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The 2 big health care fights coming up this fall

The urgency to act could not be stronger for Congress on drug prices and surprise medical billing.

Protesters supporting Medicare for All hold a rally outside PhRMA headquarters April 29, 2019, in Washington, DC. 
Win McNamee/Getty Images
Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

Lawmakers return to Washington this week with, what else, health care on their minds and their agenda.

In the coming weeks, there are two issues lawmakers want to address, if they can overcome the sizable political and special-interest obstacles to doing so: surprise medical bills and drug prices.

Tackling surprise medical bills has seemed like the ripest opportunity for bipartisan action to reduce Americans’ health care costs. The tales uncovered by Sarah Kliff for Vox, who documented people getting hit by a bus and then faced a $27,000 ER bill, prompted public outcry. Lawmakers are under intense pressure to get something done.

Key House and Senate panels have approved proposals that would limit patients’ financial liability if they visit an out-of-network hospital or are treated by an out-of-network provider during an emergency.

But, as The Hill’s Peter Sullivan reported last week, industry groups stepped up their efforts in August to stymie such legislation:

Powerful doctor and hospital groups are stepping up their opposition to those measures, warning that they would result in damaging cuts in payments to doctors.

“Big insurance companies want a one-size-fits-all approach that lets them decide what they’ll pay doctors for your care,” warns an ad launched by the group Physicians for Fair Coverage against the effort.

A separate group, called Doctor Patient Unity, which does not disclose its donors, has spent at least $10 million on ads opposing the effort, according to the Center for Responsive Politics.

Doctors also mobilized to lobby lawmakers and their staff against the effort over the August break.

From the beginning, as we covered, the hang-up for any plan to stop surprise medical bills has been determining how much the health insurer should pay the health care provider in the event that a patient ends up getting treatment out of network.

The simplest approach, you could argue, would be to simply have the insurer pay the doctor or hospital whatever they would pay an in-network provider in the same area. But doctors especially chafe at that proposal (it’s what they’re attacking in the ad copy quote above) because it effectively subjects them to a government price control.

They’ve been lobbying lawmakers on this point for a while, and both the House and Senate bills reflect that by allowing for arbitration, under limited circumstances and with significant restrictions on what can be considered, to resolve surprise bills. But it doesn’t seem to have quelled the industry’s fears.

Congressional aides believe providers want either a system that mirrors the arbitration process set up in New York state — where an arbiter simply picks between amounts proposed by the doctor or the insurer to cover the service — or nothing at all.

”I think they want nothing,” a House aide told me last week.

For now, we wait and see. Individual senators are still negotiating possible amendments to their bill, while on the House side, everybody is waiting for the Ways and Means committee to put forward a proposal.

Coming soon: a drug prices plan from Nancy Pelosi’s office

In the meantime, we’re also waiting on House Speaker Nancy Pelosi’s drug prices plan to drop. Here is the rough expected outline, according to Axios’s Sam Baker:

Pelosi’s proposal would direct the federal government to negotiate the price of certain expensive drugs with little or no competition — and, crucially, that would also become the price in the private market, not just the Medicare drug coverage price, according to Democratic aides and lobbyists working on the issue.

Whenever the plan lands, it’ll be the culmination of months of difficult navigation for Pelosi. On her left, members have been annoyed by the idea of limiting which drugs Medicare can negotiate prices for and by the previously floated idea of having a third party decide on a price if the government and a drug maker can’t agree. The right is generally skeptical of any government activity to curtail private enterprise, though the public anger over drug costs has softened them a bit.

Then it becomes a question of whether there is any bipartisan appetite to confront pharma. President Trump has talked a big game on drug prices since entering the White House, and his endorsement would have a lot of sway with the Republican members. But Democrats might be reticent to support any bill they think is watered down and that would hand Trump a win on health care.

In both these cases, drug prices and surprise medical billing, the urgency to act could not be stronger for Congress. But industry opposition and petty political considerations have snuffed out many a health care proposal before.

This story appears in VoxCare, a newsletter from Vox on the latest twists and turns in America’s health care debate. Sign up to get VoxCare in your inbox along with more health care stats and news.

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