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Healthcare was a driving issue for many voters in the 2018 mid-term elections.

The results of the 2018 election are in and we now know that the 116th Congress will be a divided Congress –  a Republican Senate and a Democratic House. Will the new Congress do anything to impact access to meaningful healthcare? Because of the division, it is unlikely that any big bills, such as a repeal of the ACA, will advance. However, there is some indication that Congress may take up protections for pre-existing conditions, surprise billing, opioids and/or drug pricing legislation. In addition, the House is responsible for government oversight, investigations and initiating the federal appropriations process. Pundits are saying the House is likely to use its oversight authority to investigate federal healthcare programs.
At the state level, Medicaid was also an issue in the midterm elections. Three states passed ballot initiatives to expand Medicaid and governors’ races in three other states have implications for expansion. Apart from one state, the results point to positive effects for access to healthcare for tens of thousands of uninsured across the U.S.
Here is what happened:
Idaho, Nebraska and Utah passed ballot initiatives to expand Medicaid. That means a total number of 36 states have now chosen to expand access to care for people up to the 138% of the federal poverty level. In addition, three governors who support expanding Medicaid were elected in Kansas, Maine and Wisconsin, providing a pathway for three more states to join the ranks of states expanding Medicaid. The one outlier of the election was the state of Montana. A ballot initiative to raise taxes on tobacco and dedicating a portion of that increased revenue for Medicaid expansion failed. Without legislative action in 2019, Medicaid expansion currently underway in Montana will sunset and the total of number states choosing to expand Medicaid will decline to 35.
What does this mean for the bleeding disorders community?
HFA has long been a supporter of expanding Medicaid to help ensure access to care for people living with bleeding disorders, particularly young adult males who had very limited access to Medicaid prior to the passage of the Affordable Care Act in 2010. There is substantial research indicating that Medicaid expansion under the ACA positively impacts access to care, affordability and utilization; health outcomes; and various economic measures.[1] In 2019, HFA will continue to champion expansion of Medicaid and work to protect and advance access to meaningful, affordable healthcare coverage and access to quality, comprehensive care.

Trump Administration seeks to curb drug prices by allowing Medicare to exclude some drugs from coverage.

On November 26^th, the US Department of Health and Human Services and the Centers for Medicare & Medicaid Services released a new rule proposal taking aim at drug prices. Under the proposed rule, private Medicare plans could drop coverage for some drugs in six currently-protected classes under Medicare Part D (including HIV treatments, antidepressants, immunosuppressants, cancer drugs, and more), beginning in 2020, if the prices of specific drugs rise more quickly than inflation. Medicare plans could also exclude coverage for new drugs that don’t represent a “significant innovation” over the original product. Medicare plans would further gain the ability to apply prior authorization and step therapy limits to drugs in the six protected classes.
The proposed rule would also codify a recently announced CMS policy that allows Medicare Advantage plans to implement step therapy for Part B drugs (a category that includes clotting factors and other hemophilia treatments). The step therapy requirements would not apply to Medicare enrollees already using a specific Part B medication.
The heads of HHS and CMS say the proposed rule changes will save money for Medicare enrollees and by giving Medicare plans new power to negotiate lower drug prices, and argue that the new limits won’t impact patients’ access to drugs. Other stakeholders, however, warn that any savings will come at a price, most likely in the form of limits on patient access to medications. HFA will continue to study this rule and plans on submitting comments (due in late January).
Quick hits:

• Open enrollment for 2019 health coverage ends soon for ACA health plans in most states (December 15) and for Medicare plans everywhere (December 7)! Don’t miss your opportunity to enroll in a health plan that will cover your needs in the coming year. For helpful tips about this year’s Open Enrollment, please see our Dear Addy posts here and here.
•  Last month we told you about new federal guidance that spells out how states can win approval to waive various ACA requirements. On November 29^th, CMS released a letter generally describing four waiver “concepts” that federal regulators might accept. One of CMS’s proposed concepts: states could allow insurance shoppers to use their tax credits to buy cheap, “skinny” health plans that don’t meet the ACA’s coverage requirements. But such a move would drive up costs for people who rely on robust insurance coverage – including people with bleeding disorders – by luring younger, healthier people out of the market for comprehensive coverage. HFA plans to submit comments opposing the CMS guidance. This is a developing story . . .
• HFA has written before about various states’ efforts to cut off Medicaid coverage for adults who don’t meet state work requirements. In November, Arkansas announced that more than 12,000 Arkansans, so far, have lost Medicaid coverage due to implementation of the state’s work requirements. Alarmed by Arkansas’s experience, the federal Medicaid and CHIP Payment and Access Commission (a nonpartisan federal agency) called on HHS and CMS to slow their approval of state work requirement waivers, and to pause disenrollments under the Arkansas waiver. (HFA joined 50 other patient organizations in a letter to HHS Secretary Azar, raising the same concerns.) CMS Director Seema Verma says that the Administration will nonetheless continue approving state waiver applications. In fact, on November 20^th, CMS re-approved Kentucky’s waiver application (earlier this year, a federal judge had overturned CMS’s initial approval of the application and had returned the matter to CMS for reconsideration).
• Earlier this month, HFA submitted comments to the National Institute of Health in response to a request for information soliciting input for future research into inhibitor prevention and eradication. HFA commended NIH for its attention to this important topic. HFA urged NIH, as it moves forward, to ensure that patients and their caregivers have a voice in setting priorities and determining questions for research; enunciating standards for treatment efficacy, safety, and tolerability; reporting and weighting outcomes; and more.

[1]“The Effects of Medicaid Expansion Under the ACA:  Updated Findings from a Literature Review,” March 2018 Issue Brief, Kaiser Family Foundation. Accessed November 19.