Earlier this week, Senate Budget Committee Ranking Member Bernie Sanders (I-VT) introduced the Medicaid Generic Drug Price Fairness Act, a bill designed to hold down spending on generic drugs in Medicaid. The bill, which has also been introduced in the House by Rep. Elijah Cummings (D-MD), is a reprise of similar legislation introduced in the last Congress.
Skyrocketing Generic Drug Prices
The legislation comes in the wake of a huge jump in generic drug prices in 2014 -- even among certain drugs that have been on the market for a considerable amount of time -- without a clear cause. In some cases, the generic drug is now barely cheaper than the brand-name equivalent that benefited from patent protection. Forbes cites a report showing that several drug groups at least doubled in price and some jumped by much more than that. A few drugs whose prices jumped by an order or two of magnitude drew the particular ire of Sen. Sanders and Rep. Cummings last year.
Some of the price increases are almost certainly the result of raw material shortages or price markups for specific compounds needed in production, but many experts suspect that consolidating market power among generic drug producers and decreasing competition may be playing a significant role. Generic drug-makers, including during testimony at Sen. Sanders' Subcommittee hearing late last year, have generally refused to clarify what the causes have been.
CQ is reporting (subscription required) that the House will take up bills in June to repeal the medical device tax and the Independent Payment Advisory Board (IPAB), two deficit-reducing policies in the Affordable Care Act (ACA).
Unlike full ACA repeal, these policies stand a chance of overcoming a Presidential veto due to the bipartisan support already exhibited for each: as of this writing, the medical device tax repeal bill in the House (HR 160) has 279 cosponsors while the IPAB repeal bill (HR 1190) has 229 cosponsors. However, repealing these policies without offsetting savings from health care or revenue would be a mistake. IPAB, in particular, should not be abolished without a replacement that can similarly restrain long-term Medicare cost growth.
As we explained earlier this year, repealing the 2.3 percent medical device tax would cost about $25 billion over ten years. Although the original co-sponsors of the bill, Reps. Erik Paulsen (R-MN) and Ron Kind (D-WI), said they expect the bill to be offset, no cost-savers have been produced yet. We suggested bundling payments for inpatient care as one option, which not only would produce enough savings to fully offset repeal but also achieve much of its savings from providers cutting their medical device costs. Thus, the medical device industry would still be asked to contribute to deficit reduction, but in a more efficient manner. There are many other options available as well, as we showed at the time and in our latest health care options.
|Potential Offsets for Medical Device Tax Repeal|
|Memo: Repeal Medical Device Tax||-$25 billion|
|Expand bundled payments for inpatient care||$25 billion|
|Reduce state Medicaid provider taxes to 4.5 percent of patient revenues||$35 billion|
|Reduce Medicare coverage of hospital "bad debts"||$30 billion|
|Encourage use of generic drugs by low-income Part D beneficiaries||$20 billion|
|Equalize payments for similar services performed in different settings||$20 billion|
|Increase Medicare Advantage coding intensity adjustment||$20 billion|
|Increase Medicaid drug rebates||$10 billion|
|Move up "Cadillac tax" by one year to 2017||$35 billion|
|Eliminate tax breaks for oil and gas companies||$40 billion|
|Increase cigarette tax by 50 cents||$35 billion|
|Close "John Edwards/Newt Gingrich" loophole||$35 billion|
|Limit tax benefit of retirement accounts||$30 billion|
|Eliminate tax exclusion for private activity bonds||$30 billion|
|Require Social Security numbers for refundable portion of child tax credit||$25 billion|
|Eliminate the mortgage interest deduction for second homes and yachts||$15 billion|
Source: CBO, JCT
CRFB has released a new compendium of over 150 options to reduce mandatory spending and raise revenue. Despite declining in deficits in recent years, the debt is still projected to rise substantially over the long term. In addition, a series of upcoming Fiscal Speed Bumps will force lawmakers to make decisions about spending and revenue that could require large amounts of offsets, or potentially add almost $2 trillion to the debt.
Click here to see the full list of options.
Our list of options is meant to assist in finding fiscally responsible Speed Bump solutions, achieve some of the unspecified savings in the budget resolution, and help make the country's fiscal situation sustainable.
This paper updates and expands a health care and revenue options report released during the fiscal cliff discussions in late 2012. The new list also focuses on revenue and health care but also includes options for other mandatory (non-health, non-Social Security) spending that may be useful in the months ahead.
A group of House Democrats introduced a bill yesterday to repeal the tax on high-cost health insurance plans, commonly known as the "Cadillac tax," set to take effect in 2018. The repeal joins a similar House Republican bill released back in February. Needless to say, repealing the tax would be very expensive - CBO has estimated the tax raises $87 billion through 2025 while raising growing amounts over time - and likely counter-productive to health care cost control efforts. Importantly, the tax already seems to be having clear effects on the design of employer-provided health plans and has shown itself to be an important tool to slow private health spending growth (and may be playing a role in the recent slowdown). At the very least, lawmakers should plan to offset the lost revenue from repeal, but they should focus on policies that can also bend the health care cost curve.
The Cadillac tax is a 40 percent excise tax on employer-provided health insurance plan premiums that exceed $10,200 for individuals and $27,500 for families. Those thresholds are adjusted for inflation in future years so they would provide tighter limits over time since health care costs have almost always grown faster than inflation. As a result, it will raise growing amounts of revenue over time.
Lawmakers cleared their second Fiscal Speed Bump of the year - the expiration of the one-year "doc fix" - earlier this month, scuttling the Medicare Sustainable Growth Rate (SGR) formula for good by adding $141 billion to deficits through 2025 ($175 billion with interest). As a result, CBO's last baseline in March is now slightly out of date, and the agency usually doesn't release new ten-year numbers until August, so here's our estimate of what the baseline looks like in the post-SGR world.
The new law increases debt by about one percentage point of Gross Domestic Product (GDP) by 2025, from 77 percent to 78 percent. It also increases ten-year deficits and health care spending by about one-tenth of a percent of GDP while slightly increasing interest spending from 2.9 to 3 percent of GDP in 2025. Not surprisingly, the law slightly increases the share of spending going to health care and interest.
|The New Ten-Year Budget Outlook (Percent of GDP)|
Source: CRFB calculations based on CBO data
*Includes net Medicare, Medicaid/CHIP, and health insurance exchange subsidies
This morning, Governor Chris Christie (R-NJ) delivered an important speech in New Hampshire on the need for entitlement reform. The speech not only focused on the need to address the rapid growth of Social Security, Medicare, and Medicaid but actually put forward a plan to begin addressing these issues. By our rough estimate -- and depending on many of the details -- this plan would save over $1 trillion in the next decade alone while significantly improving the solvency of Social Security and Medicare.
Below is a short summary of Governor Christie's plan.
Social Security Reform
In his speech, Governor Christie called for Social Security reform, explaining that the program "is slowly working its way to insolvency – which the actuaries say will come in the early 2030s, less than 20 years from now... as the number of workers relative to the number of beneficiaries continues to shrink."
To address Social Security's looming insolvency, Christie proposes a number of changes. The most significant policy, in terms of savings, would be to raise the normal retirement age by two months per year from age 67 in 2022 (as under current law) to age 69, and then index it for life expectancy. At the same time, his plan would raise the earliest eligibility age from 62 to 64.
In addition, Christie proposes to calculate COLAs based on the more accurate chained CPI (with a benefit bump-up for 85 year olds), to phase out Social Security benefits for the highest earning seniors (phased out between $80,000 and $200,000 of non-Social Security income), and to eliminate the payroll tax for senior workers.
There's a simple way to make the $141 billion House-passed Medicare Sustainable Growth Rate (SGR) bill more fiscally responsible: don't exempt it from PAYGO.
As currently written, not only would the SGR legislation add $500 billion to the debt by 2035, but it includes a provision (in Section 525 of the bill for those reading along at home) exempting it from the pay-as-you-go law specifically designed to prevent Congress from adding to the debt over the course of a year.
This PAYGO loophole not only codifies the debt increases within the bill, but it also makes it more difficult for the Congress to follow through on achieving the Medicare savings in the House and Senate Budgets.
Luckily, there is an easy solution. By simply striking Section 525 and removing the PAYGO loophole, the Senate would effectively require Congress to identify $141 billion or more of deficit reduction by the end of the year.
This wouldn't require savings to take place immediately and wouldn't hold up passage of the SGR bill, but it would allow Congress the time it needs to identify savings and reforms to ensure they don't add to the nation's credit card over the long-run. And if Congress fails to find those savings, an automatic mandatory cut would reduce the cost of Medicare and (to a much lesser extent) several other smaller mandatory programs by about $15 billion per year until savings are identified.
Notably, striking the PAYGO Loophole would not impact any of the spending or savings currently in the bill.
Lawmakers often lament the difficulty of reforming Medicare and other health care programs, but the difficulty is not a lack of viable options. One particularly lush source of ideas to examine is the President’s budget.
His budget offers $435 billion in health care savings, which would pay for reforming the Sustainable Growth Rate (SGR), new health initiatives (some of which are in the SGR bill), and repealing the Medicare sequester while leaving an additional $100 billion for deficit reduction. On top of many reforms found in previous budgets, it also includes efforts to improve the delivery system and enact payment reforms – as well as new spending – not seen in previous budgets.
Here are a few highlights of the proposed savings:
- Allow the Health and Human Services (HHS) Secretary to negotiate certain drug prices: Although this item is budget-neutral, it would let the Department negotiate with pharmaceutical manufacturers to lower the price of high-cost prescription drugs and biologics for Medicare Part D. This policy is in addition to other proposed drug payment reforms in the budget that save $165 billion.
- Equalize payments for similar care performed in different sites of service: A trend in Medicare is the shift of ambulatory care from doctors' offices to hospital outpatient facilities, the latter of which receives a higher reimbursement from the government. The budget proposes to equalize payments for services that can be well provided in physician offices, regardless of whether that care is provided in a hospital outpatient department, physician's office, or an Ambulatory Surgery Center. CBO estimates that this would save $13 billion over the next decade.
The Sustainable Growth Rate (SGR) formula returned yesterday with 21 percent cuts to Medicare physician payments, although the actual effect won't be felt for a few weeks because of Medicare's ability to withhold payments for a period of time. Lawmakers have come up with a solution that is expected to be voted on when the Senate returns from recess, but it would add about $500 billion to debt by 2035.
The legislation replaces the large and blunt SGR-prescribed cuts with 0.5 percent payment increases for five years before freezing payment growth through 2024 alongside a new, consolidated quality incentive program for Medicare physicians, called the Merit-Based Incentive Payment System (MIPS). In a budget-neutral manner, the MIPS program would reward or penalized physicians based on quality, resource use, meaningful use of electronic health records, and clinical practice improvement activities. Simultaneously, the bill would also provide payment incentives for physicians to utilize alternative payment models (APMs), such as Accountable Care Organizations (ACOs), that reward quality of care over quantity of care delivered. From 2019-2024, physicians earning a significant share of their revenue from models that involve risk of financial losses and have quality measurement would get a 5 percent bonus payment each year. Over the long run, physicians in APMs would also receive annual updates of 0.75 percent while non-APM professionals receive 0.25 percent updates.
This new system is estimated to cost $175 billion through 2025 by the Congressional Budget Office, but lawmakers are choosing only to offset the $35 billion amount by which this policy exceeds the cost of a permanent payment freeze. There is at least some hope, though, that the reformed physician payment system can begin to slow costs and improve quality of care in Medicare.
In addition, the bill extends several "health extenders" that are often included with doc fixes. Most of the extensions run through 2017, but two policies -- the Qualified Individual (QI) program, which provides Medicare premium assistance for certain low-income beneficiaries, and Transitional Medical Assistance (TMA), which allows low-income workers whose income rises to temporarily keep Medicaid eligibility -- get permanent extensions. These extenders cost $19 billion through 2025 and are fully offset.
We have spent much space on this blog highlighting the fact that temporary delays of the cuts dictated by Medicare's Sustainable Growth Rate (SGR) formula have almost always been offset (98% of the time since 2004), producing $165 billion in deficit reduction all told, almost entirely from health care programs.
And despite assertions to the contrary, these health savings shouldn’t be dismissed lightly. There have been numerous recommendations put forward by the Medicare Payment Advisory Commission (MedPAC), Health and Human Services' Office of the Inspector General (OIG), the Government Accountability Office (GAO), and others that likely would have been ignored but for the need to replace savings from the SGR.
MedPAC, for instance, has warned for years that Long-Term Care Hospitals (LTCHs) and Inpatient Rehabilitation Facilities (IRFs) are paid more than is necessary for many of the cases they handle. To offset the 10% cut dictated by the SGR in 2008, Congress adopted MedPAC recommendations to reduce payment updates for both IRFs and LTCHs, and also modified the prospective payment system for LTCHs. Then again in the 2013 “doc fix” bill, in line with recommendations under discussion by MedPAC at the time, Congress applied site-neutral payments for certain conditions treated in LTCHs.
The latest “doc fix” exemplifies this trend. The largest savings in the bill, from allowing the Department of Health and Human Services (HHS) to collect and use data on values of physician services to more accurately set Medicare payments, is a variant of a direct recommendation from MedPAC the last two years.