AcademyHealth’s Director of Advocacy Josh Caplan is guest hosting this month’s Read on Washington.
Debt Limit negotiations continue
Hanging over all other conversations in Washington, DC policymaking is the status of the debt limit. The debt limit is a cap on how much the federal government can borrow to pay for existing obligations. The debt is a function of decisions Congress makes on spending (appropriations, entitlement programs, etc) and on revenue (tax rates, tax expenditures), which makes the debt limit Congress separately authorizing the difference between those numbers. Not raising the debt limit would be cataclysmic and would very likely plunge the US and the world into an economic depression. Congressional Republicans are currently refusing to raise the debt limit unless there are still yet unspecified spending cuts and legislation tied to it. Congressional Democrats and the White House say that risking default is too dangerous and that the limit should be raised before engaging with budget conversations through regular order. The latter strategy has been the most common and bipartisan approach to the debt limit.
There are three primary proposals on the debt limit being discussed right now:
- President Biden and nearly all congressional Democrats are calling for a “clean raise” of the debt limit first, and then discussion of any budgetary debates through normal congressional order. This reflects the last three debt limit increases, which occurred with bipartisan votes during the Trump Administration.
- The bipartisan Problem Solvers Caucus plan proposes to suspend the debt limit for the rest of this year, which would allow congressional leaders to pass FY24 appropriations with unspecified “deficit stabilization controls”. This would also create a fiscal commission to craft a long-term deficit stabilization plan that would get an up or down vote in both chambers.
- Speaker McCarthy has demanded significant Republican priorities be passed in exchange for raising the limit, but has so far not clearly specified what they are. Current demands include: cuts/caps of all discretionary spending (including defense and VA medical care) of 28% by 2033 or 58% of all discretionary spending if defense and VA are spared; steep cuts in the IRS tax enforcement spending; ending student debt relief; rescinding all remaining COVID-19 funds; repealing all clean energy investments from the last Congress; increased work requirements for Medicaid and SNAP; more investments for fossil fuels; among other demands.
HELP and Finance Committees working on bipartisan drug-pricing deal
The Democratic and Republican heads of the Finance and Health, Education, Labor and Pensions (HELP) committees say they’re trying to mark up drug-pricing legislation in the coming weeks and assemble a package of bills that would also include some drug patent changes already approved by two other panels. Having a long list of small policy changes that together could equal a major overhaul may garner the 60 votes needed to pass the Senate, but the legislation is running into some jurisdictional battles between chairs. Cassidy and HELP Chair Bernie Sanders (I-Vt.) are debating how to spur new generics to market and tackle the way pharmaceutical benefit managers influence the cost of prescription drugs, among other measures. Sens. Jeanne Shaheen (D-N.H.) and Susan Collins (R-Maine) have been in discussion with Sanders about including an updated version of their bill to cap the cost of insulin for people with private health insurance at $35 per month. The HELP Committee may markup their bills on May 2.
Senate Labor-HHS Public Witness Testimony due May 18
The Senate Appropriations Subcommittee on Labor, HHS, and Education have requested written outside witness testimony on FY24 priorities, due by May 18. Information about how to submit can be found here.
Biden Administration will continue to provide COVID-19 vaccines for the uninsured
The Biden administration plans to spend more than $1 billion on a new program to offer free coronavirus shots to uninsured Americans after the vaccines move to the commercial market later this year. The program for the uninsured, which will be modeled partly on an existing childhood vaccination program and will cover an estimated 30 million people, will include a first-of-its-kind partnership with pharmacy chains in which the government will pay the administrative costs of giving the doses to patients. Pfizer and Moderna have pledged to offer the shots at no cost to those who lack insurance. The administration’s move partly resolves a critical gap in the nation’s coronavirus vaccination strategy ahead of a new booster campaign with reformulated shots that is likely to begin as soon as late summer.
HHS expanding Medicaid and ACA Subsidies to Dreamers
HHS has released a proposed rule that would allow nearly 580,000 people enrolled in the Deferred Action for Childhood Arrivals program (also known as Dreamers) will be able to obtain health coverage through Medicaid or the marketplace, two public health insurance programs for which undocumented immigrants are currently ineligible. HHS Secretary Xavier Becerra said in a statement that the proposed rule would “improve health outcomes for DACA recipients and would in turn improve the economic and productive capacity of America.” He estimated that roughly a third of immigrants enrolled in the DACA program are uninsured.
NCI’s Bertagnolli to be nominated to lead NIH
The White House is planning to nominate Monica Bertagnolli to run the National Institutes of Health. Dr. Bertagnolli is an oncologist who has run the National Cancer Institute for the past six months and is a cancer patient herself. If confirmed by the Senate, Dr. Bertagnolli would be only the second woman to serve as the medical research agency’s director on a permanent basis since its origins in the late 1800s. She is the first female director of the National Cancer Institute, which is part of the National Institutes of Health. Dr. Bertagnolli would replace Dr. Lawrence A. Tabak, who has served in an acting capacity since Dr. Francis S. Collins stepped down at the end of 2021 after more than 12 years as director.
Federal judge rolls back preventative care
U.S. District Judge Reed O'Connor, who has previously ruled the Affordable Care Act unconstitutional and was overruled by the Supreme Court, ruled that recommendations for preventive care by the U.S. Preventive Services Task Force were “unlawful.” This ruling would effectively end the ACA mandate that all insurers cover certain preventive care services without asking patients to pay anything out of pocket, including screenings for cancer, diabetes and mental health. HHS has estimated that about 150 million individuals in private health plans and 80 million individuals with Medicare and Medicaid have benefited from the policy. The ruling finds that the entire U.S. Preventive Services Task Force is illegally appointed. The USPSTF has made evidence-based recommendations on over 50 services being of high-value for patients and eligible for coverage under the ACA. The Biden Administration is appealing this ruling.
House Energy and Commerce probing NIH public relations spending
The House Energy and Commerce Committee has announced that they are investigating NIH’s spending on public information and communication services. The agency doubled the value of these contracts in 2021 to respond to the pandemic, leading to approximately $1 billion in contracts. The Committee sent letters to the 10 firms that NIH has contracted with to identify if the spending was for "legitimate government communications." At this time, the Committee has not identified any specific allegations of wrongdoing.
More Americans are putting off medical treatment as inflation and housing costs reduce funds
Nonprofits that help people access low-cost care have noted a dramatic increase in the number of people relying on their services as inflation and housing costs have further eroded the ability of patients to afford health care. In a 2022 Gallup Poll, 38% of American adults surveyed said they had put off medical treatment within the previous year due to cost, up from 26 percent in 2021. The new figure is the highest since Gallup started tracking the issue in 2001. In a survey by KFF released last summer, 43% of respondents said they or a family member delayed or put off health care because of costs. It found people were most likely to delay dental care, followed by vision services and doctor’s office visits. Many didn’t take medications as prescribed.
What I am reading
The CDC estimates that approximately six percent of US adults are experiencing Long COVID or other health problems that emerged as a result of the disease. They also estimate that up to four million adults have symptoms that significantly reduce their ability to carry out day-to-day activities. Without tests, treatments, cures, or even a standard medical definition, these patients can feel alienated from the health care system. An important step in developing care for these patients is to listen to their stories, which is why I appreciated this article from NPR highlighting real patients.
Amy Silverstein wrote in the New York Times about the tragic outcomes that can befall organ transplant recipients, who have a lifetime of immunosuppressive medications ahead of them. There has been little progress in recent decades to develop newer, safer, and more effective transplant medicine regimes that protect patients. The life expectancy of a heart transplant recipient has barely changed in the last 30 years, illustrating how little gain has been made. Silverstein is a heart transplant recipient who is now facing a terminal cancer diagnosis in part due to the medications that she needed to take to maintain her transplant.
As we continue to explore the ways AI can be used in medicine, patients may start using it to store their voices and communicate with their loved ones after losing other communication abilities. The Washington Post recently published an article on companies like Acapela Group and Voice Keeper that are now offering more affordable options for “voice banking” or storing speech in a voice that sounds like the client, using AI for patients who anticipate losing their ability to speak. This could offer some measure of relief for patients with ALS, throat cancer, and other diseases. Voice banking could improve patient autonomy and quality of life for patients with conditions impacting their speech and I am excited to see where these advances will lead healthcare and medicine.
A new study published in JAMA Network Open now recommends that Black women should start screening for breast cancer as early as age 42 while Hispanic women should start at 57. This is much lower than the US Preventive Services Task Forces recommendation of approximately age 50 which has been contentious for years. This study used breast cancer death data for over 400,000 women and concluded that the screening age should vary depending on race to reduce unnecessary radiation exposure and better early detection. Changing the guidelines for breast cancer screening has the potential to reduce cancer deaths, particularly for Black women. Despite having lower rates of breast cancer than White women, Black women are not only more likely to develop more aggressive cancers, but they are also dying at higher rates.
States that have banned abortion as a result of the Dobbs decision have seen a 10.5 percent drop in applicants for obstetrics and gynecology residencies in 2023 from the previous year, according to new data from the Association of American Medical Colleges. This decline will create even more barriers for women in these states to access life saving care as these states continue to struggle to recruit and retain healthcare workers. Maternal and infant mortality rates are far higher in the US than in peer nations, and this may further exacerbate this trend.
As the impacts of climate change worsen, it is critical that the health system focuses on climate-resilient health care infrastructure. Drs. Nwanaji-Wnwerem and Osborne wrote in JAMA about their experiences in weather-related infrastructure challenges caused by abnormally cold winter in Atlanta, Georgia. The cold weather overwhelmed the hospitals HVAC system leading to broken heating and cooling coils flooding multiple departments. There are clear and established interactions between climate change, environmental exposures, and health outcomes. The authors call for contextualizing challenges as consequences of aging infrastructure and climate extremes, and to bolster the resiliency of systems.
The ruling from a Texas district judge earlier this month revoking approval to the abortion drug mifepristone sets a dangerous precedent of politicized drug and biomedical approvals, including ones that could happen decades later. Time published an analysis on how this ruling stretches far beyond the issues of abortion or this specific drug as it raises real questions about the FDA’s basic regulatory powers as a judge with no scientific training is able to second-guess the FDA’s expertise on an exceptionally safe and widely used drug. If this ruling is upheld in any form, it puts a crosshair on all FDA-approved drugs, which would immediately reduce the incentive of pharmaceutical companies to continue drug development and for patients and providers to have trust in what they are being prescribed.