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House Passes Big Beautiful Bill; On To The President

After almost collapsing overnight Wednesday in the House, the Big Beautiful Bill gained just enough votes to pass during the afternoon Thursday. The House had to adopt the Senate version to meet the deadline of July 4. Both moderates and conservatives in the House GOP caucus were highly critical of the Senate version, but all but two relented and voted for the budget reconciliation measure. Conservative Thomas Massie, R-KY, and moderate Brian Fitzpatrick, R-PA, were the only GOPers to vote against it. The bill passed 218-214 and the bill will be signed by President Trump tomorrow, Independence Day.

I had always argued there was an inevitability associated with passage of the bill, whatever healthcare cuts are in or the impact on the deficit. The GOP sees the Big Beautiful Bill as a seminal event for the party and a movement. But for a time, the House vote looked very challenging.

Conservatives criticized the massive additional overall deficit and debt the Senate bill generates against the House version. They issued a memo criticizing both the Speaker and Senate Majority Leader John Thune, R-SD, for moving away from the House framework. At the same time, moderates criticized the fact that Medicaid cuts are actually higher than in the House bill, especially as it relates to greater limitations on the provider tax and its phasedown to 3%. Conservatives especially were converted by explanations of the new Senate Medicaid cuts as well as commitments about how certain policies will be implemented by the administration.

Trump, Vice President JD Vance, CMS Administrator Dr. Mehmet Oz, Speaker Mike Johnson, R-LA, and other House GOP leaders are given great credit for convincing the vast majority of the up to 20 GOP holdouts to support the bill. Trump made calls until about 1:00 AM Wednesday night/Thursday morning.

Reductions in healthcare exceed $1.1 trillion. Medicaid cuts center on work requirements, provider tax limitations, and eligibility tightening. Exchange reductions center on eligibility restrictions and tightening. About 17 million could lose coverage from the bill, the expiration of the enhanced Exchange subsidies, and a new Exchange rule just finalized. As I have argued, the reductions are quite stealthy, but the impact will be real.

The healthcare news website Kaiser Health News had two articles on the bill’s impact. Nineteen Medicaid expansion states are led by GOP governors. They have been mum on the potential fallout of the Medicaid reductions, which are very much focused on expansion states. The governors mostly have said they do favor work requirements. But these governors will struggle with the limitations and phasedown of provider taxes used by states to leverage federal match dollars in Medicaid. They will struggle, too, with the additional administrative requirements tied to eligibility and work requirements in both Medicaid and the Exchanges if their states run their own marketplaces.

Actuarial consulting firm Wakely also issued an analysis of the bill’s impact on the marketplace, arguing the future market will look fundamentally different as enrollment declines. Findings include:

• Gross market average premiums could increase between 7% and 11.5% because of market attrition and residual risk pool morbidity increases, not accounting for incremental claims cost trend impacts.
• Enrollment could be reduced by 22% to 27%, or 5.2 to 6.4 million enrollees. This estimate is higher than those of the Congressional Budget Office (CBO). This does not count the impact of enhanced premium subsidy expiration.

Additional articles:https://kffhealthnews.org/news/article/big-beautiful-bill-trump-medicaid-affordable-care-act-cuts-republican-gop-governors/ and https://kffhealthnews.org/news/article/affordable-care-act-aca-obamacare-coverage-gains-threatened-1bbb-uninsurance/ and https://www.fiercehealthcare.com/providers/house-votes-218-214-send-reconciliation-bill-trumps-desk and https://www.medpagetoday.com/publichealthpolicy/washington-watch/116383 and https://www.wakely.com/blog/new-wakely-white-paper-explores-potential-impacts-of-house-reconciliation-bill-on-aca-individual-market-coverage/ and https://thehill.com/homenews/house/5382837-chip-roy-says-senates-medicaid-cuts-a-bit-better-than-expected/?tbref=hp and https://thehill.com/homenews/house/5384637-house-freedom-caucus-opposition-trump-bill/ and https://thehill.com/homenews/house/5383129-house-gop-big-beautiful-bill-trump/ and https://thehill.com/homenews/administration/5384490-trump-big-beautiful-bill/

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#budgetreconciliation #trump #congress #spending #medicaid #aca #exchanges #obamacare #coverage

https://www.modernhealthcare.com/politics-regulation/mh-tax-bill-house-donald-trump

— Marc S. Ryan

Budget Bill Stalled In House

The House is in flux right now as Speaker Mike Johnson, R-LA, and President Donald Trump are seeking to cajole moderates and conservatives in the GOP caucus to support the Senate version of the Big Beautiful Bill. Conservatives criticize the massive additional overall deficit and debt the Senate bill generates against the House version. They issued a memo criticizing both the Speaker and Senate Majority Leader John Thune, R-SD, for moving away from the House framework. At the same time, moderates are criticizing the fact that Medicaid cuts are actually higher than in the House bill, especially as it relates to greater limitations on the provider tax and its phasedown to 3%.

Trump and Johnson are having some impact. Between six and 20 GOP votes might have been in the “no” column today, but some are now coming around and saying they will vote for the bill or now are open to doing so. Interestingly, one of two no votes on the initial passage of the House bill, Warren Davidson, R-OH, has now said he will support final passage.

A lack of sufficient support from both moderates and conservatives who visited the White House today so far has stalled a series of procedural votes on the floor. The House likely will be in all night in an attempt to move forward to debate and eventually to pass the bill. I have always argued there is an inevitability associated with passage of the bill, whatever healthcare cuts are in or the impact on the deficit. The GOP sees the Big Beautiful Bill as a seminal event for the party and a movement. But right now there are many to convince before final passage.

In other news, Health Affairs Forefront Blog looks at the major administrative costs of carrying out work requirements in six states.

7/3/2024 1:00 PM UPDATE: The House GOP did get a successful vote early Thursday morning to pass a rule governing debate. The vote was 219-212. Debate has happened and now Minority Leader Hakeem Jeffries, D-NY, has all the time he wants as a leader under House rules to give a speech on the bill. At just after 1:00 PM Thursday, Jeffries was still discussing his opposition to the bill and set the record for longest House floor speech, which was about 8.75 hours. A final vote now can occur to adopt the bill.

7/3/2024 3:30 PM UPDATE: The House has passed the Senate version of the Big Beautiful Bill. The vote was 218-214, with just two Republicans voting with all of the Democrats against the measure. The vote caps a saga in the House, then the Senate, and then the House again to ensure enough conservatives and moderates in the GOP caucuses were on the bill.

Additional articles: https://thehill.com/homenews/administration/trump-the-next-100-days/5380399-live-updates-house-gop-trump-bill/ and https://thehill.com/homenews/house/5381728-gop-deficit-hawks-trump-megabill-memo/?tbref=hp and https://thehill.com/homenews/house/5381441-white-house-gop-holdouts-trump-megabill/?tbref=hp and https://kffhealthnews.org/news/article/one-big-beautiful-bill-medicaid-work-requirements-affordable-care-act-immigrants/ and https://thehill.com/homenews/house/5382760-warren-davidson-trump-big-beautiful-bill/ and https://thehill.com/homenews/house/5382215-house-republicans-delay-vote-gop-opposition/ and https://www.healthaffairs.org/content/forefront/recent-experience-shows-national-medicaid-work-requirements-would-create-enormous

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#budgetreconciliation #trump #congress #spending #coverage #medicaid

https://www.modernhealthcare.com/politics-regulation/mh-medicaid-cuts-tax-bill-one-big-beautiful-bill

Senate Passes One Big Beautiful Bill

It was another wild all-nighter for the Senate GOP caucus Monday in its efforts to pass the One Big Beautiful Bill. But early afternoon Tuesday, the bill was finally passed and now goes back to the House.

A conservative amendment to lower the federal matching percentage in expansion states did not have enough votes to pass. But in the end the conservatives except Rand Paul voted for the measure. Despite helping get a rural hospital fund to $50 billion, moderate Susan Collins voted against the bill along with Thom Tillis.

All eyes Monday were on moderate Lisa Murkowski. She won some SNAP nutrition and Medicaid funding concessions in the bill for Alaska and, with the rural hospital fund increase, voted yes. That gave the bill 50 votes, allowing Vice President JD Vance to cast the tie-breaking vote for approval.

Healthcare providers and health plans universally panned the bill, which is being described by Democrats as the largest rollback of Medicaid ever. The GOP notes that the program grew tremendously since the COVID pandemic and has become unaccountable.

I will inventory all the healthcare reductions soon in an upcoming blog when the House acts. But the big major reductions generating both savings and the vast majority of the lower projected insured are work requirements, limitations on provider taxes, caps on state-directed payments, and tighter eligibility requirements, which in the Senate version phases the allowable rate down over time from 6% to 3.5%. Medicaid is slashed by $940 billion over ten years. More than $200 billion is cut from the Exchanges through various eligibility restrictions and bars on illegal immigrant participation and subsidies. Tighter access restrictions for immigrants apply to Medicare as well.

A limited Medicare physician fix was included, which will not repair the reduced rates in 2025 but boost them by 2.5% in 2026. No structural changes were adopted for the future.

The bill could also trigger mandatory reductions in Medicare due to outyear deficit increases unless the law is overridden later. Medicare cuts could hit at least $45 billion in 2026 and a total of $490 billion in the remainder of the ten-year horizon.

The bill could struggle in the House. Some moderates are not happy with the five-year sunset on the state and local tax deduction increase. Other moderates are upset about increased Medicaid cuts. And conservatives are upset about the increase in deficits and debt. Conservatives could protest at the rules committee level and on the House floor. At least six House members have said they will vote against the bill as of now, which would sink the bill. But let’s see what arm-twisting occurs.

Additional articles: https://www.modernhealthcare.com/politics-regulation/mh-senate-tax-bill-medicaid/ and https://www.modernhealthcare.com/politics-regulation/mh-tax-bill-senate-one-big-beautiful-bill/ and https://www.healthcaredive.com/news/senate-passes-reconciliation-bill-medicaid-cuts/752018/ and https://www.beckerspayer.com/policy-updates/insurers-urge-house-to-reverse-course-on-budget-bill/ and https://thehill.com/homenews/senate/5379770-senate-trump-bill-tax-cuts-medicaid-snap-student-loans/ and https://thehill.com/policy/healthcare/5378970-medicaid-cuts-senate-republicans/?tbref=hp and https://www.kff.org/medicaid/issue-brief/allocating-cbos-estimates-of-federal-medicaid-spending-reductions-across-the-states-senate-reconciliation-bill/ and https://thehill.com/homenews/senate/5380186-trumps-tax-bill-heads-house/ and https://thehill.com/homenews/house/5380166-house-conservatives-threaten-senate-bill/

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#budgetreconciliation #trump #congress #spending #medicaid #exchanges #coverage

https://www.fiercehealthcare.com/providers/senate-passes-reconciliation-bill-51-50-vote

Senate Acting On Budget Bill

The Senate began debating the budget reconciliation bill and the process will go late into Monday at a minimum before any final vote. A procedural vote to open debate passed on a 51-49 vote Saturday, with conservative Rand Paul, R-KY, and pragmatic conservative Thom Tillis, R-NC, voting “no.” Paul likely will never support the bill due to debt concerns. The debt limit is actually hiked $5 trillion vs. $4 trillion earlier. Tillis opposes the deep Medicaid reductions. But the bill’s passage is by no means certain right now. A lot has to happen before final passage. The bill went through a wide-ranging debate over the weekend and a Vote-a-Rama (unlimited amendment offerings) started on Monday.

Four other conservatives – Ron Johnson, R-WI, Rick Scott, R-FL, Mike Lee, R-UT, and Cynthia Lummis, R-WY – only voted “yes” on the bill after commitments from leaders that a vote will be held on reducing Medicaid expansion matching rate for new enrollees (not existing ones) who are able-bodied. What if the amendment fails? Will one or more of the conservatives jump off the bill? Johnson and Scott have not said they will vote for the final bill yet. Further, moderates Lisa Murkowski, R-AK, and Susan Collins, R-ME, are concerned about the Medicaid and Exchange reductions and one or both of them could still vote “no” on final passage. (Sen. Josh Hawley, R-MO, now seems OK with the latest draft.)

Moderates did win a $25 billion rural hospital fund (over five years) to offset some of the reductions in Medicaid. But they wanted $100 billion and Collins is expected to offer an amendment to make the fund at least $50 billion by taxing the super-rich. The bill does put the state and local tax deduction back in at a cap of $40,000 for five years. Some House moderates could still oppose the compromise. The House had no sunset. Modifications to the nutrition program were made to satisfy some moderates.

The provider tax limitations that were struck by the Senate parliamentarian because they did not meet the Byrd rule were re-written by the GOP. The provisions now have a one-year delay (from 2027 to 2028) before the phasedown of the provider tax from 6% to eventually 3.5% begins. The House had a more limited provider tax reform, which sought to put a moratorium on new or increased taxes. The stricter provider tax limitations worry both Senate and House moderates.

A big fight occurred on whether the bill is truly consistent with the Byrd rules under reconciliation as the GOP is using the “current policy” vs. “current law” to determine fiscal impacts. The Senate parliamentarian agreed with the GOP that the Senate Finance Chair decides the issue. This allows the GOP to extend the 2017 tax cuts under a “current policy” basis and still meet the Byrd rules to pass the bill with a simple majority. My view is this is a budget gimmick and fiscally irresponsible. A vote to stay with “current law” scoring failed on a party-line vote of 53-47.

Despite all this drama, I would expect that the bill will pass with either a 51-49 vote or 51-50 — Collins voting “no” in the end (she is up for re-election in a Democratic-leaning state), with the vice president casting a tie-breaking vote in favor. Then, it would return to the House, where things could still be tough.

In other news:

A new Congressional Budget Office (CBO) analysis estimated that the Senate’s legislation would lead to about 900,000 more than the House bill. So, the total potential uninsured count would increase now by about 17M when counting the expiration of enhanced Exchange subsidies and a regulatory change in the Exchanges.

A conservative amendment to be voted on would prevent new enrollees in Medicaid expansion states from receiving the 90% Federal Medical Assistance Percentage (FMAP) if they are nondisabled and don’t have dependent children. The reduction would occur in 2031. It would further reduce Medicaid spending by about $300 billion over ten years. House Speaker Mike Johnson, R-LA, previously poured cold water on a similar proposal in the House.

Sen. Thom Tillis, R-NC, said Sunday that the Senate version of President Trump’s massive spending bill “will betray the very promise” the president made to not interfere with people’s Medicaid benefits. Trump attacked Tillis over his vote against moving forward with the bill. Tillis has announced since then he will not run for re-election.

The House hopes to vote on any Senate-passed bill Wednesday morning. But 16 Republican representatives wrote a letter to Senate Majority Leader John Thune, R-SD, and Speaker Johnson saying they “cannot support” a final reconciliation bill that includes the provider tax limits, changes to state directed payments, and other changes affecting hospital funding. At least six have said they will vote “no” when the bill returns to the House. Johnson has pleaded with the Senate to keep the bill as close to the House version as possible, but to no avail. Conservatives and moderates in the House are busy attacking the Senate version for different reasons – due to greater Medicaid cuts and for more spending.

Additional articles: https://thehill.com/homenews/senate/5376782-susan-collins-amendment-tax-rate-rural-hospitals/?tbref=hp and https://thehill.com/homenews/house/5376299-house-could-vote-on-big-beautiful-bill-by-wednesday-morning-emmer-announces/?tbref=hp and https://thehill.com/homenews/senate/5376251-tillis-criticizes-trump-medicaid-bill/ and https://thehill.com/business/budget/5377378-gop-senators-vote-trump-tax-priorities/?tbref=hp and https://thehill.com/homenews/senate/5376222-scott-pushes-medicaid-reduction/?tbref=hp and https://www.fiercehealthcare.com/providers/provider-tax-changes-some-medicaid-funding-restrictions-ineligible-reconciliation and https://thehill.com/homenews/house/5377946-house-gop-senate-megabill/ and https://thehill.com/homenews/administration/trump-the-next-100-days/5376452-live-updates-trump-senate-big-beautiful-bill/ and https://www.modernhealthcare.com/politics-regulation/mh-trump-republicans-tax-bill-medicaid/

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#budgetreconciliation #trump #congress #spending #medicaid #exchanges #coverage #providers #ruralhealthcare  

https://thehill.com/homenews/senate/5377427-trump-megabill-gop-holdouts

Victory For Preventive Services

As expected, the Supreme Court ruled 6-3 in favor of allowing preventive services to continue under the Affordable Care Act (ACA). The majority was a mix of conservatives and liberals. The high court determined that members of the U.S. Preventive Services Task Force, which makes recommendations for coverage requirements under the ACA, are selected within the bounds of the Constitution. The court agreed that the task force is appointed by an executive appointee and could be replaced. The religious arguments on the provision of certain services were largely sidelined.

Additional articles: https://www.fiercehealthcare.com/regulatory/scotus-upholds-aca-preventive-services-task-force-6-3-ruling and https://www.healthcaredive.com/news/supreme-court-aca-preventive-care-mandate-decision-braidwood-kennedy/751806/ and https://www.medpagetoday.com/primarycare/preventivecare/116288 and https://www.modernhealthcare.com/politics-regulation/mh-aca-preventive-care-ruling-reactions/ and https://thehill.com/homenews/ap/ap-business/ap-supreme-court-preserves-key-part-of-obamacare-coverage-requirements/?amp_gsa=1&amp_js_v=a9&usqp=mq331AQIUAKwASCAAgM%253D&tbref=hp

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#prevention #preventiveservices #aca #obamacare

https://www.modernhealthcare.com/politics-regulation/mh-supreme-court-aca-preventive-coverage

Budget Reconciliation Saga Continues With Parliamentarian Ruling

President Donald Trump took to the so-called campaign trail today to advocate for passage of the tax-cutting Big Beautiful Bill and said he wants the legislation on his desk by July 4. But the “Byrd Bath” process and the Senate parliamentarian threw a monkey wrench into the works today. The parliamentarian, who interprets Senate rules (especially as they relate to the reconciliation process), agreed with Democrats that several provisions on healthcare are not allowable under the Byrd budget reconciliation process rules. In general, provisions in a budget reconciliation bill must be very germane to the process to allow the bill to pass in the Senate with a simple majority and not with a supermajoriy vote of 60.

Majority Leader John Thune, R-SD, said he will not seek to overrule the parliamentarian on a majority vote for fear of setting a huge precedent for what is allowed in budget reconciliation processes in the future. The GOP may rewrite some provisions to see if they can be approved, but the ruling potentially creates huge problems for leaders in both chambers.

While moderates in the House and Senate will like that certain Medicaid and Exchange cuts may not make it, conservatives are insistent that sufficient reductions are in the bill to offset tax cuts and some spending increases. As well, they desperately want to rein in the size, scope, and spending in Medicaid. The struck reductions could mean a loss of spending reductions of several hundred billion dollars over a decade.

The provisions ruled not allowable under the Byrd rule include:

• Capping and limiting provider taxes
• Restricting Medicaid drug spread pricing
• Barring government health insurance participation and funding for those without verified immigration status (all government programs)
• Reductions in federal matching dollars to states that have expanded Medicaid and use funds to offer Medicaid coverage to immigrants without legal status

In other news, Rep. Ryan Zinke, R-MT, said he is a no vote on the Senate version due to a mandate to sell off up to 1.2 million acres of public lands.

Additional news: https://thehill.com/homenews/administration/trump-the-next-100-days/5369987-live-updates-trump-hegseth-iran-supreme-court-senate/ and https://thehill.com/homenews/house/5371828-zinke-senate-gop-bill-public-land/?tbref=hp and https://www.fiercehealthcare.com/providers/provider-tax-changes-some-medicaid-funding-restrictions-ineligible-reconciliation and https://www.beckershospitalreview.com/finance/medicaid-changes-dont-meet-senate-rules-parliamentarian/ and https://thehill.com/homenews/senate/5371008-thune-senate-parliamentarian-medicaid/?tbref=hp and https://thehill.com/homenews/senate/5370671-medicaid-trump-bill-senate-parliamentarian/ and https://thehill.com/homenews/senate/5371057-tuberville-senate-parliamentarian-medicaid/ and https://thehill.com/homenews/5371186-hardline-house-conservatives-senate-parliamentarian-ruling/

#budgetreconciliation #trump #congress #medicaid #aca #obamacare #exchanges #providers #coverage

https://thehill.com/policy/healthcare/5372232-senate-republicans-medicaid-ruling-challenge

Senate And House Jockey On Budget Bill

Senate moderates and pragmatic conservatives are working on a rural hospital relief fund to offset the impact of numerous Medicaid and Exchange cuts in the budget reconciliation bill. Their chief complaint is that the $15 billion budget crafters are willing to put up is clearly inadequate. They believe a fund closer to $100 billion is needed to ensure the hospitals’ solvency. At least three senators are very vocal here, with others certainly sympathetic.

One pragmatic conservative up for re-election, Thom Tillis, R-NC, believes that the healthcare cuts being considered in budget reconciliation will mean the GOP losing control of Congress. His seat is especially vulnerable as a popular moderate Democratic former governor, Roy Cooper, could challenge Tillis in 2026.

Another major sticking point in discussions between the House and Senate is the status of the state and local taxes (SALT) deductions. Primarily to satisfy two dozen or so House moderates from Blue states, the House included a boost in the SALT allowance on federal income tax to $40,000 from $10,000. The Senate stripped the increase entirely. Negotiations continue.

As well, sixteen House members penned a letter to their party’s leadership warning that they cannot support the current Senate draft with the additional Medicaid cuts, including additional provider tax limits.

Additional articles: https://thehill.com/homenews/house/5370059-salt-negotiations-republicans-bessent/ and https://thehill.com/homenews/senate/5369675-senate-republicans-rural-hospital-relief-fund-medicaid/ and https://thehill.com/homenews/senate/5367877-tillis-republicans-mediticaid-cuts/

#budgetreconciliation #trump #congress #spending #coverage #medicaid #ruralhospitals

https://www.fiercehealthcare.com/providers/16-house-republicans-tell-leaders-senates-medicaid-changes-go-too-far-threaten-pulling

Senate Budget Bill Could Be in Trouble

Both sides of the House caucus declared that they could oppose the current Senate version of the budget reconciliation bill if it passes the upper chamber and returns to the House. Senate Majority Leader John Thune, R-SD, has an uprising in his own chamber between moderates and conservatives, but both sides of the House have already declared their concerns.

More than a dozen House Republicans warned they won’t support the Senate’s version because the proposed Medicaid cuts are too steep. The Senate added more reductions in the area of provider taxes, state directed payments, and work requirements. This moderate opposition does not even fully take into account those who oppose the bill if the state and local tax deduction does not come back over with a generous increase. Right now, the Senate has no changes from the low $10,000 limit.

On the conservative side, House Freedom Caucus Chairman Andy Harris, R-MD, said he would oppose the Senate version because it waters down critical savings in the House version, does not do enough on deficit reduction, has insufficient Medicaid reductions, and eliminates major provisions of the Green New Deal. Harris voted present when the bill passed the House but would now vote no. This could lead other conservatives to bail on the bill. Speaker Mike Johnson, R-LA, had no votes to spare the last time.

The House conservatives also want the Health Savings Account (HSA) expansion and related individual premium (ICHRA) provision put back in the bill. They were stripped by the Senate. The House conservatives favor a strengthening of indvidual health insurance options.

In other news, the Congressional Budget Office (CBO) said states would be forced to reduce provider reimbursements to cope with the Medicaid cuts. This is similar to a private study released recently.

Another study from The Third Way think tank finds that the healthcare cuts could push medical debt up by $50 billion. The number of people in families facing medical debt could increase by 5.4 million, with debts increasing by up to $22,800.

As well, a bipartisan group of lawmakers is introducing legislation that would allow the Department of Veterans Affairs to bill Medicare Advantage (MA) plans for care provided to members. They say the current law pays twice for care furnished veterans. MA plans netted $1 billion by pocketing rates without paying back the government agency. The agency can bill Medicare Supplement plans but not MA plans right now.

Additional articles: https://thehill.com/policy/healthcare/5367133-house-gop-moderates-senate-tax-bill-medicaid-cuts/ and https://www.modernhealthcare.com/politics-regulation/mh-medicaid-cuts-tax-bill-provider-pay-cbo/ and https://www.beckerspayer.com/policy-updates/lawmakers-target-medicare-advantage-va-loophole-wsj/ and https://www.cnbc.com/2025/06/23/big-beautiful-bill-health-care-cuts-may-add-to-medical-debts-report.html

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#budgetreconciliation #trump #congress #medicaid #exchanges #medicareadvantage #medicaldebt #coverage

https://thehill.com/homenews/house/5366809-harris-freedom-caucus-senate-trump-bill/?tbref=hp

Plans Announce PA Initiatives To Forestall Regulatory Action

After commitments by Trump administration officials to reform prior authorization (PA), about fifty health plans, including some of the biggest, met with Health and Human Services (HHS) Secretary Robert F. Kennedy, Jr. and Centers for Medicare and Medicaid Services (CMS) Administrator Dr. Mehmet Oz to unveil their plans to streamline PA and tackle claims denials. The health plans represent as many as 75% of America’s insured. The Blue Cross and Blue Shield Association and trade group AHIP also attended the meeting.

Health plans will commit to reduce the number of codes that are subject to PA and to establish a standard framework to increase how many authorizations are adjudicated electronically and in real time. PA changes will occur by 1/1/2026, with electronic PA reforms in one year later. The plans also will increase education on PA and appeals, accountability, and transparency around denials of PAs and claims. Plans will also honor PAs for 90 days when a consumer changes plans.

The federal government will not take regulatory action pending how insurers perform under the new system but will do so if officials are not satisfied. Dr. Oz also noted that this is just a first step, indicating that regulatory changes could be coming down the road anyway.

A healthcare policy group KFF study looked at MA claims denials, appeals and their outcomes from the 2023 contract year. About 6.4% of all claims submitted for prior authorization were denied in full or part. About 12% of those denials were appealed, and 82% of denials were overturned.

Additional articles: https://www.fiercehealthcare.com/regulatory/oz-insurers-prior-auth-pledge-opportunity-industry-show-itself and https://www.modernhealthcare.com/insurance/mh-medicare-advantage-prior-authorization-denial-rates-kff/ and https://www.ahip.org/health-plans-are-making-voluntary-commitments-to-support-patients-and-providers and https://thehill.com/policy/healthcare/5364803-hhs-cms-kennedy-oz-preauthorization/?tbref=hp and https://www.beckerspayer.com/payer/payers-to-reduce-prior-authorizations/ and https://www.cms.gov/newsroom/press-releases/hhs-secretary-kennedy-cms-administrator-oz-secure-industry-pledge-fix-broken-prior-authorization

(Some articles may require a subscription.)

#healthplans #priorauthorization #claimsdenials #oz #rfkjr

https://www.fiercehealthcare.com/payers/insurers-pledge-smooth-out-prior-authorization-process

Budget Reconciliation In Senate Still In Limbo

After going to bat for deeper healthcare cuts for conservatives, Senate Majority Leader John Thune, R-SD, is facing an uprising on the right and left. Three conservatives – Mike Lee, Rick Scott, and Ron Johnson, are threatening to be off the bill unless deeper cuts occur, including in healthcare. Rand Paul appears already against the bill due to a provision that increases the debt limit. This would sink the bill.

At the same time, at least three moderates or pragmatists – Lisa Murkowski, Josh Hawley, and Susan Collins – remain very concerned about the depth of certain cuts, especially provider tax restrictions.

Thune wants to vote on the bill next week.

Rural providers, particularly hospitals, continue to argue the bill jeopardizes their livelihoods and that hospitals in under-served areas could shutter.

An impasse over the state and local tax deduction threatens passage of the budget bill in the House even if it passes the upper chamber. The Senate put no increase in the bill, while House moderates have demanded a $40,000 cap, up from $10,000. They say that is what they can live with.

In other news, the Trump administration finalized an Exchange integrity bill that removes special enrollment periods, shortens the open enrollment period, and strengthens eligibility requirements. The change is expected to mean 900,000 people lose enrollment. The administration argues the rule lowers premiums, but insurance regulators are looking at huge rate hikes for consumers due to the likely expiration of the enhanced premium subsidies and cost increases.

As well, the Senate parliamentarian said today that certain portions of the House-passed bill did not meet Byrd rules in the Senate, which would mean the bill as is could not pass on a majority vote.  These provisions will most likely be cut as the GOP is not expected to overrule the parliamentarian on a majority vote. The struck provisions have little or no impact on the healthcare reductions, but the provision to have states take on some nutrition program costs has been tagged as violating Byrd rules.

Additional articles: https://thehill.com/homenews/senate/5360488-parliamentarian-rules-bill-trump-agenda/ and https://thehill.com/homenews/house/5360071-impasse-over-salt-cap-deepens-as-house-moderates-stand-firm/?tbref=hp and https://www.modernhealthcare.com/politics-regulation/mh-one-big-beautlfil-bill-rural-healthcare/ and https://www.cms.gov/newsroom/press-releases/cms-finalizes-major-rule-lower-individual-health-insurance-premiums-americans and https://www.cms.gov/newsroom/fact-sheets/2025-marketplace-integrity-and-affordability-final-rule

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#budgetreconciliation #congress #trump #spending #medicaid #exchanges #hospitals #coverage

https://thehill.com/homenews/senate/5360058-conservatives-demand-deeper-spending-cuts