But, Republicans did add in a one-year PEPFAR extension in the House Appropriations State, Foreign Operations, and Related Programs bill to stave off the program until a different administration is elected. Foreign Relations Chair Bob Menendez (D-NJ) offered up an amendment on the Senate floor during the NDAA process to reauthorize PEPFAR for five years, which failed.
The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act of 2018 provided federal resources toward prevention, education, coverage and treatment to fight the opioid epidemic. The bipartisan legislation contains numerous provisions that are set to expire this year without congressional action.
The House Energy and Commerce Committee advanced a package that will reauthorize critical programs included in the SUPPORT Act and some additional provisions to expand treatment options and response efforts to the opioid epidemic on a bipartisan basis. Some of these provisions include: lifting the Medicaid IMD exclusion, requiring state Medicare programs to monitor the use of anti-psychotropic drugs in long-term care facilities, and bolsters prescription drug monitoring programs by requiring the study of remote monitoring for prescribed drugs.
General Landscape for September
While the clock is ticking for reauthorizations, Congress is also staring down a deadline of funding the government by Sept. 30. As both chambers remain far off on spending limits, there is growing concern that this stalemate may result in a government shutdown if a continuing resolution is not passed. Making matters even more challenging is the new statutory requirement, as agreed to in the recent passage of the Fiscal Responsibility Act, that Congress must pass all 12 appropriations bills by Dec. 31 or an automatic trigger will ensue, cutting both domestic and defense spending across the board by 1%—resulting in billions of dollars in additional cuts.
Congress’ additional priorities include passing the National Defense Authorization Act and reauthorizing the Farm Bill. If Congress passes a CR and an end-of-year vehicle comes together, there are talks of pulling together small packages on China and Ukraine, AI and tax extenders. PBM reforms could also be considered in this group.
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