Industry Voices—What to expect on pending healthcare legislation when Congress returns from recess

Washington DC National Capitol Building
Surprise billing, drug pricing and the Cadillac tax are expected to be top of the list of healthcare issues Congress will seek to address when members return from recess. (Getty/lucky-photographer)

When the House and Senate return from summer recess, surprise billing, drug pricing, and the so-called Cadillac tax are among the key healthcare issues that Congress wants to address.

And there's still work still to be done on each piece of legislation.

Here’s a rundown of what to look for:

Surprise Billing

How to address the amount that will be paid as part of a “surprise bill” remains controversial.

The issue is whether to benchmark the amount, have arbitration, or a hybrid process. Those opposed to benchmarking payment for out of network bills say that it is essentially price setting and raises concerns about access to care in rural areas. The other approach to payment disputes is independent dispute resolution (IDR). IDR allows for the negotiation of payments for each individual, between healthcare providers and insurance companies. This practice is also referred to as arbitration. 

RELATED: Hospitals, doctors raise alarm over surprise billing legislation advanced by Senate lawmakers

In the House, the Energy and Commerce Committee reached an agreement to amend the benchmark rate proposed in the No Surprises Act by adding an arbitration process to address certain payment disputes, creating a hybrid solution. The committee combined the No Surprises Act within a health extender package, H.R. 2328. The House Education and Labor Committee has jurisdiction over surprise billing as well and may mark up its own version. The Ways and Means Committee also has stated they may want to do their own bill as well.   

In the Senate, the Lower Health Care Costs Act reported out of the Committee on Health, Education, Labor and Pensions (HELP) included a provision to address surprise billing.  That provision used the benchmark approach.  The overall bill has bipartisan support but was blocked from being considered by the Senate prior to recess because of concern about the benchmark approach.   

Drug Pricing 

Passing legislation to lower drug prices has bipartisan support. How to do that is still subject to debate.  

In the Senate, the Finance Committee favorably reported the Prescription Drug Pricing Reduction Act (PDPRA) before recess. The bill caps Medicare beneficiary out-of-pocket costs for prescription drugs at $3,100 per year and requires drug manufacturers to rebate Medicare if prices are raised above inflation. The Congressional Budget Office estimates savings to the Medicare program of $85 billion during the next decade. On Aug. 13, Senate Finance Chair Chuck Grassley (R-IA) publically asked stakeholders to support the bill. At the committee’s mark up, it was clear that a number of members wanted to address additional issues in drug prices. Many amendments were ruled out of order because they were not in the committee’s jurisdiction. Most likely, this bill will have to be married with legislation coming from other committees. When the legislation comes to the Senate floor, many amendments can be expected.

In the House, the House Energy & Commerce Committee passed a drug-pricing transparency bill, renamed the More Efficient Tools to Realize Information for Consumers (METRIC) Act that requires drug manufacturers to give the Department of Health and Human Services (HHS) 30-days advance notice of price hikes with justification, among over drug pricing provisions. The companion bill in the Senate, the FAIR Drug Pricing Act, was included in the Senate HELP committee’s Lower Health Care Costs Act, yet senators are discussing possible changes before the package can go to the Senate floor.

House Speaker Nancy Pelosi (D-CA) is leading a draft legislation that allows Medicare to negotiate lower drug prices, with discounts that can be applied to all payers, including private plans. The legislation has not yet been released, and more details are expected as the House returns to session.

Cadillac Tax 

The politics of the Cadillac tax have changed.

RELATED: KFF: 1 in 5 employers may face the ACA's 'Cadillac' tax on high-cost health plans

The tax is an excise tax on health plans to be paid by insurers on employer-provided health insurance plans that cost more than $11,200 per year for individuals and $30,100 for families. The tax was part of the funding of the Affordable Care Act. Once supported by ACA backers, the tax has been controversial. Labor Unions were strong opponents of repeal. 

However, unions are now saying that the benefits they sought to protect are disappearing and are concerned with the rise in premiums. 

In the House, repeal passed in a 419-6 vote before the recess.

In the Senate, a companion bill to the House legislation has 61 cosponsors. Sens. Mike Rounds (R-SD) and Martin Heinrich (D-NM) have asked Senate Majority Leader Mitch McConnell (R-KY) to bring the bill to the floor for a vote, as have a variety of stakeholders. Sen. McConnell has yet to make a decision. 

Mariam Eatedali is a research associate on the federal public affairs team of McGuireWoods Consulting in Washington, focusing on healthcare policy related to Medicare/Medicaid and prescription drug pricing issues.