Health Policy Report

August 23, 2021

Capitol Hill Update

The House will convene for a brief legislative session this week as lawmakers eye action on the Senate-passed budget resolution for fiscal year (FY) 2022. Members will vote today on a rule that will set up debate on the budget resolution, voting rights legislation, and the bipartisan infrastructure deal. While the budget resolution and John Lewis Voting Rights Act (H.R. 4) are both slated for final up-or-down votes tomorrow, the bipartisan infrastructure deal is not expected to be taken up until later in the fall after a budget reconciliation package has been clinched. Nearly a dozen moderate Democrats are continuing to press for a vote on the infrastructure package as soon as possible, however, with some threatening to vote against the budget resolution absent a vote on Biden-endorsed legislation. Meanwhile, Speaker Pelosi doubled down her position in a “Dear Colleague” letter last week that emphasized the importance of triggering the reconciliation process, while taking a swipe at the Senate’s infrastructure bill for “not [being] reflective of the totality of Democrats’ vision.”

CMS to Revisit Medicaid Beneficiary Eligibility Post Pandemic

The Centers for Medicare and Medicaid Services (CMS) sent a letter to state health officials outlining Medicaid redetermination after the pandemic ends. The guidance comes after CMS Administrator Chiquita Brooks-LaSure said that the agency is focused on ensuring that beneficiaries do not lose coverage gained during the public health emergency (PHE). The Trump administration initially laid out a plan that gave states six months after the PHE to remove ineligible beneficiaries following the pandemic, allowing ten days for beneficiaries to respond to determination forms. The new guidance alters these regulations, providing states with a year to resume eligibility analyses and offering at least 30 days to respond to redetermination forms. Additionally, the Biden administration is requiring that states cannot remove beneficiaries from Medicaid until they have completed a new redetermination at the end of the PHE. The administration maintained Trump-era guidance giving states four months to begin processing applications.

States must keep Medicaid beneficiaries enrolled through the PHE to receive federal funding. However, some experts estimate that up to 30 percent of beneficiaries could lose coverage during the redetermination process. States worry that the redetermination process cannot be completed during the PHE, leading to unfair determinations to remove beneficiaries from their Medicaid plans and a buildup of redeterminations that could last for years. To comply with changes to the Trump-era guidance, CMS is encouraging states to review their risk-based approaches to guide their redetermination work. Health care advocates generally see the Biden administration’s tweaks to the guidance as a step in the right direction, though concerns remain. Some stakeholders are hoping that higher rates of electronic data utilization can ease the burden of the redetermination process, and others are calling for more detailed public reporting of redetermination statistics.

CDC Gears Up for Booster Shots Amidst New Data

After reviewing new data from the Centers for Disease Control (CDC), top Biden administration officials determined last week that Americans will need COVID booster shots. CDC officials presented data to White House Covid-19 task force officials last Sunday that had been compiled over the last several months. The data confirmed growing speculation that initial vaccination protections wane over time. The administration had been preparing for this possibility as the booster debate occupied health officials and the media since Pfizer submitted an application for its booster shot to the Food and Drug Administration (FDA) earlier this month. The FDA approved both Pfizer and Moderna’s two-shot vaccines for immunocompromised individuals two weeks ago.

The Biden administration is expected to roll out a formal booster strategy shortly. The plan will rely on about 100 million doses of Pfizer and Moderna shots that are currently available, as well as a new contract for 400 million doses to be administered as needed. FDA still needs to authorize the booster shots, and CDC must formally recommend that people obtain a booster eight months after their first vaccine series. The CDC’s vaccine advisory committee has its next booster meeting the week of August 30th. Federal officials are still waiting on a Johnson & Johnson booster study to make a determination regarding the necessity of a second shot of the drug maker’s vaccine.

Despite the administration’s determination, The World Health Organization (WHO) has been urging developed nations to hold off on booster shots until developing nations have access to sufficient supply to provide initial vaccinations. Infectious disease experts worry that prioritizing boosters over providing initial doses for other nations will make the world vulnerable to new variants. However, if drug companies apply for booster shot approval and the FDA deems the treatment effective, it will be incredibly difficult to stop Americans from seeking the additional dose.

In 2020, Overdoses Decrease in Part D

The Department of Health and Human Services (HHS) Office of the Inspector General (OIG) released its Opioid Overdoses in Part D Beneficiaries Decreased In 2020report. This report offers a different analysis from the CDC’s Provisional Drug Overdose Death Counts for 2020 report in July, whichindicated a spike in overdose deaths. According to the new HHS report, over 43,000 Medicare Part D beneficiaries overdosed in 2020 despite a decrease in opioid prescriptions. An average of 4,000 Part D beneficiaries were treated for overdoses per month in 2020, with a peak in June and July. Twenty-four percent of beneficiaries received at least one prescription for an opioid, down from 26 percent in 2019 and 29 percent in 2018. OIG said that the decline is likely due to a steep decrease in short-term opioid prescriptions since most elective surgeries were postponed during the pandemic. As a result, Part D paid out $2.7 billion for opioid prescriptions, less than in previous years.

Rates of medication-assisted treatment (MAT) utilization increased by eight percent in 2020. While this data continues to show that MAT utilization amongst Part D beneficiaries continues to grow, the rate of growth for 2020 is slower than previous years. OIG attributed the slower increase of MAT utilization to the pandemic. Regardless, over 225,000 beneficiaries used MAT during the year according to the report, bringing the overall utilization rate to about 13 percent. The report noted that utilization rates are lower than desired, and OIG was also concerned with a decrease in naloxone usage to treat overdoses amongst the Part D population.

While overdoses decreased as a whole for the Part D population, the data was not entirely positive. OIG encouraged CMS to continue educating beneficiaries about MAT and naloxone and to closely monitor utilization rates. The agency also recommended that prescribers offer beneficiaries ample opportunity to reevaluate their utilization of high-dose opioids and actively look into decreasing dosage. OIG found that beneficiaries at risk for overdose and misuse were likely receiving very high dosages or were “doctor-shopping” to obtain higher doses. In response to that finding, OIG also encouraged prescribers to utilize state databases to check a patient’s opioid history.

CMS Ushers in New Vaccination Requirements in Nursing Homes

On Wednesday, CMS and CDC issued an emergency regulation requiring the nation’s 15,000 nursing homes to require staff vaccinations. The “no-jab, no-job” order poses new challenges for nursing homes. Most notably, non-compliance with the rule would result in halting Medicare and Medicaid reimbursements. Nationally, about 62 percent of nursing home staff are vaccinated (compared to 83 percent of residents), with state vaccination rates amongst nursing home workers ranging from 44 to 88 percent. In June, cases of the Delta variant were at a low of 319, though cases have since spiked to 2,696 reported cases at the beginning of August. Over 2,000 nursing home staff members and 130,000 residents have died of COVID.

Throughout the pandemic, high infection and death rates in nursing homes have been partially attributed to staff shortages, among other factors. Proponents of the guidance argue that requiring staff vaccinations will encourage some who left the industry due to safety concerns to return to work.