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In the first episode of 2023, Kathleen Haddad and Chris Fleming discuss, the $1.7 trillion omnibus bill, the coming end of Medicaid eligibility for millions, a new COVID variant, and more. With no shortage of news in the health care space, we're excited for a new year of Health Affairs This Week.
Health Affairs This Week places listeners at the center of health policy’s proverbial water cooler. Join editors from Health Affairs, the leading journal of health policy research, and special guests as they discuss this week’s most pressing health policy news. All in 15 minutes or less.
00;00;08;27 - 00;00;19;24
Kathleen Haddad
Hello and welcome to another episode of “Health Affairs This Week”, the podcast where Health Affairs editors go beyond the headlines to explore the health policy news of the week. I'm Kathleen Haddad.
00;00;20;17 - 00;00;21;20
Chris Fleming
And I'm Chris Fleming.
00;00;21;29 - 00;00;49;00
Kathleen Haddad
So, Chris, last episode, we recapped the major developments of last year. But one last piece of health policy news broke after our last show. The 1.7 trillion omnibus spending bill that was enacted right before Christmas. It not only kept government open but contained important health policy advancements. Before we get rolling on that discussion, though, there were two news items of the past week that received scant attention.
00;00;49;16 - 00;01;07;16
Kathleen Haddad
First, the FDA announced that misoprostol could be sold in pharmacies. That's the abortion pill, and it can be prescribed via telemedicine appointments. Previously, the drug could only be given at a doctor's office, which was an inconvenience and that made it inaccessible for many women.
00;01;08;01 - 00;01;11;01
Chris Fleming
And Kathleen, what's what's the second news item that you mentioned?
00;01;11;21 - 00;01;38;14
Kathleen Haddad
Chris, there's a new COVID variant amongst us. Yeah, it's called XBB.1.5. Dr. Zeke Emanuel, a former White House COVID policy adviser, says this this new variant comprises about 40% of current infections, which seem to be rising or are expected to rise after the effects of the holidays show in the data.
00;01;39;05 - 00;01;47;26
Chris Fleming
Oh, well, it seems kind of redundant to say this with any sentence that it contains the word new variant and COVID, but that really doesn't sound like good news, Kathleen.
00;01;48;14 - 00;02;08;25
Kathleen Haddad
Well, medical experts say it's the most infectious variant yet. And that will be interesting just to see how it plays out and how much strain it puts on the hospital system. But Chris, let's move on to the huge government funding law enacted just before Christmas. It's hard to know where to start in dissecting this massive law, but what can you tell us?
00;02;09;19 - 00;02;36;23
Chris Fleming
Well, Kathleen, as you know, and you referred to earlier, we've developed this habit of ending our congressional sessions with these very large, catch-all bills at the end of the session. And, you know, I'd say that this is a crazy way to run a railroad if I wasn't watching the as we record today on January 5th, the House trying to choose a speaker and going through multiple ballots for the first time in a century.
00;02;37;15 - 00;03;19;16
Chris Fleming
But anyway, these these omnibus bills, as they're referred to, they're always chock full of pretty much everything and then certainly chock full of important health policy provisions. And this year was no exception. One example, physicians were facing a reduction in Medicare payment of, I think, 8.5% for 2023. And needless to say, they weren't particularly happy about that. The omnibus eliminated a big chunk of that impending cut -- that made physicians happier --but it still left a 2% cut for this year, for this year, for 2023, plus another 3.5% cut scheduled for next year for 2024.
00;03;19;16 - 00;03;28;24
Chris Fleming
And that, needless to say, made physicians less happy. But the nature of these huge bills is that, you know, you tend to get half a loaf, you know, rather than the whole loaf.
00;03;29;17 - 00;03;32;27
Kathleen Haddad
So, Chris, what about the value based payment?
00;03;33;06 - 00;03;54;02
Chris Fleming
Right. So Congress, there was a value-based care bonus for physicians who participate in alternative payment arrangement. That would not...before the omnibus that would not have been available next year. Congress did make it available, but they reduced it. Used to be 5%. They cut it down to 3.5%.
00;03;55;04 - 00;03;57;16
Kathleen Haddad
So what's in the law on the hospital side, Chris?
00;03;58;09 - 00;04;28;14
Chris Fleming
Ah, well, the omnibus. One of the things the omnibus did is it extended through 2025 two programs that help out rural hospitals that were scheduled to expire this year. The programs are the low-volume hospital program, which helps hospitals with a small number of Medicare patients. And on the other end, the Medicare Dependent Hospital program. And that's a program that helps hospitals where the Medicare share of total patients is high.
00;04;29;13 - 00;05;10;10
Chris Fleming
Would also, the omnibus also does extend for two years some telehealth flexibilities that were introduced during the pandemic through CMS waivers. These relax the site restrictions the the restrictions on the geographic sites that telehealth can be used for. And also it provide some flexibility regarding the use of audio only telehealth. We tend to think of video and high tech when we talk about telehealth, but turned out, maybe surprisingly to some, that audio-only because some people just don't have access to broadband.
00;05;10;10 - 00;05;38;02
Chris Fleming
And for other reasons, audio-only became very important during the pandemic. Many had hoped that that that these would be these would be extended permanently. But, you know, obviously, two years, in the view of many is better than nothing. And back to the half a loaf theme from earlier now. And I also should add very quickly that the omnibus also extended something called the Hospital Home program, and that's something that was important during the pandemic.
00;05;38;02 - 00;05;47;06
Chris Fleming
It allows hospitals to treat more acute care patients at home through mechanisms like remote patient monitoring, telehealth and in-person care.
00;05;47;16 - 00;06;01;01
Kathleen Haddad
Right. And I think what the Health Affairs journal, we've published a number of articles on that topic. Let's go move forward to the Medicaid related provisions. What do you know about that?
00;06;01;09 - 00;06;31;08
Chris Fleming
Yeah, there's there was some really important stuff that, you know, raising will raise some challenges, but there's some the omnibus attempted to to meet that challenge by including some some safeguards as well. Let's back up a little bit in the Families First back, I think in 2020, early in the COVID pandemic, in the Families First Act, Congress gave states this bump in Medicaid funding, I think 6.2 percentage points.
00;06;31;08 - 00;07;00;08
Chris Fleming
But to get that money, states had to to to do follow what are called, “maintenance of effort” requirements, which meant that they had to suspend Medicaid eligibility redeterminations during the public health emergency. And that was declared by the federal government in connection with COVID. So once someone was on Medicaid, you couldn't go through and do the sort of the normal process that states do of checking whether they were still eligible.
00;07;00;18 - 00;07;22;06
Chris Fleming
So this is a big deal because, you know, during the pandemic, the that was a big deal because that Medicaid program grew. It grew like 30%. And the program had, you know, really it was a really huge kind of pillar for folks trying to weather the pandemic who might have lost their jobs and would have lost health insurance.
00;07;22;28 - 00;07;44;14
Chris Fleming
So the emergency that this was tied to, the public health emergency, is still in effect. But the omnibus actually ended this maintenance of effort requirement, and that ends as of April of this year, April 2023. And that means that states at that point will be able to return to normal eligibility redeterminations.
00;07;44;21 - 00;07;50;22
Kathleen Haddad
Chris, what are the protections against immediate disenrollment for Medicaid enrollees?
00;07;51;10 - 00;08;13;29
Chris Fleming
Right, and that's that's an important question, because the worry is, you know, that it won't just be people who are actually, who've who've become ineligible that would lose their eligibility would be pushed off the rolls. It might be people who were still eligible, but they're you know, communications issues, getting in touch with many Medicaid beneficiaries, there are bureaucratic errors.
00;08;14;09 - 00;08;50;16
Chris Fleming
So, you know, the omnibus tries to deal with that. It has this instead of just eliminating that 6.2 percentage point bump in Medicaid payment entirely, it has a transitional phase where the payment is still there for the rest of 2023, but goes away in stages. And to get that money, states do have to agree to some safeguards. So, for instance, if they try to mail...reach a Medicaid enrollee by mail and don't get a response, they just can't kick him off the roll-- him or her-- off the rolls.
00;08;50;29 - 00;09;15;12
Chris Fleming
They need to try to reach the person at least one other way. Joan Alker on the “Say Ahhh!” blog and many of her colleagues at Georgetown, they do a great job of covering these safeguards and the omnibus in general. They note also, for instance, importantly, that, you know, there are some some pro-coverage elements involved as well. So states will end up covering children continuously
00;09;15;12 - 00;09;35;09
Chris Fleming
now for 12 months in Medicaid and CHIP as a result of the omnibus, regardless of changed circumstances. And the omnibus also extends the overall CHIP funding with some important policies, such as express lane eligibility for two years. And I think now through the end of fiscal year 2029.
00;09;35;09 - 00;10;10;21
Kathleen Haddad
I think HHS estimates that 15 million people could could lose Medicaid coverage and that maybe half of them or almost half are are eligible, even though they might get notices or be dropped. So these protections are important. I wanted also to note that Medicaid can now extend post-natal coverage from two months to 12 months. That's a permanent provision. Now, I think currently 27 states do that.
00;10;11;07 - 00;10;40;19
Kathleen Haddad
And so that is something that's important for post-natal health and mental health. I wanted also to mention, Chris, that the omnibus provides a lot of funding for mental health programs and changes in Medicare mental health coverage. Previously, Medicare didn't pay for counseling provided by marriage and family therapists or licensed mental health counselors. Now, Medicare will pay for that under the law.
00;10;41;02 - 00;11;19;28
Kathleen Haddad
And to address the mental health workforce shortage, the law funds 200 new residency slots with half reserved for training psychiatrists. The 988 emergency mental health line colloquially only known as the Suicide Hotline, received $400 million in increased funding to address the opioid crisis. The law now allows doctors to prescribe buprenorphine without a special waiver from the DEA. The drug used to treat its use to treat opioid use disorders, and advocates say it is simply not being used widely enough.
00;11;19;28 - 00;11;26;13
Kathleen Haddad
So this provision is aimed at increasing the use of appropriate use of buprenorphine.
00;11;26;26 - 00;11;46;25
Chris Fleming
And now let's bring it back to the public health arena where we started this this session. One of the things about the omnibus that's interesting from a health policy point of view is it requires, I believe, Senate confirmation of the CDC director, right? That that sounds like it'll be a non-contentious confirmation hearing.
00;11;47;26 - 00;12;17;16
Kathleen Haddad
Right, Chris. So currently the CDC director appointment does not require Senate confirmation as do other agency heads. But beginning in January of 2025, confirmation will be required. And the interesting part of this is that it was a bipartisan bill or effort that put this provision in sponsored by Patty Murray and Richard Burr. I it's going to be interesting to see how it plays out.
00;12;18;00 - 00;12;33;10
Kathleen Haddad
Their purpose, legislative intent, there was to cope with another pandemic more easily than we did this one. But like you say, it'll be interesting to see if that's that's really the case.
00;12;33;10 - 00;12;45;08
Chris Fleming
Well, I think, you know, there's much more to be said about the omnibus and the other news that you started us out with. But I think we're we're pretty much running out of time today, so I think we may have to end it there.
00;12;46;00 - 00;13;22;01
Kathleen Haddad
As you say, Chris, the omnibus is chock full of health policy provisions, including many we haven't been able to get to. I also want to remind listeners that next week, on January 11th, we'll be restarting our “Health Affairs Pathways” podcast series, which is our fellowship program. Next week we begin with Michael Shen who is a physician. He talks about how Medicare payment and Medicaid payment to hospitals doesn't fund everything they need funded in order to do their jobs.
00;13;22;14 - 00;13;44;15
Kathleen Haddad
The podcast is terrific. I suggest you listen if you want to understand anything about payment to hospitals in our disjointed health care system. This is where to learn it. But thanks for your knowledge, Chris, and Happy New Year and thanks to our listeners. Be sure to subscribe to “Health Affairs This Week” wherever you get your podcasts.
00;13;45;02 - 00;13;55;27
Chris Fleming
Thanks, Kathleen. It was it was fun, as always.