Billy Wynne J.D.

Chairman

A.B., Dartmouth College; J.D., University of Virginia

(202) 309-0796
billy@wynnehealth.com

Billy Wynne is a nationally respected strategic advisor to elite health care organizations, including Fortune 500 companies, marquee health systems, and prominent foundations. After building one of Washington’s largest health policy practice, he and his team established the Wynne Health Group in January 2018.

Prior to his private sector career, Mr. Wynne served as Health Policy Counsel to the Senate Finance Committee where he was a key drafter and negotiator of several health care laws and assisted in the development of the health care reform “White Papers” that served as the basis for the Affordable Care Act. He has published several dozen articles in Health Affairs and other platforms, often appears on cable news, and is frequently cited by the New York Times, Washington Post, Politico, and other publications.

Mr. Wynne is also an entrepreneur, having founded Policy Hub, the only comprehensive aggregator of federal health policy analysis, and the Public Option Institute, which is dedicated to providing clear analysis of public option programs and developing recommended best practices for states to consider.

Mr. Wynne received a bachelor’s degree in Government from Dartmouth College and a law degree from the University of Virginia. He is a member of the District of Columbia and Virginia bar associations and serves on the boards of Operation Smile, Chinese Children Adoption International, and the Zen Center of Denver.

When he’s not working in Washington, Mr. Wynne lives in Denver, CO with his wife, Christy, and their children, Eleanor and Lei.

Investing in Providers During the Pandemic: How Have Federal Dollars Been Distributed?

Commonwealth-Fund 400x200The COVID-19 pandemic has wreaked havoc on the U.S. economy and put countless businesses at risk of failure. The health care industry has been hit particularly hard because of drops in revenue driven by decreases in elective care, stay-at-home orders, and the costs of preparing for a pandemic, such as increasing hospital capacity and purchasing personal protective equipment. Recognizing these challenges, and the critical role the industry plays, Congress and the U.S. Department of Health and Human Services (HHS) acted quickly to support the health care system and frontline workers in three primary ways: provider relief funds, the Paycheck Protection Program, and the Medicare Accelerated and Advance Payment Program....
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Democrats Will Adopt Their Health Care Platform Next Week — Here’s What It Says

After four years in the veritable wilderness of the Trump Administration and Republican-controlled Senate, Democrats have some pent up policymaking zeal to express. If Joe Biden succeeds in winning the presidency and the party takes control of the upper chamber, which polls suggest is within reach, they will have a wide avenue to institute these aspirations. Next week, the party will convene for its National Convention, primarily in virtual isolation, of course. Amid the made-for-TV, they will formally adopt the Party Platform that they preliminarily endorsed in late July....
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Washington Begins Horse Trading over Next Phase of COVID-19 Aid

California-Health-Care-Foundation 400x200Negotiations in Congress over the next COVID-19 aid plan are expected to start after the July 4 break, and a package is likely to pass before Congress adjourns for the August recess. In total, we expect the bill to include up to $3 trillion in funding based on the House proposal, the HEROES Act. The Senate, House, and Trump administration proposals are starkly different, so the exact contents of the final legislation remain to be seen. The main political pull is essentially between those who want the aid to be mostly about funding economic recovery and those who would focus on boosting medical care and public health....
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Five Reasons Medicare For All (Or Anything Like It) Won’t Pass In 2021

While conventional wisdom, and some presidential candidates, have already begun to temper these expectations, my goal here is to document five reasons why Medicare for All (M4All), Medicare buy-in, or federal public option legislation cannot pass in the near future. My hope, in doing so, is that we Democrats spare ourselves the precious time, internal acrimony, and political fallout that Republicans faced when their lofty ACA repeal promises went unfulfilled....
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CMS Releases Advance Notice For Medicare Advantage And Part D Plans

Last week, the Centers for Medicare & Medicaid Services (CMS) released Part II of its Advance Notice of Methodological Changes for Medicare Advantage (MA) Capitation Rates and Part D Payment Policies for Calendar Year (CY) 2021 (fact sheet). The agency also released its proposed rule on policy and technical changes to MA and Part D for CYs 2021 and 2022 (fact sheet). A press release for both developments is available here. This post focuses on summarizing the Advance Notice component of this package of policies....
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The Forecast for Legislative and Regulatory Activity on Health Care in 2020

As the impeachment trial has concluded with the acquittal of President Trump, Congress is now returning to some sense of normalcy. On the health care front, policymakers will need to secure a deal relatively quickly on top-priority issues like prescription drug pricing and surprise medical billing. The apparent deadline for final legislation in both regards is the May 22 expiration date of funding for several public health programs (e.g., community health centers), which many are eyeing as the last real opportunity for meaningful reform this year. Many doubt whether Congress will produce much after that date because of compressed schedules to accommodate party conventions and an extended recess in October. However, health care is in the forefront of voters’ minds. ...
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New Legislation to Control Drug Prices: How Do House and Senate Bills Compare? An Update

Commonwealth-Fund 400x200As Congress grapples with an evolving impeachment inquiry, lawmakers have remained focused on lowering prescription drug costs. In December, the House passed the Elijah E. Cummings Lower Drug Costs Now Act (H.R. 3) by a 230–192 vote, largely along party lines with no Democratic defections. House Democratic leaders successfully assuaged grumblings from the Congressional Progressive Caucus that H.R. 3 did not go far enough by doubling the minimum number of drugs subject to price negotiation, among other policy changes....
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Surprise Medical Billing Might Get a Hybrid Solution

California Health Care Foundation LogoReaching a consensus on how to protect patients from surprise medical bills has eluded Congress for most of the year even though members in both parties and chambers are highly motivated to find a fix. With an agreement reached over the December 7–8, 2019, weekend, a solution seems closer than it has in a long time....
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A Look Inside The Hospital Transparency Final Rule

On November 15, 2019, The Centers for Medicare & Medicaid Services (CMS) finalized a controversial set of requirements for the disclosure of hospital pricing data to degrees heretofore not seen. Stemming from the recent transparency Executive Order (EO), the final rule reflects the current administration’s overall push to increase pricing and cost transparency throughout the health care system. While the original proposal faced substantial backlash from stakeholders, CMS’ final decision is nearly identical to what the agency originally proposed....
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New Legislation to Control Drug Prices: How Do House and Senate Bills Compare?

Commonwealth-Fund 400x200The following tables compare H.R. 3 based on the legislative text advanced by key committees of jurisdiction and key provisions of related proposals: the Prescription Drug Pricing Reduction Act of 2019 (S. 2543), advanced by the Senate Finance Committee in July; and the Advanced Notice of Proposed Rulemaking (ANPRM): Medicare Program, IPI Model for Medicare Part B Drugs, issued by the Centers for Medicare and Medicaid Services last October....
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Proposed Stark Law, Anti-Kickback Reforms Aim To Facilitate Value-Based Care

On Wednesday, October 9, the Department of Health and Human Services (HHS) announced highly anticipated proposed reforms to current regulations implementing the Physician Self-Referral Law (the Stark Law) and the Federal Anti-Kickback Statute (AKS). Also addressed were related civil monetary penalties (CMPs) for inducements to beneficiaries to utilize services. HHS identified the regulations as they stand now as potential impediments to value-based purchasing arrangements for providers and suppliers participating in federal health care programs, as well as in the commercial sector....
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White House Requires Immigrants to Purchase Health Insurance

California Health Care Foundation LogoOn Friday, October 4, 2019, President Trump issued a proclamation to suspend entry of immigrants into the United States if they cannot prove that they will obtain unsubsidized health insurance coverage within 30 days of entering, or that they have the financial means to pay for any foreseeable health care costs (fact sheet). The proclamation is not yet in effect, and we anticipate legal challenges....
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A Single Public Plan Option Versus A Multiplan Approach: A Colorado Case Study

Colorado and Washington State are in the process of implementing public option programs. Other states continue to explore similar actions as well as a variety of Medicaid buy-in proposals. A core consideration states implementing these programs face is whether to allow multiple public option plans (potentially offered by multiple carriers) to any given consumer or just a single public option plan. In both forerunner states and presumably those to follow, policy makers are charged with striking a delicate balance between maximizing affordability and maintaining market stability, including in their exchanges, where such plans are likely to be offered. ...
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Medicare for All: What it Means, and Where it’s Headed

Medicare for All is the titular banner carrying the promise of comprehensive healthcare coverage for every U.S. resident and, along with it, reduced costs, improved quality, and patient-focused care. While phrases like “universal coverage” and “single-payer” have traditionally been reserved to the fringe of American politics, the idea of a single, government-run insurance plan is now taking center stage. But what does it really entail? And can we reasonably expect its fruition? We seek to provide some clarity on both questions. ...
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The Final Public Charge Rule Is Out. Here’s How It Affects Immigrants.

California-Health-Care-Foundation1-400x200The US Department of Homeland Security (DHS) has finalized significant new restrictions to reduce immigration by creating a preference for wealthy, English-speaking, insured, and educated immigrants and putting up new hurdles for impoverished immigrants and their families....
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Accelerating Primary Care Redesign: CMS’ Innovation Center Announces Five New Transformative Models

On April 22, 2019, the Centers for Medicare and Medicaid Services (CMS) announced the Primary Cares Initiative (PCI), a suite of five voluntary payment models aimed at overhauling primary care. Marking the Trump Administration’s latest investment in Medicare value-based reform, PCI focuses on the role of primary care providers as the central coordinators of patient health, with the goal of enhancing patient care while lowering overall Medicare fee-for-service (FFS) costs. Once implemented, CMS estimates that more than a quarter of all Medicare FFS beneficiaries – nearly 11 million individuals – will be included in these transformative primary care delivery models....
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A Tell-All on Telehealth: Where Is Congress Heading Next?

Commonwealth-Fund 400x200The Centers for Medicare and Medicaid Services (CMS) recently enacted modest but important expansions in Medicare’s telehealth policy. Telehealth, which uses telecommunications to support virtual health care delivery to improve access to and quality of health care, is moving from promise to reality. The benefits are appealing: Patients can interact with their providers remotely, which improves access to care and can help providers manage chronic conditions from afar....
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Medicare Direct, A Blueprint For Public Option Waivers, Part 1: Introduction, Administration, And Financing

There is a reason that Medicare for All has captured the enthusiastic support of a large majority of the public: The status quo for our health care system is unsustainable economically and unforgiveable morally. An honest assessment of the probability of Congress enacting Medicare for All–related legislation, however, demonstrates it is highly unlikely in the foreseeable future. ...
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Medicare Direct, A Blueprint For Public Option Waivers, Part 2: Benefit Design, Provider Networks, And Reimbursement

In all of the discussion and debate regarding Medicare for All and public option proposals, three essential considerations often get short shrift: the benefits enrollees will receive, the network of providers they will have access to; and the rates providers will be paid for delivering these services. These elements, however, really are the guts of any meaningful initiative of this scope. ...
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Medicare Direct, A Blueprint For Public Option Waivers, Part 3: Waiver Design, Legal Authority, And Conclusion

Perhaps the greatest weakness of the Medicare for All, Medicare for More, and public option proposals issued thus far is the fact that they require Congress to pass new legislation. That is certainly true for Medicare for All, it’s true for a Medicare buy-in, and it’s likely true for federally run public options. The biggest strength of Medicare Direct, by contrast, is that it requires no such action. ...
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These Four Federal Proposals Would Have Major Health Implications for Immigrants

California-Health-Care-Foundation1-400x200The Trump administration is seeking to modify federal regulations with harmful changes that could dramatically affect immigrants’ access to health care and other public benefits and weaken the health and social safety net. These policies affect access to health coverage, food assistance, housing, protections against discrimination, and more. These proposed changes could have major consequences for the health and well-being of immigrants across the country and especially in California, which has more immigrants than any other state....
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The Drug Pricing Debate Part II: The Many Acts of Congress

Commonwealth-Fund 400x200As we outlined earlier this spring, congressional action on drug pricing continues to intensify. Key committees have advanced an array of reforms, demonstrating Congress’ intent to finalize legislation this year. We aim to clarify what that might include....
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Public Option 1.0: Washington State Takes An Important Step Forward

On Sunday, the Washington State legislature passed a bill to create standardized health plans in the state’s Exchange and establish new public option-ish plans that contract directly with its Health Care Authority, which operates the state’s Medicaid program. The hallmark of these new plans, and the foundation of their claim to the title “public,” is they are required cap provider reimbursements at Medicare-based levels....
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The Drug Pricing Debate: Sizing Up Recent Actions and What May Come Next

Commonwealth-Fund 400x200What goes up must — or rather, should — come down. Such is the thinking of the Trump administration when it comes to prescription drug pricing, at least. Over the past five years, 12 of the 20 most commonly prescribed brand-name drugs have seen price increases of more than 50 percent. To date, most of what we’ve seen from the federal government is messaging and some initial proposals, with the majority coming from the administration. Congress, for its part, has initiated a series of drug pricing hearings and begun introducing meaningful legislation. The result is a wide array of policy alternatives, some of which stand a chance of being enacted....
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Medicare For All Can Begin In 2021: Here’s How

While Democratic presidential candidates and the newspaper headlines hash out the ideological nuances of a Medicare-based single payer coverage scheme, work is underway to consider how coverage can be expanded to those in need within a realistic timeframe at minimal cost or disruption to the existing system....
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What to Expect in Health Policy Under a Divided Congress

California-Health-Care-Foundation 400x200The 2018 midterm elections were powered by a “blue wave” that flipped control of the House of Representatives from the GOP to the Democrats but left the Senate in Republican hands, meaning the two chambers of Congress will be divided at least until 2020. In the Senate, Republicans have a 53 to 47 majority and will continue to be led by Senator Mitch McConnell of Kentucky, while House Democrats gained a 235 to 199 majority....
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What the 2018 Midterm Elections Means for Health Care

The fundamental shift in the balance of power in Washington will have substantial implications for health care policymaking over the next two years. In this post, I’ll take a look at which health care issues will come to the fore of the Federal agenda due to the outcome Tuesday, as well as state expansion decisions. And it should of course be noted that, in addition to positive changes Democrats are likely to pursue over the next two years, House control will allow them to block legislation they oppose, notably further GOP efforts to repeal the Affordable Care Act (ACA)....
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The 660-Page Opioids Bill Is Now the Law. Here’s What’s in It.

California-Health-Care-Foundation 400x200Opioids killed an estimated 49,000 Americans in 2017, including nearly 2,200 Californians. They harmed many more, including children forced into the foster care system, babies born with neonatal abstinence syndrome, young adults who overdosed from dangerous new street drugs like fentanyl, and countless others who became addicted to opioids while trying to manage chronic pain....
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Immigrants and the New Proposed “Public Charge” Rule

California-Health-Care-Foundation 400x200On September 22, the Department of Homeland Security (DHS) released the text of highly anticipated proposed changes to “public charge” rules that could disqualify many immigrants from gaining permanent residency in the US. Public charge is the determination that evaluates whether someone is likely to become reliant on public benefits, and consequently whether he or she may enter the country or modify his or her immigration status to become a permanent resident (a “green card” holder). ...
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Creating Medicare Advantage Premium Support For All, Part 5: Which Proposal Is Actually Medicare?

With the burgeoning debate around single payer, primarily oriented around "Medicare for All," CEO Billy Wynne takes a look under the hood of Sen. Bernie Sanders' "M4All" proposal and discovers it is not actually based on Medicare. He also continues his inquiry into what bona fide Medicare for All would actually look like, in this case by explaining the basics of the Medicare Advantage program, which covers 33% of Medicare enrollees this year....
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What Might Happen in Federal Health Policy Before the Midterm Elections

California-Health-Care-Foundation 400x200An in-depth guide to the key health policy issues that will dominate DC through the midterm elections....
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Here’s What the House Passed to Tackle the Opioid Crisis

California-Health-Care-Foundation 400x200A breakdown of all of the key provisions in the House-passed opioid package. From the intro: "After months of debate, the US House of Representatives passed a package of bills on June 22 addressing the opioid epidemic by a vote of 396 to 14. H.R. 6, the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT), incorporates dozens of House bills. ...
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Medicare’s Hospital Outpatient Prospective Payment System Proposed Rule: Big Changes For 2019

CEO Billy Wynne's breakdown of the key policy changes described in the CY19 Medicare Hospital Outpatient Prospective Payment System proposed rule....
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Creating Medicare Advantage Premium Support For All, Part 4: Financing

In this fourth installment of his Medicare Advantage Premium Support for All series, CEO Billy Wynne demonstrate that this universal coverage approach can be fully funded with current spending (i.e., no new taxes would be necessary). ...
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“Public Charge” Rule Would Disrupt Safety-Net Access for Some Immigrants

California-Health-Care-Foundation 400x200The Trump administration has signaled its plans to significantly alter the rule on eligibility of applicants for permanent residency and applicants intending to immigrate to the US by redefining “public charge” determinations related to the use of public benefits. This would make it harder to enter the country and reduce access to a broad range of health and human service safety-net programs for immigrants already living here, including US citizen children. ...
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With Great Power Comes Great Responsibility: Medicare Advantage’s Newfound Supplemental Benefit Flexibility

California-Health-Care-Foundation 400x200The Centers for Medicare and Medicaid Services (CMS) recently made a series of interrelated policy changes to give Medicare Advantage (MA) plans more flexibility than ever to offer additional services outside of traditional Medicare. Known as supplemental benefits, these services have historically included items like dental, vision, and hearing. By allowing plans to offer an even wider and more tailored array of services, CMS expects that plans will be better positioned to attract members and meet beneficiary needs. ...
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The Consumerization Of Health Care To Improve Value: Secretary Alex Azar’s “Radical” Vision

HHS Secretary Alex Azar recently laid out a four-part strategy to achieve a "radical" vision of reforming health care: giving consumers greater control over health information, encouraging price transparency, using experimental models in Medicare and Medicaid to drive value, and removing government burdens. While certain elements of the secretary’s strategy reflect important reforms, his recommendations raise questions about the desirability of a shift toward consumerization of health care and whether these changes are actually in the best interest of consumers....
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Creating Medicare Advantage Premium Support For All, Part 3: Provider Considerations

"In the first post of this series, I hypothesized that a Medicare-for-all approach that puts market-based principles at its core will have the most success not only in winning sturdy, bipartisan support but in actualizing high-quality universal coverage at lower cost. In Part 2, I explored modest benefit enhancements that would be needed to maintain the quality of coverage various populations have under existing programs, some of which were reiterated in the CAP proposal. "In this post, I will examine what a Medicare Advantage (MA)-based universal coverage regime would mean for providers, who will continue to be the heart of our system and whose decisions affect the cost and quality of our care more than anyone else’s."...
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What Does Alex Azar’s Plan for Value-Based Care Really Mean?

California-Health-Care-Foundation 400x200New HHS Secretary Azar has articulated a four-point plan for value-based transformation of our health care system, but so far concrete details regarding the initiatives he will pursue are scarce. In this post, we break down the components of his plan and their potential implications for various health care stakeholders....
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The CHRONIC Care Act Passes Senate, Obstacles Remain

his post outlines the key components of the now adopted Chronic Care Act, assessed its outlook in the House, and considered what its progress may tell us about the prospect for more bipartisan action on health care in the future. ...
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Creating Medicare Advantage Premium Support for All, Part 2: Benefit Design

This is the second installment in my series examining the potential for a bipartisan Medicare-for-all approach that leverages competition among private payers and consumer choice via an advanceable tax credit....
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Breaking Down The MACRA Final Rule

On November 2, 2017, the Centers for Medicare & Medicaid Services (CMS) released a final rule making changes to the 2018 Quality Payment Program (QPP) under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The QPP includes both the Merit-Based Incentive Program (MIPS) and Advanced Payment Models (APMs). This post explains the key policies implemented in the final rule....
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The Health Implications of Tax Reform

California-Health-Care-Foundation 400x200This post breaks down the key components of 2017 Federal tax reform and its impact on the health care sector....
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State Waivers As A National Policy Lever: The Trump Administration, Work Requirements, And Other Potential Reforms In Medicaid

As states line up to avail themselves of new flexibilities in the section 1115 Medicaid wavier process, we thought it important to examine exactly what was approved in Kentucky and Indiana, and to survey the current landscape of pending proposals in search of what other reforms may be on the horizon....
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The Arduous Road to Renewal of CHIP Funding

California-Health-Care-Foundation 400x200After months of uncertainty, on January 22, 2018, Congress passed legislation renewing long-term federal funding for the Children’s Health Insurance Program (CHIP). Nearly nine million children and 370,000 pregnant women nationwide rely on the program for health coverage. This post examines the pathway renewal of the program took through considerable delays and political controversies....
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Navigating The Section 1332 Waiver Process: For States, A Treacherous Road Ahead

In light of the mounting legislative efforts to make changes to the section 1332 waiver process, especially in the Alexander-Murray market stabilization package, and enhanced state interest in availing themselves of this opportunity, we figured it timely to provide an overview of this aspect of the Affordable Care Act (ACA), the record of how state applications have been adjudicated so far, and the prospects of change to the policy in the near term. Unfortunately, given the considerable uncertainty in both the legislative and executive branches regarding the future of these waivers, states cannot safely expend meaningful resources on developing new applications for the program at this time....
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The Alexander-Murray Market Stabilization Package: What’s In It And Where’s It Going?

They may have done it. The apocryphal bipartisan deal to “fix” Obamacare is being struck (at least by two important Senators, for now, in part …). Today, Senators Lamar Alexander of Tennessee and Patty Murray of Washington announced they are converging on an agreement on a short-term package to help stabilize the individual insurance market. Even better, the policies included would likely be somewhat successful in achieving their purported purpose...
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In Health Affairs, Billy Wynne Breaks Down the Alexander-Murray Market Stabilization Package

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Senate Bill Isn’t “Better Care” for Anyone

With the release of the Senate’s “Better Care Reconciliation Act of 2017 (BCRA),” the public finally gets a glimpse of legislation crafted in utter secrecy for the past two months, and now we know why. Despite the fanfare and feigned earnestness of the upper chamber’s efforts to improve on the “mean” House-passed American Health Care Act (AHCA), the Senate bill would be disastrous for low-income families, patients with pre-existing conditions, children, and the aged, while undermining health care security for virtually everyone else....
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CBO and America’s AHCA Headache

The much-anticipated Congressional Budget Office (CBO) score of the American Health Care Act (AHCA), the GOP’s effort to dismantle the Affordable Care Act (ACA) released yesterday, indicates that the bill would cause 23 million people to become uninsured while reducing the federal deficit by $119 billion. In that sense, there is little change from their assessment of the original version of AHCA. ...
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The Bipartisan ‘Single Payer’ Solution: Medicare Advantage Premium Support For All

In my last Health Affairs Blog post, I outlined a potentially bipartisan four-step plan to move past the American Health Care Act’s (AHCA’s) disastrous framework toward a more stable, less expensive health care system. For those seeking incremental, near-term solutions, I hope those recommendations provide helpful guidance. But the AHCA’s reckless drive through the US House of Representatives has taught us something about the current status of health care politics and may have opened the window to more significant, ultimately more successful, reforms....
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100 Days of Health Care

Before November 8, no one anticipated that health care would be the predominant focus of the next president’s first 100 days. Now, let the record reflect, that is precisely what has happened. What have we learned in the process and what do we have to show for it? The latter question is easier to answer: nothing, save for considerable uncertainty and burgeoning disruption for the health care system. As for the former, Republicans have hoisted their own petard in epic fashion. ...
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What Now?: A Four Step Plan For Bipartisan Health Reform

As I concluded in my Health Affairs Blog post last Monday, it should be clearer now than ever that new steps to improve our health care system must be pursued on a bipartisan basis. In the past week, several Members of Congress and the President himself have expressed interest in finding consensus solutions to the challenges we face. Democrats, meanwhile, have responded in kind....
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With ‘Repeal, Replace’ in Ashes, Democrats Can ‘Repair’

The front-page failure of Republicans’ effort to repeal the Affordable Care Act last week has opened a remarkable and unexpected opportunity to get beyond the rhetoric of repeal and undertake a thoughtful repair of the shortcomings of our current health care system. As former staff to two of the Democratic Party’s most constructive, collaborative, and accomplished health care lawmakers of the last half century — Sens. Ted Kennedy and Max Baucus — we see last week’s legislative failure as an opportunity to explore a chance for real progress....
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Five Lessons From The AHCA’s Demise

While the keyhole of history has had insufficient time to bring the failed launch of the American Health Care Act (AHCA) into focus, it’s not too soon to begin learning some of the lessons it can teach us. Legislative efforts have a lifespan but our health care system does not. So whether we are still rejoicing or recriminating, let’s take a look at some timeless principles we can apply to the ongoing effort to improve health care in the United States. ...
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Five Reasons The ACA Won’t Be Repealed

Since November 8, a chill has descended among individuals nationwide who are involved with or otherwise care about health care. Like sheep herded to their fate, there has been a resignation that the Affordable Care Act (ACA) will be repealed, taking with it coverage for over 23 million people, strong protections for consumers, and innovations in care delivery....
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MACRA Final Rule: CMS Strikes A Balance; Will Docs Hang On?

On Friday, the Centers for Medicare and Medicaid Services (CMS) released the Final Rule implementing the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)—aka the “SGR” repeal bill, aka Medicare physician payment 3.0. The central theme of the MACRA Final Rule is its softening of key program parameters in an effort to allay provider concerns, rally participation, and avoid adverse consequences out of the gate....
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Breaking Down The MACRA Proposed Rule

The mother ship has landed. On Wednesday, April 27, the Centers for Medicare and Medicaid Services (CMS) released the highly anticipated proposed rule that would establish key parameters for the new Quality Payment Program, a framework that includes the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs)....
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Brave New World: Medicare’s Advanced Payment Models

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) established a new framework for Medicare physician payment. Under the law, beginning in 2019, health care professionals participating in the program will come to a crossroads on their path to reimbursement. In one direction—the default direction—they will be subject to the Merit-Based Incentive Payment System (MIPS), a revamp of Medicare’s fee-for-service (FFS) payment system that consolidates existing quality programs into a unified reimbursement component....
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Moops?: A Roadmap To MIPS

After a seemingly endless stream of stop-gap “doc fixes,” President Obama on April 14, 2015, signed into law a permanent repeal and replacement of Medicare’s Sustainable Growth Rate formula. The 2015 law, known as the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (P.L. 114-10), permanently reformed Medicare physician payments and (finally) put to rest what had become a dreaded perennial legislative ritual of blocking reimbursement cuts. ...
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Implementation Of The Biosimilars Provisions Of The ACA — Where Are We Now?

Despite the passage of a 2010 law addressing such medicines, the Food and Drug Administration’s (FDA) approval this year of the first biosimilar has prompted a flurry of regulatory activity aimed at filling gaps left by the statute. For a helpful primer on the issue, see a recent Health Affairs Health Policy Brief. This post will address key concerns raised by recent FDA guidance, as well as other widely anticipated but yet-to-be released regulatory activity, such as the pivotal interchangeability standard....
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Review Of Proposed 340B Omnibus Guidance: How We Got Here And What It Says

In a previous post—now almost one and a half years ago—I described “the coming storm” I anticipated would develop around the 340B drug discount program. After a brief tornado hit the House Energy and Commerce Committee when they considered including 340B reforms in their 21st Century Cures initiative, a slower, hurricane-style churn over the Administration’s proposed guidance on the topic has settled in....
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May The Era Of Medicare’s Doc Fix (1997-2015) Rest In Peace. Now What?

After seventeen years (eight months, 9 days…), over a dozen acts of Congress and innumerable reams of debate and conjecture about its fate, it’s time to say goodbye to the Medicare Sustainable Growth Rate (SGR) formula. As a proper wake, let’s take a moment to reflect on this enigma of health care economic theory. And then let’s not ever do it again....
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The Lame Duck Device Tax?

In a recent Health Affairs Blog post, I explored the types of changes that might be made to the Affordable Care Act (ACA) if and when Congress decides to revisit the law in a bipartisan manner. While that day is likely still some years away, Republican control of the Senate this year does raise the probability we’ll see action on some more central elements of President Obama’s signature domestic policy achievement....
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Washington Wakes Up To Socioeconomic Status

John Mathewson, executive vice president of Health Care Services for Children with Special Needs (HSC) – a Medicaid managed care plan in D.C. for children on Supplemental Security Income (SSI) – recently spoke at the Association for Community Affiliated Plans (ACAP) CEO Summit before the July 4 Recess. Mathewson described what he has dubbed The Kitten Paradox: When HSC examined environmental factors for children with asthma, it found that the presence of pets in the house was a common thread, not too far behind having a smoker around....
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The Coming Storm Over The 340B Rx Drug Discount Program

Beneath the glare of the wind-down of the ACA open enrollment period and wind-up of the 2015 Medicare regulation cycle, another Administration document is sitting at a few top officials’ desks for final review. It’s targeted for release in June but could come any day....
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Travels In Hyperreality: What If Bipartisan ACA Fixes Were Possible?

Since enactment of the Affordable Care Act in March 2010, a strange, relatively unnoticed phenomenon has occurred: Congress has passed bipartisan changes to it. These amendments were generally to such esoteric components of the law that they dodged the political block-aid that otherwise surrounds it. But what would happen if things were different?...
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Medicare Advantage Rolls On

Monday afternoon, the Centers for Medicare and Medicaid Services (CMS) released the final rates and other reimbursement policies for Medicare Advantage (MA) plans, referred to as the Final Call Letter. Once again, the Administration took pains to ameliorate planned cuts to MA, demonstrating the program’s increasing popularity with seniors and, by extension, its robust political strength....
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Unpacking the Doc Fix

If you blinked on Thursday, you might’ve missed the House passing the latest Medicare’doc fix’ After posting the bill in the wee hours of Wednesday morning, House leaders faced opposition over its stop-gap approach and some of the cuts employed to offset the cost of the bill. With some arm-twisting, they managed to suppress objections for the handful of seconds necessary to hammer the gavel and call it done....
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Unpacking the Wyden Chronic Care Bill

As he ascends to the Chair of the Senate Finance Committee, Senator Ron Wyden’s recent proposal to reform Medicare by improving care for the chronically ill has garnered significant attention and support. Its topline goal of incentivizing integration of care for high-risk patients is resonating with stakeholders across the health care continuum....
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The Month of Anti-Deadlines

As we shake off the carb-coma and make our pre-resolutions, Congress and the Administration head into a sprint to the holiday recess fraught with health policy implications. Unlike every December in recent memory, there isn’t very much Congress actually has to do. Here are the top five things you need to know to follow the fun and prepare your organization for the changes afoot. ...
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