What’s Coming in 2024? Health Policy Forecast for the New Year
January 24, 2024
1:00 pm-
2:00 pm
Virtual Event
Event Description
In 2023, there was significant development in the executive, legislative, and judicial branches, including the expiration of the COVID-19 Public Health Emergency and the issuance of the executive order on artificial intelligence. This event featured an analysis of potential health policy priorities at both state and federal levels for this upcoming election year, and provided a review of major legislative milestones from 2023 and their potential implications for 2024. Panelists also discussed how the election will shape policymaking on the federal and state level along with must-pass legislation for 2024.
Learning Goals
- Identified key pieces of legislation and regulations that were signed into law in 2023 and their impact on 2024.
- Discussed how different health policy priorities will be affected by the 2024 presidential election.
- Discussed health-related items that are up for reauthorization.
- Identified themes and topics that will be top of mind for federal lawmakers in 2024 and potential vehicles for movement.
This event was made possible with support from the National Institute for Health Care Management (NIHCM).
Speakers
Sarah Kuehl Egge, MPP
Founding Partner & Principal, SplitOak Strategies
Sarah Kuehl Egge, MPP, is a founding partner of SplitOak Strategies in Washington, D.C., a bipartisan consulting firm, where she focuses on health care policy across a wide range of sectors and federal programs. Sarah began her career on Capitol Hill over two decades ago as a Legislative Assistant and Policy Analyst to former Finance Committee member Senator Bob Kerrey (D-NE), advising him on tax, health care, Social Security, budget and appropriations matters. For nearly a dozen years, Sarah served as the lead health and entitlements analyst for the Democratic Staff of the Senate Budget Committee under Chairman Kent Conrad (D-ND), where her portfolio included private health insurance coverage, Medicare, Social Security and transportation issues. She worked extensively on multiple budget resolutions, reconciliation bills and key legislation, including the Affordable Care Act, the Budget Control Act, the Statutory Pay-As-You-Go Act, and the Deficit Reduction Act. Sarah was a key advisor to Chairman Conrad during his participation with the National Commission on Fiscal Responsibility and Reform (aka, “Bowles-Simpson Commission”). During her Senate tenure, Sarah was selected by Co-Chairman Patty Murray (D-WA) to serve as Deputy Staff Director of the Joint Select Committee on Deficit Reduction (aka, the “Supercommittee”), where she helped Committee members navigate the complex issues and tradeoffs associated with significant deficit reduction. Sarah received a bachelor's in history and public affairs from the University of Denver and a master's degree in public policy from the Kennedy School of Government at Harvard. She is a native of Omaha, Nebraska.
Nicholas Uehlecke
Principal, Todd Strategy Group
Nicholas Uehlecke joined Todd Strategy Group in 2021. He is a former Senior Advisor to the Secretary of the Department of Health and Human Services. In his role, he worked on Medicare, Medicaid, commercial and general insurance issues, health care reform and a range of other topics under the jurisdiction of the Centers for Medicare and Medicaid Services and the Health Resources and Services Administration. Nick also spent time working on key areas related to regulatory burden relief, drug pricing, health care data, health IT, health system integration, and efforts to make health care more value-based in America.
Nick also served as HHS staff-lead on the Advancing American Kidney Health Initiative and worked on a range of issues related to the COVID-19 public health emergency, including the administration of the $178 billion Provider Relief Fund.
Prior to HHS, Nick was a Professional Staff Member for the Committee on Ways and Means in the House of Representatives for eight years, working on issues ranging from Medicare’s Parts A and B, Medicare Advantage and Part D, and commercial insurance and Affordable Care Act reforms.
Before Nick’s tenure on Capitol Hill, he spent time as an analyst for the Marwood Group, working on health care as well as financial services, education, and energy policy.
Hemi Tewarson, J.D., MPH
Executive Director, National Academy of State and Health Policy (NASHP)
Hemi Tewarson, J.D., MPH is the executive director of the National Academy for State Health Policy (NASHP), a nonprofit and nonpartisan organization committed to improving the health and well-being of all people across every state. At NASHP, Hemi leads an organization that is at the forefront of engaging state leaders and bringing together partners to develop and advance state health policy innovations. Under her direction, NASHP is leading efforts with states in areas including state COVID-19 recovery, health care costs and value, coverage, child and family health, aging, family caregiving, health care workforce, behavioral health, social determinants of health, health equity, and public health modernization. Previously, Hemi worked at the Duke-Margolis Center for Health Policy as a senior fellow and served as the director of the Health Division at the National Governors Association’s Center for Best Practices. She also served as senior attorney for the Office of the General Counsel at the U.S. Government Accountability Office addressing Medicaid and related health care topics for members of Congress. She holds a JD from George Washington University, an MPH from George Washington University, and a BA in Psychology, University of Pennsylvania. She lives in Maryland with her husband and two daughters.
Julie Rovner
Chief Washington Correspondent, KFF Health News
Julie Rovner is Chief Washington Correspondent at KFF Health News and host of its weekly health policy news podcast, “What the Health?” She joined KFF Health News after 16 years as health policy correspondent for NPR, where she helped lead the network’s coverage of the passage and implementation of the Affordable Care Act. A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A-Z,” now in its third edition. In 2005, she was awarded the National Press Foundation’s Everett McKinley Dirksen Award for distinguished reporting of Congress. Before working at NPR, Julie covered health policy for National Journal’s Congress Daily and for Congressional Quarterly, among other organizations.
Presentation: Speaker Slides
Event Resources
Key Resources
Transcript
0:04
Welcome, everyone, and good afternoon. Thank you so much for taking the time to join us today. My name is Allison Jones. I’m Director of Program Strategy and Management here at the Alliance for Health Policy. We are non partisan, non-profit organization dedicated to helping policymakers and the public better understand health policy, the root of the nation’s health care issues, and the tradeoff posed by various proposals for change. We’re so thrilled today to be presenting our webinar, what’s coming in 20 20 for Health Policy Forecast, but a New Year.
0:35
The Alliance has served as a trusted educational resource for the health community for over 30 years, and today’s discussion will explore anticipated state and federal policy priorities for the coming year. We’re excited to showcase the different viewpoints and perspectives of our fantastic panelists that we have here, as we look ahead to what to expect during this upcoming election year. Before we get started, I just want to take a moment to thank our generous sponsor. Today’s webinar is generously supported by the National Institute for Health Care Management.
1:04
We are grateful for your support for this program, and for all you do to improve health care by advancing diverse perspective on health.
1:11
I also want to take a moment to share a few quick logistical note.
1:14
We invite you to follow the Alliance for our policy on LinkedIn to stay informed about upcoming events like this one. You can also find us on Facebook and YouTube.
1:22
Today’s panel has a Q&A section at the end, and we encourage you all to be active participants. So please share your questions at any time, and we will add those to the list for discussion at the end.
1:32
You should see a dashboard on the right side of your web browser that has a speech bubble icon with a question mark. You can use that speech bubble to submit questions that you have for the panel if at any time, and we’ll collect them and address them during the Q&A. Throughout the webinar, you can also chat us any technical issues you may be experiencing, and our team appear to be. If we don’t get to your question, please don’t hesitate to reach out to us at info at all health policy dot org. And we’ll do our best to connect you to additional information.
1:59
With that, I am so pleased to introduce our moderator for today’s discussion, Juli Raptor.
2:04
Julie as the Chief Washington correspondent at … Health News, and host of its weekly Health Policy News Podcast, what the ****?
2:12
He joined PFS Health News after 16 years, as a health policy correspondent for NPR, where she led the network coverage of the pathogen implementation of the Affordable Care Act, a noted expert on health policy issues. Juliet, the author of the Critically praised Reference book, Healthcare Politics, and Policy Aided, the Now in its third edition. You can read more about Julie’s background and the bios of our other fantastic panelists on the Alliance website. And now I’ll turn it over to you, Julie. Thank you.
2:39
Alison, thank you for that kind introduction. I’m so excited to be here. We have a ton to talk about and only an hour to do it. So, let me introduce our speakers very quickly. As Allison mentioned, you have their full bios, and then we will get to it. First rehab Seroquel, Aggie, she’s founding partner and principal and split Oak Strategies. Sarah has been a longtime Senate staffer including 11 years at the Senate Budget Committee. Next is Nicholas you lucky he’s a principal at the Tod Strategy Group and a former staffer for the House Ways and Means Subcommittee on Health. Nick also worked at HHS and the Trump Administration.
3:15
Finally, we have … president and Executive Director of the National Academy for State Health Policy, before joining, Nash Behemoth, or sorry, before joining Nash behind me. Worked at GAO and the National Governors Association. So we have an eminently qualified panel to give us a guide to what we think might happen this year. I want to start with a couple of questions for each of you to answer. the first one is a two parter. What was the most significant thing that happened in 20 23 for health policy, and what was the most significant thing that didn’t happen that you expected to happen? Sarah? Why don’t you start?
3:51
Sure, thanks, Julie. Great to be here today. Thanks, everybody, for joining. And I think the most significant thing from my perspective, that happened this year was how much bipartisan, this last year, I should say, as much bipartisan, legislating. There was on the topic of healthcare.
4:07
We had to, you know, pieces of legislation advance in December out of the house with very broad bipartisan support. The lower costs more transparency legislation, which covered a range of topics from transparency issues to PBM reforms to public health investments. And then the the Support act Reauthorization legislation, which also advanced with huge bipartisan support by the same token over in the Senate.
4:34
I mean, I can’t remember the last time we had a year with two health care markups at the Finance Committee and they advanced not only legislation on PBMs and prescription prescription drug pricing reforms, but a robust extenders package that that is, you know, part of the conversation ongoing on what to do on extenders and same with the Help Committee. They passed a bunch of legislation on prescription drug pricing, reforms, PBM, reforms and Primary care Health investments in terms of things that most surprised me.
5:05
I think the thing that most surprised me this year is what the committees, particularly in the House, didn’t do. I was expecting a really robust oversight effort by Republicans, looking at a range of administrative actions. And really, there wasn’t, as much as I expected, a little bit uncovered 19 oversight. You know, certainly some robust conversations around accelerated approval, and the NCD on Alzheimer’s, drugs coming out of CMS. But didn’t get as much into oversight of the IRA implementation, as I expected this year.
5:42
So Nick, what was, what was most significant thing that you saw happen, and what should have happened, But didn’t.
5:50
Yeah.
5:51
No, I think that can be, you know, pretty, pretty quick. Just, I completely agree with Sarah.
5:56
You know, it’s, I think I was a little bit surprised that a lot of the work of transparency and that, all three committees or five committees, however you wanna look at, it, took a look at our healthcare system and realize that we’re finally moving away from the Token keyword Middleman and actually kinda pull it. pulling up the, you know, the cloak on, on all of it.
6:19
And hopefully, continue to move forward on these concepts of, you know, understanding that while competition requires some level of negotiation that happens between private entities. There has to be a level of transparency, We’re going to look at this healthcare system. That’s, you know, such a significant portion of our GDP while at the same time, so foreign to the average American. As they look at their health care costs rising, not understanding that, you know, there are ways for us as a system to lower them.
6:50
So, people, you know, to have all those Chairman kinda take a look at, that was great, you know, and seeing the attention to rural health was another really kind of strong aspect in the last year.
7:03
Chairman Eric Senate budget Chairman Smith.
7:06
Both have RFPs that are, you know, RFIs out on how can we improve rural healthcare. That’s, you know, that’s the rule.
7:15
They’ll kind of, that’s probably what was most exciting to me.
7:19
Well, what happened, know, and what didn’t happen. I agree that there are some things that we expected just to be assigned. I think that they’re, you know, when we extend things like …
7:31
and, you know, short-term, short-term extensions, on SCR of programs that require, I guess, a level of view in the future. You know, the assignment of grants, things like that. You know, we’re, we’re kind of just lagging when we do that right, lagging behind the system and act and, actually, expanding the programs are expanding access to programs.
7:55
But, really, my surprise, is that we haven’t done much on the side of, of mental health. I had expected that there would be more work done in that year on support the suicide rates in our country.
8:10
Are her appalling. And, you know, even if you just look at our numbers here in DC, there, it’s almost every day.
8:19
And so, with that, the most surprising thing to me was, was that the post koven, we want to, we want to put it behind us, that kind of attitude that, that, that belief almost pervaded or, you know, almost got into the fact that we also didn’t want to talk about how covert caused, you know, a very major mental health crisis in America.
8:42
And so that’s kind of lagging behind my hope again as we can talk about this later on on the webinar, that we move forward on things that address those issues. But that’s kind of, that’s, that’s my response.
8:53
Hear me while we were here in Washington, watching Congress kind of spinning its wheels, What were the States doing, and what did you think the States would do that they didn’t?
9:01
Yeah, no, thank you for the question. And so happy to be here representing the state perspective with our work with state leaders across executive and legislative branches. So, I would just say two things. one was, states were very active this past year. Incredibly busy, passing a lot of legislation, taking a lot of executive action in a number of different areas. I was actually surprised by the level of activity that we saw. The most significant event First Eats was Medicaid Online. And we can talk more about this later, Julie.
9:32
But you know, just thinking about, we have almost 29 million people that have been re determined for coverage and another one who are just enrolled, massive. You know, we determine eligibility event after we had our lowest levels of uninsured rates because of the continuous Medicaid eligibility coming from the pandemic, so we can talk about that in greater detail. So that I think was the most significant event for states to handle this past year, and there are still in the midst of it, frankly, a number of them. But one thing I just wanted to raise was the focus on health related social needs, formerly known as social determinants of health.
10:09
This has been a topic that I’ve been working on for many years now with states and I really feel like it was all of the challenges, housing, food insecurity has really been exacerbated by the pandemic. And that’s also true on Behavioral Health, Healthcare Workforce, all these other topics that we can talk about later.
10:26
But I just want to focus on this topic for a moment, know, states have been looking for more flexibility to think about how Medicaid can pay for those services that are not traditional. Healthcare services in light of the whole person, and how their, their health is related to all these different pieces. With CMS putting out their framework and starting to do more approvals of allowing Medicaid to pay for things like short-term rental assistance in short-term food prescriptions, as a bridge to longer term housing and food resources. I think is really started a trend that had already begun before this past year.
11:02
What we’re looking at, eight states that received approval over the waivers, it’s gonna allow Medicaid to do things that didn’t before. And we have another, you know, at least eight states in the queue, so that is something, I think, is very significant in terms of policy change, in thinking differently about the Medicaid program.
11:19
Alright. Well, we lost Nick, but he is back. There were a lot of things that Congress, as I mentioned, was supposed to do in 20 23 that didn’t get done, starting with all of the appropriations bills. So what, and I think Sarah NICU already referred to some of them. Go back into, what are some of the authorizations that expired? And what will it mean if they don’t get done? You might want to explain what this Court Act is for the probably 10 or 15 people here who don’t know.
11:47
Now, I’m happy to kick things off, and the net, Please feel free to jump in.
11:51
You know, I think the important thing to note is a lot of the programs that expire, particularly HRSA programs, the Community Health Center Fund, Teaching Health Center, Jamie, National Service Corps, Number, the Medicare and Medicaid provisions that expire. are actually currently not expired because they were extended as part of the recent CR and will continue to March eighth. But there are definitely a number of provisions, particularly in the pop of a pandemic preparedness legislation.
12:20
And in the Support Act, which is a piece of legislation meant to help communities address substance use disorder in this country that expired at the beginning of the year.
12:30
I think the positive thing is that a lot of the provisions that expired or authorizations of appropriations and so long as those programs continue in the CR or should we get to an omnibus and omnibus appropriations bill. Those progress will continue. but I think the really important point is poppa and support have not been re-authorized for five years.
12:54
You think about how much has transpired not only in the uptick in the opioid epidemic.
13:01
Obviously we’ve had a major pandemic occurs since the last time we were authorized poppa.
13:06
There’s a lot of a lot of policies that need updating and depending on what your views are of the current administration to the extent these programs aren’t authorized And we end up funding them in a CR and not in an omnibus. That comes with a comprehensive conference report along with it. It delegates a lot of authority to the agencies to decide how to spend those dollars. And then there are important policies that, that are bipartisan, that those chambers have been working on, such as scheduling of …. That simply won’t get done unless those bills are, you know, included as a reauthorization perhaps as part of a march eighth package.
13:46
Want to add something?
13:49
Know, there is such a professional she got.
13:52
She kinda hit all of it and, no.
13:55
I think those are all things that you, again, just want to touch on the concern that, you know, while I agree that there are a lot of programs that can be kind of hunted month to month.
14:06
But there are definitely programs that we’re we’re definitely struggling to keep afloat.
14:11
Some of those grant programs where you really can’t be a grantee, 4, four months, right?
14:19
And so, we know it ends up being, you know, it’s sort of one of those weird rock and a hard place situations where, yes, you want to signal that you support these programs.
14:31
So you include them in the CR, but how much of that money actually goes to advancing the program, as opposed to probably just advancing?
14:39
You know, the folks that are receiving a salary from, from the grid and having them continue their work.
14:45
Which may or may not, was supposed to discontinue.
14:48
At that time, if the grant was supposed to go somewhere else, which, you know, is the frustration I’m hearing, particularly from HHS and from folks that work in, those, in those agencies.
14:59
But that’s, that’s all, that’s all I really have to add. there.
15:03
The appropriations bills, the speaker is committed to getting it done.
15:08
You know, we’ll, we’ll have to see the next one, the next month looks, speakers think, committing to get it, getting the appropriations done since last year. And the previous speaker also committed to getting the appropriations done. Let’s, let’s finally turned to 20 24. What are 2 or 3 things that you’re looking to be popping in the states on Health Policy this year?
15:33
Yeah. I appreciate next comment on behavioral health, because that has been front and center for state policy makers, really thinking about, just to mention a little bit for 20 23. There were, like, billion dollar packages put together in more than one state, during their state legislative process of investing in mental health, as well as substance use disorder services. We have opioid settlement dollars that are flowing to the states, and counties that need to be invested in. So I, we really are taking a look at and will continue to be working with states on what they’re going to be doing in behavioral health, specifically, in 20 24 with respect to just a couple of different areas, I’ll mention: behavioral health workforce, we have shortages, the children’s mental health crisis in particular has been very challenging for stage, you see crisis stabilization units popping up across states because kids don’t have anywhere to go and they are being treated in the ED which is not the appropriate place and we’re setting of care. So, there’s a lot of thought about what to do about that. Integration of behavioral health and primary care.
16:32
I really do think there’s a change in how we think about mental health services, The stigma that has been sort of long associated with how we talk about mental health services to me has really ratcheted way down in the conversations that are happening at the State level and how people are thinking about trying to get broader access to services. So, I’m hopeful, on the integration side, we’re gonna get some real progress in 20 24 on the integration piece and you have things like CCBHCs, which are continuing to expand across states. This is another area. The second topic, I would just say, is Healthcare Workforce, so that, you know, coming out of the pandemic, yes, we have sort of needs for nursing and primary care physicians. Nurse practitioners, PA’s, but there’s also some real thinking around paraprofessionals and thinking about how we better connect with community and get people to services. And so there’s a lot of interest.
17:28
And we’re seeing across states, more Medicaid coverage of of professions such as doulas, midwives, community health workers, the long term care aids, and really thinking about how do we help professionalize those groups. And really get them on a track to attract people into the positions, as well as keep them there. So I were going to spend a lot of time, I think, with states, and that. And you’ll see a lot of legislative packages that address those and make investments.
17:56
Great. What are you looking for this year?
18:02
I think, not to harp on the behavioral health situation.
18:08
You know, my hope, and I think everyone’s hope, right now, is that we hopefully avoid just kind of talking about the cool things that are that are popping up on your Google searches. You know, AI is great. We’re still probably a few years out for full integration into the health care of the way that we talk about it.
18:27
You know, like I think there’s the tinfoil hats are back. You know, when people need to understand that Skynet is not a real thing.
18:35
If the computers were going to take us down and they would have done it 10 years ago, they, you know, we’ve been living in this world, and that’s important, but you know, the telehealth extensions are going to be really important this year. And again, I understand that it’s very expensive, and that’s going to be a challenge as, as Congress figures out, how to do it.
18:56
You know, when it’s on the behavioral health side, that’s going to be important.
18:59
You saw the numbers of folks that saw behavioral health and mental health services when telehealth was available and those increased, as you know, you know, older, white males have been very reticent to be speaking to him is a stigma, right.
19:16
People have been very reticent to do so, and those numbers actually jumped particularly during coven.
19:20
And what I really, you know, I hate to look at silver linings from the from a tragedy. That was cove it. You know, the one thing is, is that we had a loneliness epidemic in our senior population already. We had a mental health problem in our VA and senior population that has been going on for years, and largely ignored, and now it’s the general population. And that’s something that, you know, I hope, that between the committees of authorization, jurisdiction will, will, will take a look at it. You know, otherwise.
19:50
You know, hopefully, we’re going to have a longer term continuing resolution, at least to get us that, that carries health care.
19:58
Policies to get us to lame duck, or at least past September. You know, I’d hate for us to have this conversation on a consistent basis, You know?
20:09
I’m excited to see, you know, the 40 to 3, you know, tax package come out of ways and means and see if there’s an opportunity there. Particularly when it comes to advancing the conversation of families and children and the child tax credit.
20:25
And seeing, kind of how that all turns out. It’s, it’s definitely a 90 degree turn from, I think where a lot of people were like it two years ago or a year ago, where all the BBB stuff was going on. But excited to see that that’s there.
20:38
And that’s, that’s kinda where, you know, the things that I really kind of look to 20 20, 404. Hopefully, there’s more health care markups, particularly on the house side, more, discussion on innovation.
20:51
The, you know, I think where the Centers for Medicare and Medicaid services CMS is on the advancement of innovative diagnostics, innovative You know, pharmaceuticals.
21:06
I think we’re in this really weird place where the FDA has started to evolve.
21:12
You know, you got AI, you got apps, you’ve got these things that the FDA is willing to take a look at, assign people to jobs, and then go and really go after it. And we’re not, we’re not seeing it. And it’s been a wonky, but, like, benefit category, and all this, you know, like stuff about what CMS is and isn’t allowed to cover. But my hope is that we start to address some of these things, because they’re crazy innovative diagnostics out there.
21:37
Now, just use one example that can probably help us lower costs in the future, you know, but as usual, were little bit held captive by our actuaries. Whether it’s at HHS by the actuarial office or in Congress by CBO and so you know, how do we get over that?
21:55
So we all we all have supercomputers in our pockets every single day.
22:01
You know?
22:01
And we live in a world where We don’t, We don’t do enough, and, you know, why or, Why are there still people dying of, you know, diabetic?
22:10
No diabetic reasons, you know, in their homes alone? When we have all the technology in the world that can identify situations like that.
22:18
Emerging, you know, different ones, but anyways.
22:21
Sorry to blab on but I’m going to turn it over to Sarah.
22:24
What do you see coming down the pike? Well, the two things I’m paying a lot of attention to, I mean, I’m going to be frank. The first is what is going to happen with this package on March?
22:36
You know, there is a robust set of policies potentially on the table for consideration, and I think there are some differences of opinion about whether we should go narrow and more short-term, a streamlined package with, you know, taking a lot of the offsets that have been under discussion off the table. Versus a more robust package, you know, two years worth of extend or that, that potentially brings in some of the Behavioral Health Investments potentially brings in some of the Transparency PBM and pharmacy reforms.
23:06
And so, I think, how that plays out is going to tell us a lot about, how much is being kicked down, kicked down the road to the lame duck, And I think may even tell us about how difficult it may be to advance policies during the lame duck.
23:21
The other issue that I’m paying a lot of attention to, which definitely has crossover with, you know, what Amy index said on behavioral health workforce, primary care, workforce investments and telehealth is what if anything is Congress going to do this year on physician payment reform?
23:42
There is definitely a growing consensus that a system that does not provide for inflationary updates for physicians is starting to break down.
23:51
You know, Medpac just endorsed a set of recommendations that would provide for a partial MBI update for 2025, as well as some additional incentives, bonus incentives, to care for patients, who are lower income. There is a lot of concern that, you know, budget neutrality is really tying CMS’s hands. Anytime they want to do something to update the payment system that, you know, advantages, one group of physicians, everybody gets a cut as a result, and that does not lead to sort of healthy outcomes overall. And Congress has to come along and help provide potentially Conversion Factor relief as a result, which is under discussion for this March eighth package.
24:31
So I think that is something I’m going to be paying a lot of attention to.
24:34
I mean, you talk about physicians getting fed up, burnout, selling their practices to health systems and health plans.
24:42
You know, it’s tied in with the consolidation conversation that’s that’s ongoing, but, you know, making changes costs money, and how are we going to pay for that? And there are not a lot of offsets sitting around on the shelf at CBO will actually do have a lot of offset sitting around on shelf. So it’s just that they’re not politically viable offsets.
25:02
That’ll be a big question for me, and I think it’s just an interesting year, too, with so many, you know, well respected members of the Dark Caucus retiring at the end of this Congress, and, you know, what might that mean for, for the end of this year and beyond?
25:17
Yeah, there’s a lot of a lot of expertise that’s gonna walk out the door at the end of 2024. Well, 2024: it’s not just an election year, but a presidential election year. So how will that affect what might or might not get done, Are there things that are more or less likely to happen because it’s an election year, Hey me.
25:35
I know that, obviously, this is not directly applicable to the States but it’s going to be an election year for a lot of state legislators, do and a lot of governors, is due, to think, do more things happen in even numbered years or is it kinda like Washington where everybody freezes in place?
25:51
No, I think, I appreciate the question, so, no, states do not freeze, they have to balance their budgets in the work must continue. But there are some dynamics, I think, because this is a presidential election year.
26:01
A couple of things, and we have 11 GOV’s up, and eight of those are going to flip, so in those states, you will have new leadership, and, you know, I’ve worked with sort of states for a long time, whenever you have a new governor. Even, if same party things change different priorities, different approaches, and so there will be sort of work to do on that front. It’s, what’s another piece that it’s a little bit of a shorter legislative here for a number of states. Their sessions are shorter for different reasons.
26:27
And there’s a couple of states where they’re not, they don’t have their legislative year this year. They’re skipping this year, there’s four states of the on that front. So I do think it might it will be a busy legislative year, but 20, 25. I think there’ll be even more things happening. one of the things that states are very attuned to is when there is administration potential change our election. What can we get from CMS before they start not approving things and, you know, what are they going to be pushing out? So, you know, especially for states that have waivers pending. I think there’s concern about how many of these are actually going to be able to get done. We know CMS is short staffed, and they’re not able to process everything as quickly as they like. They have Medicaid in wind also going on in other priorities. And so, you know, what are the things that states are really going to want to ask for, and be able to receive with respect to federal approval? I think, as a question for a number of them. The other thing I will also say is, it’s a very active here for the Innovation Center. They have rolled out a number of different models targeted at states. We’re working with states across all of these models. We’ve yet to see the … or two of them.
27:31
So, I think another question as well, You know, are we going to apply for that? Are we already in one model, Are we going to be allowed to apply for that. And that’s across, you know, behavioral health, maternal health, the head model, and making care primary.
27:43
So, so, all of those activities are, I think, creating a lot of action at the state level. Thinking about, do we have the bandwidth to move forward on this, and how quickly is the federal government going to move?
27:55
So, Sarah and Nick, you know that it used to be that a presidential election year. All bets were off nothing happened. I don’t think that’s really true anymore. I think that things don’t happen sometimes, as we’ve seen in odd numbered years. Well, what do you expect the fact that it’s an election year, and, you know, presidential election year, that would give something, a push, or that would push something down on the agenda? What I guess, I’m asking, why the, what are the items that are most politically sensitive?
28:26
Let me, I’ll jump in, you, know, in one, kudos to both of my fellow panelists for bringing up the duck, duck payment issues. Obviously, we’re at where we’re back at the cliff, or back at the new SGR with the macro stuff coming down.
28:43
So, you know, like, that’s, that’s something that really needs to be talked about, and as well as the discussion over CMMI lys Fowler and her team have really ramped up working with the states and getting everything done there.
28:56
And that has done a terrific job of going from the ground up. And, so, some of those answers that you’ve asked for are definitely important. As to the election year, You know, we live in it.
29:08
We were, we were just at the, at an event where, you know, the word unprecedented has sort of now become a word that I really hate. hearing. You know, it’s waking up is unprecedented at this point.
29:21
So, know, what are we look for, 20 or the present, show where you can probably say that in every prison.
29:33
So you’re starting in June. You sort of shut down the policy world, and it’s only the presidential platform.
29:43
In this election, I think the platform of who are the two likely candidates for, for each party, have been very well established.
29:52
Um, and I don’t know that Congress in a world now, where the house is passing most legislation under suspension of the rules, is looking to say, Oh, well, we can or can’t get anything done.
30:03
You know, Sarah pointed out, everything hinges on what happens on March, 1 and 8, because are we doing this again in June, right? You know, like that means something has to be done.
30:13
And so I while I believe that the same issues that Karl Rove spoke about in 2004, you know, are still front and center.
30:24
Know, if everyone still just talks about the economy, they should be safe.
30:28
Um, but, you know, I do think that some of the Supreme Court decisions that are set to drop this year, especially monumental ones that dropped in the last two years, are gonna be of topic.
30:42
And if people can, know, stick to states’ rights are states’ rights. And, and go back to it, I think that’s probably good.
30:51
Be that the safest place that you’re gonna start seeing.
30:54
But, you know, everyone gets paid it in an election year. And so, we’ll see, I mean, the issue of reproductive health is always one that’s going to be a lightning rod, and the issue of guns is going to be a lightning rod.
31:03
And both issues are for one side or the other problem for them with their base.
31:08
And so, you know, that’s No, it’s, it’s going to be unprecedented in a presentation here. I hate that word almost as much as synergy and vertical integration.
31:20
But, it’s But, I think that’s But that’s what I. That’s what I predict, is you will the world has largely become desensitized to personal Presidential elections.
31:30
And so Congress will move forward in a different manner and not be as involved in the National Platform as they would have been 10 or 8, 12, 16 years ago.
31:41
Tara, anything that’s going to jump out or recede into the background? because it’s Presidential election year?
31:49
So, I think, you know, the committees have been working, as we’ve already discussed, in a bipartisan way, on a range of issues. And I think that’s going to continue this year, particularly on physician payment reform telehealth. There’s a bunch of other centers that have to get done, like extending the, you know, acute hospital, home program, things like that. That work will continue apace, but none of it is going to make it across the finish line it to the President’s desk until after this election is over, and then, I think, all bets are off.
32:16
It depends on the election outcome and who wins the White House. And, you know, does anybody taken back or retained the House or the Senate? How that all plays out? But I think where there’s going to be just a tremendous amount of ongoing action is in the administration. I mean, they are really doubling down. We’ve seen in recent weeks, on protecting women’s healthcare and women’s access to contraception.
32:41
We’re going to see, you know, more on behavioral health, you know, her said in CMMI certainly made their announcement on maternal health or are making it this week on sort of new new investments that they’re making. Health equity continues to be front and center for this administration.
33:01
No, more to come on AI in the coming weeks as a result of the administration’s executive order on AI from last year, and I think more to come on the competition front, as well.
33:13
You know.
33:16
Everybody’s behaving, as, you know, you gotta prepare us, that this is your last year of the administration, with great hope, that, you know, it is really only the last year of the second, the first term, before the second term starts. And everybody wants to get as much out the door before the end of the year as possible.
33:33
So, Nick, I was glad to hear you mentioned the Supreme Court, because that’s my next question. We already know that the Supreme Court is going to hear to abortion related cases before the end of this term on regarding the abortion one regarding the abortion pill, mister … and one on state obligations under EMTALA the Emergency Medical Treatment and Active Labor Act. But there’s another big health related case that doesn’t feel very health related, because it’s about herring fishing. We all know those of us who who really get down in the weeds that if the Supreme Court overturned the Chevron deference precedent, it could have a big impact on health care, couldn’t it?
34:13
Absolutely. I mean, this case is critical to, essentially, every agency at HHS.
34:22
The key question is whether, you know, when Congress passes a law and the President signs it into law, and they are crystal clear about every single provision and how it ought to be implemented, how much of, you know, the implementation can, can be deferred to the agency to figure out what makes sense?
34:42
And, you know, the Court case, that that the Chevron case that’s been sort of, you know, precedent has been in existence since 19 84.
34:52
And you think about, just how detailed all of the payment policies at CMS implementing the No Surprises Act related to surprise billing, implementing the prescription drug pricing reforms from the IRA. Provisions from the ACA on, you know, preventive services. All of these are very complex pieces of legislation.
35:14
And a lot of latitude was given to the agencies to implement them in, in, sort of, you know, common sense ways in accordance with with what, you know, the agencies think was Congress’s intent. The notion that this could be thrown out the door.
35:30
And the implications that’s going to have not only for future court challenges of existing regulation is already on the books, but also the amount of staff that would have to be hired by Senate and House ledge counsel. I mean, I loved the team I worked with at Senate Ledge Counsel.
35:49
I mean there aren’t enough. There’s not enough manpower ever to write with the level of detail that may be needed if Chevron is overturned.
36:00
Mean, this is a could have a huge impact on the states to write in the way that the state to deal with the federal government and with stakeholders.
36:09
We have actually been getting questions from state leaders about you know, what they worry about as they’re often implementing. There are a lot of different garments, and I think sometimes and this is this is true at the state level as well.
36:20
Those who legislate don’t necessarily see all of the different implementation steps. And so the thought of, like, you know, to Sarah’s point, if there was litigation around existing regulations, and programs that have already been implemented at the state level, and you would have to think about how to do those differently, would be a huge undertaking, not just at the federal level, but also at the state level, particularly on programs like Medicaid. So I think there’s a base marketplaces all of those areas like the touch the AAC, for example.
36:48
Among many other. So, I think there’s, there’s questions about, how is the federal government really thinking about this? What are the course going to do, And then, how to states even start to think about to prepare for something like that. And you can just only watch and wait, because states have to react to whatever sort of in front of them, and that’s, that’s how it will roll out. But, they’re already questions that are coming to us about, What is the potential impact, and how do we even start thinking.
37:10
I want to add something to this now, and then. I was talking to my colleague, Lanie about this earlier today, you know.
37:17
You look at what happened when a liner was decided by the Supreme Court and you saw this, how, how it slowed down regulatory behavior within the departments. And that’s just talking about the, you know, the obliteration of the subregulatory abilities that the agencies have. This is 100 times that.
37:36
So, you know, and a lot of, I mean, slowed down to the point where, if you look at even the statutorily required rules and the average day amount of days, they were late.
37:49
No, right afterwards.
37:51
I mean, I think there was even a year where we had two inpatient rules, like, it’s just, it’s a wild. It’s going to be a little bit of a Wild West that, you know, I hope, in the end.
38:03
Well, we’re not never going to tell the Supreme Court what to do But it will definitely create a struggle for whoever wins the White House because it won’t just be filling up your, your, your presidential, appointee folks. It will be bringing back.
38:21
Some people from years ago that have the experience and understand how all of it was built up to where it is today, to be able to unwind some of the things, as have you mentioned, especially on the state level.
38:33
Because it’s, it’s good.
38:34
And it really just depends on how the the the ruling is.
38:38
He’s written.
38:39
But you know, if it’s if it’s retrospective, we were in for a very interesting, very nerdy conversation after that.
38:49
Well, this is certainly a court that doesn’t really worry about shaking things up. So we will obviously see by this summer what they decide to do. I’m going to turn to a couple of audience questions.
39:01
Lost my screen.
39:02
Here’s one, can you expand about ways that states will address workforce, that the workforce issues that care for older adults? I think this is a, you know, we’ve got the baby boomers retiring. We’ve got, basically, no long-term care policy in the United States.
39:18
And no one seems to be doing anything about it, I’d say. I wrote my first long term care story in 19 87, You know, thinking, like, you know, 2003 or 2004.
39:28
This will all be worked out, and now we’re at 20 24, and it’s not yes.
39:34
I’m happy to take that first, so I will just say, you know, silver lining, perhaps, an aging is become a top priority for state leaders. And I say that, because when I was the National Governors Association, I was like, let’s do product on aging.
39:47
Very lukewarm response, I’ll be very honest. But coming out of the pandemic, I think that the bright light that was shown on nursing homes, and kinda their failures, to really be able to meet the moment. and the amount of folks that want to be receiving care in their homes, they do not want to be nursing homes. The polls are showing between 70 to 80% of people do not want to be nursing homes, but we don’t have the staff to really fully support people in their homes. So, I, this states have really been focused on this. There have been Governor’s Task Force, is setup, there been Legislative Actions. And just to get a little bit more specific, ARPA actually provided some funding, where there’s been a lot of innovation at the state level, of thinking about how to invest in the direct care workforce. Raising rates, doing bonuses, thinking about sort of longer term recruitment and retention plans. Thinking about paying family caregivers, And number of states are doing that, now, I’m really trying to incorporate the family caregiver, is another part of the puzzle.
40:42
There’s interest in nursing home reform, both on inequality and consumer experience, as well as the payment side. And I would say just in the home and community based services, thinking about how to really get rid of those waitlist and making investments and how to get more people into those services. They’re all by waiver, right? So it’s a very fragmented system that we have here. And Medicaid, unfortunately, is the primary payer for many of those services. Because we don’t have a private long-term care system, to your point, Julie. So I’ll just say, because I’m an optimistic person, I do think there’s a lot of interest. Like very high levels at the state level, at least, to like how do we really do more about it. There’s lots of states doing master plan on aging’s now across the country. Again, something that wasn’t happening before thinking holistically about how we support the population, not just about the health care services, but housing and food insecurity. Those are all really cropping up as real challenges.
41:35
So, so, I just say one thing, just to get more specific and direct your workforce there are some states that are really thinking about how to or more uniformly provide credentialing for licensed and unlicensed. Direct care workers to really professionalize the, the job and bring people in from different areas who can serve different populations, both on the aging and disabled side. So, so, good work going on there.
42:01
Sarah and Nick, you know, I remember when aging was a really big issue on Capitol Hill both houses had aging committees, and they were pretty active. It seems to not be top of mind for a lot of federal lawmakers which surprises me because older people vote.
42:19
I mean I think on the democratic side of the aisle there’s still a lot a tremendous amount of interest in wanting to do something on long term care. I mean certainly this was a key piece of the BBB. And I think many people sort of have post-traumatic stress disorder from the BBB.
42:34
But Senator Casey was really a leader on a lot of those components related to home and community based services and the workforce related issues. And there’s still a strong interest in moving forward.
42:48
And, of course, mister …, when he was Chairman, introduced legislation to essentially create a Medicare Part D, that would have advanced, you know, more long term care services for senior populations. And I think the question around focus, and why aren’t they focusing on it now? I mean, I think so much of it has to do with finding a dance. Partner on the other side of the aisle.
43:14
And how do we pay for it?
43:18
Yeah, Nick, that’s gotta be sort of the biggest thing. I mean, these are all services that people need. And many of them don’t have the money to afford it themselves. Which is why they’re at the government in the first place.
43:30
Yeah, No. You made a point.
43:35
You know, it’s interesting that there used to be a lot of action and a lot of work being done here.
43:41
It’s interesting to look at the fact that most of the people that are in Congress are going to be looking at, potentially long-term care. And, you know, it’s one of those, the, you know, it’s easy to throw stones until something that you see, whether it’s you or your parents.
43:58
Um, I mean, for me, this comes down to, are we going to get to a point where, on a bipartisan basis, we understand the overutilization of the Emergency Department in America?
44:11
You know, where we don’t have services, preventative services, when we don’t have emergency services where we don’t have long-term care services, it just becomes the, the, it just becomes the ER.
44:24
That is where everyone goes because, you know, EMTALA you know, Basically, it requires you to be there and, know, I I’ll tell you, in my time, working on the Hill, I got calls from members all the time.
44:39
Its constituents are called, you know, the hospital won’t know, keep me long enough to let me go into a nursing home. The nursing home says that I’m fine, but I can’t really stand, I gotta get, you know, I have to, I have to go back home, I’m scared to go home, I live alone, You know, like, you know, go out and solve these, these constituent problems.
45:00
Each and every one of those scared, people, calls 911.
45:04
And each 911 call costs more than providing care in the home.
45:09
And, you know, and again, I hate to harp on this.
45:12
But until we’re no longer hostage to no kind of actuarial, the actuarial bodies that run our government, basically, they’re the most powerful legislators we have on the state and federal level, they tell you something costs money, you know. The chances of that going through have now dropped through the floor, right?
45:35
And that, and, you know, and, you know, one of our good friends, who was at CBO and the two thousands predicted the part D was never going to work, right? And there’s no real, like, turnaround to the fact that that didn’t actually happen, or maybe the fact that we’re the last, you know, budget analysis was $1000 billion off.
45:54
You know, all that time, there’s activity that’s not being done to advance legislation, that can help people, because of the fact that we live by this predict predictive analysis.
46:06
So, you know, that’s, that’s just kind of where my, my head is on, where we can and can’t move forward, but long term care suffers from that.
46:14
Problem is that if we were to provide standard services for, you know, unhealthy adults, particularly, and we can start even with just multiple chronic conditions, let’s just shave off the cream on this and say multiple chronic conditions.
46:31
We’re going to provide more at home health because of the fact that you are more likely to end up in the emergency room and cost three times as much for one day than you would have for weeks.
46:44
So, until we get to that point, none of these policies can move forward.
46:48
Even in the ACA, with the supermajority, no, they didn’t.
46:52
They didn’t authorize funding for the Class Act, right, which was something that everyone dreamed about, and it has dreamed about for a long time. Because you can agree, we can’t.
47:01
Because, again, the actuary’s said no, that will cost you way too much money. Even though we don’t think about kind of know how the behavioral change of enacting new policies going through. And we’re going to be, we’re going to be stuck spinning our wheels in our health care system. And I’m jealous that Haven’t been working with the states, at least. You know, I’m starting to see a lot more action there on that kind of new, innovative programs, you know where the Fed, we’re still a little bit stuck.
47:28
Well, like, if it doesn’t save money, you know, and it’s like, But, Will it help people will keep people healthier? Will it help people live? We’ll let you spend three or more months with your grandmother. You know, that doesn’t matter, right?
47:39
Because it costs too much, and then you start drawing partisan lines on what can and can’t be spent.
47:48
I have a much shorter term question from the audience. If I find it Oh, thoughts on whether Congress will just end up doing … for the whole year and what’s the likelihood of adding the PBM reform that we’ve been talking about to the next CR? Or a lame duck duck fix if we don’t get to it before then?
48:12
Re really meaty questions. Which one to start with first?
48:18
So on on sort of the PBM question, I think, you know, look, there’s a lot of commonality and a lot of interest between some of the PBM provisions between the two chambers and you could see, you know, potentially, some of the issues around, you know, banning spread pricing in Medicaid for example.
48:37
Transparency for PBMs is definitely, you know, one that all of the committees agree needs to happen, but some of the, The, the additional proposals related to de linking Medicare de linking, came out of the Senate Finance Committee. Commercial, de linking has been discussed, the Senate help committee. I think there’s more of an open question about whether the time is ripe for those. And there are sort of bipartisan consensus can be found on some of those provisions. And I think the other open question is whether to the extent that some of these PBM and pharmacy reforms are included, do, the savings from that get plowed back into improving the part D benefit? For example, through, you know, some limited rebate pass through for, for a certain part, D drugs? Or are they used to offset of the provisions in the bill? And, that, I think we’re, you know, that the parties land on that will be important and plays into what happens on the physician payment text.
49:40
I think there is still very strong bipartisan interest across all the committees to provide some level of conversion factor relief. For 2024, I suspect it’s going to be done on a prospective basis, because nobody wants to spend money unnecessarily for CMS to reprocess claims or force physicians physicians to reprocess beneficiary cost sharing.
50:04
But, how much room there is for relief really depends on how many offsets are available at the end of the day.
50:10
I know in the past, CMS has pending claims if they thought that Congress was about to do something about the duck during all of those pre mac or years. And we had the SGR. are they not doing that now? I’m not sure whether any of our panelists not. Yeah, they are officially not for. Now.
50:28
It’s just just to add it’s something that has been kind of much talked about since probably early fall of last year. And it seems as though these the better solution has just been to figure it out.
50:41
And give that relief on a truncated schedule. So, it’s 12 months of relief, and we pass it at March seven.
50:50
You know, it’s really good at about nine months of relief, that that will be kind of the same amount of money. But, but just over that course of time, 12 months of relief into nine months. Yeah, yeah, and so, you know, which then, again, you know, just creates a higher cliff at the end as we play.
51:10
We play this game before, and you know, so you know, on the CR thing I think, until we see less rhetoric, I don’t know how we avoid …. Being the way that we pass things. You know, back in the day we used to blink and then all of a sudden the bipartisan deal would be passed and everyone got already beyond their airplane by the time you go blue screen. And I just don’t know if that’s the case and more, and you know to the comments on the PBM work.
51:37
I think the PBMs are very interesting entities, because they’re highly unregulated, and it’s because there were no employer benefit managers until Part D happened, and no one really expected them to step in.
51:48
You step into the void, and so to Sarah’s point, you know, I look at a lot of these policies, and there’s always ways, you know, when we when the administration put out the rebate rule, which ended up being just the biggest pay for it, in the history of America.
52:01
But, You know, we, you saw behavioral change and unregulated entities and all of a sudden, you know, they’re there, they’re shifting funds one way or the other, and, and so on, where some of this legislation actually takes us forward.
52:16
The interesting I look at things like the linking, though, and I challenge, you know, our attendees to take a look at companies like, uh, capital RX, it’s a PBM. That’s a technology PBM that’s already dealing, right?
52:29
They don’t do, they don’t do the make money off of drug price aside.
52:34
And you look at the savings they’re able to garner per patient on the cost of drugs.
52:39
And so you look at that, you see it already happening and so to that point, hopefully people are looking at kind of real life, real evidence to say what’s going to be done and you know regrettably, I think the word transparency is now used just as much as synergy was used in the early two thousands.
52:56
You know, where, what, what, where’s the end game on, on transparency.
53:02
If we’re going to be successful, you know, where, you know, major insurers currently already have all those apps, where you can look at the costs of everything you do, and they have less than 1% utilization by the patient population. Maybe because they don’t know, but they because it’s complicated. But at the same time, just because something is available to be seen, doesn’t mean people are looking at it. And so, that’s, that’s where, kinda to that question, you know, unfortunately that we do see some of that stuff passing through. Whether we get it done on a CR is going to be tough.
53:33
All right, well, we’re running out of time, but I want to go go around quickly, to ask each of you what is, if there’s one thing, if you have narrowed down to one thing that you think will be most important in health policy this year, what will it be?
53:45
Sarah, want to start, the most important thing in health policy for this year? for this year? OK.
53:54
I mean, I think I’m gonna double down that the workforce and behavioral health issues are the most critically important things that I think we need to make progress on this year. And that we don’t make progress on. Are going to hamper our ability to work on a lot of other issues in the future.
54:16
Tammie.
54:18
Sarah stole my two topics, So behavioral health workforce is clearly it’s hopeless. I will just also say one thing we haven’t talked much about is affordability. And really thinking about affordability, politically, elected leaders at the state level, been asking like, healthcare costs too much do something, please do something. So I do think at the state level prescription drug costs to keep our health system consolidation. And what we do about that is going to be a topic of much debate as well.
54:44
Yeah, no, I think those are those are 100% top of the line where it is, you know, the unfortunate part about massive legislation for, for victims and for vulnerable populations only happens, and I don’t mean to be rude about this, but when the wrong person dies, right?
54:59
And, you know, you look at the fact that, you know, 20 years ago, breast cancer and awareness was nowhere where it is and now the NFL sponsor to sponsor it for a month.
55:10
Right.
55:10
We have to get to that place on mental behavioral health because it has, it is by far going to be someone something that much like Alzheimer’s is going to touch.
55:19
Every single human being in the United States, over the course of the next 12 months, you’ll, you’ll see it somewhere in your life and it’s, it’s only gonna get important if we all make it important.
55:32
Well, thank you all. I’m going to turn it back over to Allison.
55:37
Great. Thank you so much, Julie Haney, Megan, thera for joining us today. And thanks to all of you who stayed a few minutes after for this conversation. We’re so grateful that you took the time to participate in the discussion. And we hope you found it very informative and will take what you learned and apply it in your work. Before we go, we want to hear from you. We appreciate you taking a few minutes to complete a brief evaluation survey, which you’ll also receive via e-mail later today. As a reminder, the recording of this webinar will be available on our YouTube channel. The alliance website. And you will receive a copy of that in an e-mail shortly here at the Alliance. We have educational webinars, and in person events throughout the year, so please visit our website to sign up, our e-mail list, to receive the latest updates. And, and you can join this event. Our upcoming events, like are really exciting briefing next week on February first perspective for Media on value based Care, and thank you so much again for taking the time to be here with us.
56:31
Hope to see you at a future event.