By Abe Sutton
With the 2020 election in the rearview mirror, the Senate has turned its attention to vetting President-elect Biden’s cabinet nominees. As Senators on the Finance and HELP committees prepare their questions for California AG Xavier Becerra, the nominee for Health and Human Services (HHS) Secretary, they should consider probing in three areas to understand his health policy priorities.
In this post, I suggest Senators consider asking the nominee about his plans for the future of the Center for Medicare and Medicaid Innovation (CMMI), as well as how he aims to encourage healthcare competition and foster innovation.
His answers may be illuminative about his potential tenure as secretary, and should factor into Senators’ decisions on whether to vote for confirmation amid questions regarding his qualifications. Senators may also wish to weigh the nominee’s moral and human services priorities, topics not discussed in this post.
The Center for Medicare and Medicaid Innovation (CMMI) is a powerful tool to reform Medicare. It not only allows HHS to test innovations to see if they either improve quality or reduce costs, but it also allows HHS to implement changes throughout the Medicare program if proven effective through a pilot. As such, understanding the HHS Secretary nominee’s views on existing models matters, as does understanding which new areas he intends to prioritize for model development.
The nominee should be asked:
- Do you commit to continue prioritizing models that “on the basis of improvement potential in a hypothetical full rollout across the nation” either: “reduce avoidable events by at least 10 percent and/or mortality by at least 2 percent;” “reduce expenditures by $10 billion annually once expanded nationally;” or “empower beneficiaries by increasing choice and access?” These criteria were laid out in a fact sheet for physician-focused models in 2018 and were designed to ensure models tee up large changes in the Medicare program. If not, what criteria will you look at to determine which models to prioritize?
- What, if any, existing or announced models do you intend to cancel? Are you willing to commit to implementing all announced models? Does this include the Geographic Direct Contracting model on which initial letters of intent were submitted in December?
- How do you intend to handle the Most Favored Nation model, which has run into legal issues? Will you commit to reissuing the IFR as an NPRM and seeing the rulemaking process through to address the disparity between what Americans pay for drugs and the prices paid in other OECD countries?
- What actions will you take to build on the progress initiated by the Advancing American Kidney Health effort? Have you considered expediting the date the new evaluation metrics first apply to Organ Procurement Organizations to 2024?
- What are your new model priorities? Are there specific disease areas you are interested in building models around? What Medicaid models do you intend to build out, given that Medicaid has been a relatively underdeveloped area for CMMI to date?
- Are there any existing models which even if certified by the actuary as meeting the criteria to be implemented throughout the Medicare program you would decline to implement?
Consolidation, choice and competition
As California Attorney General, Xavier Becerra confronted healthcare consolidation to protect consumers. Simultaneously, at the national level, HHS, Treasury, and Labor issued a report in 2018 that walked through policy changes that could be made to increase choice and competition in healthcare.
Given the negative impact consolidation has had on healthcare prices, and the lack of competition in healthcare markets today, it is worth understanding how committed the HHS Secretary nominee is to promoting choice and competition, particularly as some of his prior actions aimed to reduce patient choice.
The nominee should be asked:
- When making policy changes, do you intend to consider their impact on consumers? Will you avoid changes that decrease consumer choices and reduce competition?
- Which recommendations from the 2018 HHS, Treasury, and Labor report will you prioritize for implementation? Are there any recommendations in the report with which you would not move forward? How do you intend to encourage states to promote choice and competition?
- Given your focus on consumers, do you regret your comment opposing the Health Reimbursement Arrangement proposed rule? The HRA rule is projected to increase individual market insurance coverage by over 10M people by 2024. Will you commit to keeping the regulation in place? What actions will you take to encourage HRA growth and empower patients to choose their own health plans?
- STLDI is an affordable healthcare option for those who would otherwise be unable to afford health coverage. Do you regret suing to try and take away this health insurance option from Americans? Do you commit to keeping the current regulations in place, or do you intend to take away peoples’ health insurance?
- Medicare beneficiaries have gained access to new benefits and faced more competition to serve them based on EO 13890. Do you commit to keeping the reforms implemented pursuant to the EO in place?
Decisions by the federal government shape the incentives that innovators face as they improve our health system. The COVID-19 pandemic brought this home when changes by the FDA enabled rapid vaccine testing and approval. Investors can choose to invest in the next social media app, or in a startup seeking to transform healthcare delivery. The federal government’s commitment to pay for value and spur healthcare innovation impacts what investments are made and how our health system develops.
The nominee should be asked:
- Should the WHO refocus on communicable diseases that spread across borders, rather than spend time on issues such as lactation or universal health coverage?
- Do you think the time is right to pursue a universal flu vaccine? If so, what will you do to make this happen?
- How should our country approach infectious diseases differently in light of COVID-19?
- What will you do to move the country onto a permanently faster vaccine development track?
- Should additional telehealth services reimbursable by Medicare on an emergency basis due to COVID be permanently reimbursable? Are there particular category 3 services you envision shifting to category 1 or category 2?
- How do you propose to address the “valley of death” in medical device development? Are you committed to the MCIT reimbursement framework? Will you commit to finalizing the proposal?
- Do you commit to granting future 1332 waivers similar to the one Georgia recently obtained? Will you keep in place the current 1332 guidance that maximizes state flexibility?
Some commenters have raised concerns about Xavier Becerra’s nomination due to his past positions, such as his support for “Medicare for All.” I believe Becerra’s confirmation vote should hinge on his familiarity with the issues outlined above and his willingness to commit to centrist positions.
While serving at HHS and the White House the author contributed to a number of health policy initiatives, including development of CMMI models, the kidney health effort, the HRA regulation, the STLDI regulation, the 1332 guidance, and other reforms referenced in this post.