Searching for 50 Votes: Changes to Health Bill, CBO Score Coming This Week

Senate Republican leaders are expected to make a series of changes to the healthcare legislation released Thursday as they scramble to gain the support of at least 50 lawmakers in a showdown vote scheduled for later this week.

GOP leaders are expected to offer additional changes on Medicaid, continuous coverage and opioid addiction funding in an effort to entice senators, including five lawmakers who announced their outright opposition and several others who expressed reservations about the draft bill. The Congressional Budget Office also is expected to release its analysis as soon as today, including estimates on insurance coverage and premiums, and the draft bill’s impact on government spending.

Senate Majority Leader Mitch McConnell (R-Ky.) this week will try to strike just the right balance of legislative changes to woo moderates and conservatives who oppose the current draft, now called the Better Care Reconciliation Act. It’s a tightrope exercise, and it’s not clear whether McConnell can succeed. He can only afford to lose two votes from his 52-seat majority.

The Senate will take a procedural vote Wednesday to bring up the bill and then debate the legislation for up to 20 hours, split evenly between the two parties. After that, senators will begin a “vote-a-rama,” a series of rapid-fire votes on dozens of amendments in a marathon session that likely could stretch for hours.

GOP leaders will offer their changes to the House-approved bill as one package, called a “manager’s amendment.” Democrats are expected to offer a series of amendments designed to draw political blood from Republicans, on issues such as restoring insurance regulations and addressing prescription drug prices. Many amendments will never see a vote because the Senate parliamentarian is expected to rule them ineligible to be added to a budget reconciliation bill, which generally can include only provisions that directly impact government spending and taxes.

Will Republicans get the votes they need to pass the bill? That’s not currently clear. Some senators who have expressed opposition are expected to ultimately vote for the bill after their policy or state-specific issues are addressed in the manager’s amendment. But several key senators say their issues can be addressed only in ways that may undermine the coalition McConnell is trying to assemble.

Will the vote occur this week as McConnell has pledged? All signs point to a vote at the end of the week, even if Republicans don’t have the support to pass their revised bill. Some senators, including Sens. Ron Johnson (R-Wis.) and Susan Collins (R-Maine), have said a vote should be delayed until after the Fourth of July recess to allow lawmakers time to understand the bill and its implications – or for additional legislative tweaks and arm-twisting by GOP leaders. But some Republican leadership aides say delaying a vote until mid-July likely wouldn’t improve its prospects.

No Democrat is expected to support the bill. But some Republicans speculate that if Sen. Shelly Moore Capito (R-W.Va.) can be persuaded to vote for the bill with certain Medicaid changes and a dramatic boost to opioid addiction funding, Sen. Joe Manchin (D-W.Va.) might vote for it too. Manchin, who has given no public indication he would support the bill, is seeking re-election in 2018 in a state where President Donald Trump received 69 percent of the vote last November.

FDA User Fee Renewal Stalled Until July

With the focus in the Senate on securing votes for Republicans’ plans to replace the Affordable Care Act, action on renewing expiring Food and Drug Administration (FDA) user fees is likely to slip until after Congress’ Fourth of July recess.

House and Senate committees have approved a five-year renewal of user fees for pharmaceutical and medical device manufacturers, but neither chamber has voted on their bills. Congressional leaders are seeking to avoid a conference committee by harmonizing the legislation before it passes the House and Senate.

The bills that won approval in the Senate HELP and House Energy and Commerce committees do have some differences. But leaders have worked to keep both bills free from controversial language, and committee staff say the differences shouldn’t stand in the way of reaching an agreement.

The user fees expire Sept. 30. Without congressional action by Aug. 1, mandatory notices will be sent to FDA staff whose jobs are tied to user fee funding, warning of potential layoffs if Congress fails to renew the program. Lawmakers in both parties say they want to avoid triggering those notices.

Lawmakers Call on VA to Address Payment Backlog

A group of House Republicans is calling on the Department of Veterans Affairs (VA) to address the “alarming amount of late payments” for medical devices in the VA system.

Rep. Jim Banks (R-Ind.) is circulating a draft letter among his colleagues to VA Secretary David Shulkin. Banks, a member of the House Committee on Veterans’ Affairs, is planning to finalize the letter this week but so far has nearly four dozen lawmakers who have agreed to sign on.

Banks said some medical device manufacturers have outstanding VA invoices going back as far as 2013, with accounts receivable reaching into the millions of dollars. He said the VA is routinely more than 90 days late on more than one-third of payments for medical devices used in VA healthcare.

Overall, the VA owes as much as $15 million for replacement knees, replacement hips, spine implants, cardiac pacemakers and defibrillators provided through the VA Prosthetics Program, according to the letter.

Republican, Democrat Question Pharma, Insurers on Insulin Costs

The leaders of the Congressional Diabetes Caucus say they are “gravely concerned” about the rising cost of insulin, and they are calling on trade associations representing pharmaceutical manufacturers and insurers to meet with the caucus next month.

Reps. Tom Reed (R-N.Y.) and Diana DeGette (D-Colo.), the co-chairs of the caucus, said the average price of insulin tripled between 2002 and 2013, and many patients are facing high payments due to high deductibles, co-insurance and formulary exclusions.

They requested meetings on July 28 with the Pharmaceutical Research and Manufacturers of America, the Pharmaceutical Care Management Association and America’s Health Insurance Plans. The lawmakers said Congress may need to step in to stabilize insulin prices but first they want to hear from stakeholders.

Lawmakers Call for Relief from DME Competitive Bidding

More than 150 House lawmakers are calling on the U.S. Department of Health and Human Services (HHS) to provide relief from the Center for Medicare and Medicaid Services’ (CMS’) recently enacted competitively bid rates in rural areas for durable medical equipment.

In a letter to HHS Secretary Tom Price, the lawmakers said CMS’ action is coming at the expense of Medicare beneficiaries and shifting costs to institutional and clinical care.

Sent by a group led by House Republican Conference Chairwoman Cathy McMorris Rodgers (R-Wash.), the letter calls on Price to provide relief for non-competitive bid areas, which are primarily rural communities. The lawmakers also call for changes to the overall program before the next scheduled round of competitive bidding in 2019.

When he served in the House, Price was an outspoken opponent of DME competitive bidding.