House Republicans vote to ban certain pricing metrics in federal programs

In a party line vote, House Republicans voted to ban certain pricing metrics in federal health programs such as Medicaid, Medicare Advantage and VA Health Care.

Under the proposal, titled the Protecting Health Care for all Patients Act (PDF), which passed 211-208 on Wednesday, the legislation will end the usage of quality-adjusted life years (QALY) and other metrics in federal health programs, like it does already in Medicare.

The bill will now head to the Democrat-led Senate but is unlikely to pass assuming party line voting continues. If passed by the Senate, the law would take effect starting in January 2025.

Republicans say QALY is a discriminatory measure that devalues people with disabilities or chronic diseases. Rep. Cathy McMorris Rodgers, R-Washington, shared an impassioned story on the House floor to express her support for the bill. She explained that her children like her son, who was born with Down syndrome, should not be subjected to bereaucracy determining whether care is necessary. 

"We shouldn't be discounting their potential or prejuding the quality of their life just because of their disabilities," she said. "Unfortunately, several tools frequently used in our health care system do just that."

McMorris Rodgers said that QALY assigns a dollar value to determine whether a treatment is cost-effective, potentially denying necessary healthcare. QALY, she added, removes the unique circumstances a patient faces.

She also argued that Democrats previously have supported banning QALY indexes—both when the Affordable Care Act was first passed and banned QALY in Medicare, and again in 2020 as part of the Democratic National Committee platform. McMorris Rodgers cited advocacy groups and nonpartisan health organizations that support the legislation and noted that it doesn't prevent federal payers from trying other cost-effective treatments first.

"This would be a big deal," she said. "Medicaid is the largest payer for people with disabilities, and we are letting it use measures that discriminate against the very people it was designed to support."

Rep. Frank Pallone, D-New Jersey, called the legislation a "Trojan horse" meant to undermine the Biden administration's efforts to lower drug costs for families. He said that the Inflation Reduction Act (IRA) already requires state Medicaid programs to cover all drugs.

"H.R. 485 goes further than current law and opens a back door that will be used to bar the use of any value measures by the federal government," he said. Pallone added that he tried to amend the bill in a markup hearing to address these concerns, but the effort was shot down on a party line vote.

"I respect the chairman [McMorris Rodgers] a great deal, but she keeps talking about how she's banning similar discriminatory measures," he said. "The fact of the matter is that the bill doesn't say similar discriminatory measures … this says QALY or similar measures. The problem is this will be used by pharma to raise prices."

McMorris Rodgers dismissed those concerns, reading directly from current law that states Medicare already prohibits the use of "QALY metrics and other similar measures." She said she's unable to understand why the language used in her bill is suddenly problematic, as Medicare law would now be applied to other federal programs.

Pallone said the bill is backed by the pharmaceutical industry for a reason and that it could be used as justification in court to thwart the drug price negotiation program under the IRA.

The Congressional Budget Office (CBO) estimates (PDF) this legislation would increase spending for prescription drugs in Medicare, Medicaid and other health programs by $1.1 billion in the next 10 years. To fund the bill, Pallone said Republicans want to "gut" the Affordable Care Act's Prevention and Public Health Fund.

In her statement, McMorris Rodgers countered that the CBO said in its report it does not believe the bill would affect prices that result from negotiations between CMS and drug manufacturers. And if CBO expects $1.1 billion in increased costs, that suggests discriminatory measures are currently being used against individuals due to denying care.

Like the House Democrats, the Biden administration does not support the bill.

"The administration opposes efforts to undermine the Affordable Care Act by stripping dollars from the Prevention and Public Health Fund and undermining its critical investments in health and wellbeing, and therefore opposes H.R. 485," said the Executive Office of the President in a letter Feb. 5. "As the majority intends to amend the bill, H.R. 485 would strip funding from the Prevention and Public Health Fund, which supports critical investments to help prevent disease."