In this edition of AcademyHealth’s Situation Report, we examine a crowded and increasingly contentious landscape for federal health policy: competing congressional proposals to address health care affordability ahead of a fast-approaching deadline, a new decade-long Medicare payment model that could reshape digital chronic care, an unprecedented, politically charged approach to distributing a $50 billion rural health fund, mounting concerns about internal FDA actions that could undermine vaccine oversight as well as directives prompting a reassessment of the childhood immunization schedule amid ongoing debate over hepatitis B vaccination policy.
In this issue:
- Senate Republicans consider health care bills as ACA subsidies end
- CMS releases ACCESS proposal
- Rural Health Fund comes under scrutiny
- FDA political leaders reduce trust in vaccines
- ACIP proposes rolling back lifesaving childhood vaccine access
Multiple Proposals, Little Consensus on Health Care Affordability Bill
Two Republican leaders—Senators Mike Crapo (R-Idaho), Chair of the Senate Finance Committee and Bill Cassidy (R-La.), Chair of the Senate Committee on Health, Education, Labor, and Pensions (HELP)—are circulating the outline of a health plan. The plan does not extend the ACA tax credits, which were at the center of the 43-day government shutdown; rather, the plan would provide funds for ACA Marketplace enrollees using a health savings account (HSA). Under this GOP plan, ACA enrollees ages 18 to 49 earning less than 700 percent of the federal poverty level would receive $1,000 in an HSA and $1,500 if they are between 50 and 64 years old. The measure would also fund ACA cost-sharing reduction payments that would cut subsidies to some ACA enrollees but lower overall premiums, and provisions related to low-cost "catastrophic" health plans—“essential health benefit” plans with lower premiums but the highest allowable level of cost-sharing— would be expanded to increase availability. Lastly, the bill would cut Medicaid funding to states that provide coverage via state dollars to undocumented immigrants.
The Senate is expected to vote on the Democrat-supported three-year extension of the ACA tax credits, which would lower premium payments for roughly 20 million Americans. That vote is expected to fail, and it is unclear whether the Senate GOP circulated outline will also get a vote by the end of next week. House Speaker Mike Johnson (R-La.) is expected to introduce a health care plan this week, which he says has support from those in House leadership. However, House Republicans in swing seats are largely in favor of extending the ACA tax credits, something Speaker Johnson has strongly opposed. One House Republican, Rep. Brian Fitzpatrick (R-Pa.), is slated to introduce a bipartisan bill and is open to pursuing a discharge petition to force a vote if GOP leaders refuse to allow the vote. With multiple proposals and many competing interests, it is unclear whether and how Congress will address health care affordability before its self-imposed deadline of December 19.
New Medicare Payment Trial Focuses on Digital Care for Chronic Disease
A new 10-year Medicare payment trial, called ACCESS, could determine whether the federal government can promote digital health applications like remote monitoring to manage chronic illness among the Medicare population. While traditional Medicare pays providers based on the volume of individually billable services they deliver, this new model would pay providers and suppliers a fixed amount, with full payment based on patient outcomes, to manage chronic issues like hypertension, diabetes, and depression. It is hoped that this initiative will provide an incentive for hospitals and health systems to further invest in digital care infrastructure. To encourage this, CMS plans to develop a directory for digital health vendors to list available technology. The model will launch in July 2026.
The administration is encouraging the use of digital health tools across its initiatives, though somewhat unevenly. In June of this year, the administration launched a program to allow patients to share personal health data and medical records across health systems and apps run by private tech companies, ostensibly focused on diabetes and weight management, as well as using AI and other digital tools, which alarmed some privacy experts. In addition, two digital health initiatives currently in limbo, Medicare telehealth flexibilities and the Hospital at Home program, will expire in January if not extended. It’s unclear if or how the ACCESS trial would impact these other initiatives.
Health Policy Experts Scrutinize Fine Print of $50B Rural Health Fund
All 50 states submitted proposals to the Rural Health Transformation Program in November describing their plans to improve health in rural America. Since the Trump administration plans to distribute the money in part based on how aligned states’ plans are with the administration’s vision for the rural health program; several states have changed or pledged to change their own laws, such as those that restrict Supplemental Nutrition Assistance Program (SNAP) funding from use on “non-nutritious” food and drinks, to vie for more funding. States will receive various levels of “credit” depending on whether they change the laws or simply intend to, but if states do not implement the intended policies by the end of 2027, or 2028 for more time-intensive policies, the administration may take back some of the funds. Many health policy experts fear this unusual approach to distributing funding will result in outcomes that favor political allies.
While both political parties support some of the incentivized policies such as expanding telehealth services and promoting nutrition education in medical school curriculums, other policies such as those related to SNAP restrictions and short-term insurance plan deregulation have split support along party lines and among the medical community. Thus, variation is high across states in terms of which states are pledging to change or have already changed their laws to align with the Trump administration's policies.
Most states have made their applications public, including indications of which policies in H.R. 1 they are proposing to adopt or not. However, following the lead of federal regulators, some states are withholding parts or all of their applications, which may ultimately hinder effective and innovative implementation of rural health policy.
CMS has indicated that awards will be announced by the end of the year. Researchers should monitor the announcement and prepare to research how awards are distributed, how states move to implement policy changes, and eventually, how this influx of policy changes impacts rural communities.
FDA Vaccine Oversight Could Cast Doubt on Vaccine Safety, Efficacy
Career scientists in the vaccine space have voiced concern for the future of vaccine regulation after a top official at the Food and Drug Administration (FDA), Tracy Beth Høeg, proposed relabeling COVID-19 vaccines to claim that the risks outweighed the benefits for men ages 12-24. In doing so, she would effectively restrict access to vaccines for this group. Høeg eventually back tracked after push back from her colleagues, who claimed that vaccine access had already been restricted through narrower booster approvals, thus making the additional restriction unnecessary. While this additional restriction was vetoed by her colleagues, Høeg and vaccine center director Vinay Prasad have taken considerable actions that have derailed public trust in and access to vaccines without consulting career staff or sharing their ideas with the FDA’s vaccine advisory committee. Indeed, the two have taken control of the FDA’s vaccine surveillance program and have increasingly taken issue with the methodology of studies they disagree with. They have reportedly taken down at least one unpublished internal study that found COVID-19 vaccines to be effective and safe, taking issue with the study’s methodology, for example. They have also questioned the approval of the COVID booster, vaccine mandates, and the U.S. childhood vaccine schedule, claiming that there must be a multi-million-dollar study introducing more controls to examine the safety of receiving multiple vaccines at once. While scientists have said they are open to improving methodologies, many question the need for such an expensive study when observational data has indicated that the vaccine schedule is safe. Moreover, scientists warn that discourse purporting that anything beyond a near-zero individual risk is unsafe could threaten population-level interventions that work for most people. In doing so, this narrative threatens public health outcomes.
Taken together, health services researchers should prepare for shifting regulatory standards, tighter control and centralization of vaccine surveillance data, and changing methodological demands amidst changes at the FDA. Consequently, the field can also expect a rise in public mistrust as FDA officials continue to cast doubt in vaccine safety and efficacy.
Administration Prompts Review of Childhood Vaccine Schedule
Hours after the CDC’s Advisory Committee on Immunization Practices voted to remove the universal hepatitis B birth dose recommendation, an official presidential memo was issued directing Health and Human Services Secretary Kennedy to review the childhood vaccine schedule and potentially revise it. The president affirmed the decision and reiterated misleading statements that most babies are at no risk for Hepatitis B, characterizing the diseases as one mostly sexually transmitted or via dirty needles. Critics counter that while transmitted through bodily fluids, the virus can live on surfaces for up to a week, placing newborns at risk of contracting serious disease. Critics of this decision point to the fact that prior to the universal birth dose recommendation in 1991, the risk-based strategy was not working. Since the universal dose was introduced, annual infections among infants and children dropped 99 percent from 16,000 to less than 20.
Aligning the U.S. childhood vaccine schedule with other developed countries in Europe has been central messaging, including in the president’s memo, which implied Americans deserve evidence-based medical advice. However, public health experts counter comparisons to countries such as Denmark, who does not include a birth dose for Hepatis B in their schedule. These “peer” countries benefit from their national health care systems that provide universal access and can more comprehensively track patient records. Conversely in the United States, some women struggle to access regular prenatal care and many infants are lost to follow up as soon as they leave the hospital. The U.S.is certainly not an outlier, with 116 countries of the 194 World Health Organization member states recommending universal hepatitis B doses.
For health services researchers, this situation underscores the importance of communicating the complete body of evidence. When evidence is presented selectively or without context, opponents of evidence-based practice can construct misleading narratives that appear credible to the public.
Previous Editions
This is the latest in a series of Situation Report updates from AcademyHealth. You can find prior issues here.
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