1 big thing: What's next after transparency drama

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2. Hearings and markups to watch

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3. 1 fun thing: Lunch with David Sanders

Welcome to Tuesday. After a dramatic start to the week, we have the backstory on House leaders' decision to cancel Monday's vote on the House health price transparency bill, and possible next steps.

We'll be back tomorrow — or sooner, if there's breaking news.

✅ Thank you for reading Axios Pro Policy, and thanks to editor Adriel Bettelheim and senior copy editor Bryan McBournie.

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Health Care Policy

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1 big thing: House budget hits Medicaid again

2. What to watch at HELP's primary care markup

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Welcome back. Today we have a timely look at how House Republicans' 2024 budget resolution is reviving some conservative health policies just in time for the elections. 

We'll be back in your inbox tomorrow  — sooner, if there's breaking news.

1 big thing: House GOP goes on budget offense

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2. Catch me up: Republicans' CR, physician pay fight

Welcome back, gang! Today we're looking at the balancing act House Republicans face as they mark up their 2024 budget while trying to make good on a pledge not to touch Medicare and Social Security. 

Watch your inboxes tonight for an alert if the House passes the transparency bill as expected. 

👾 Download the latest Axios Pro report on key AI laws, lawmakers and companies shaping the future of the technology.

✅ Thank you for reading Axios Pro Policy, and thanks to editors Adriel Bettelheim and David Nather and senior copy editor Bryan McBournie.

1 big thing: Takeaways from Senate HELP's big markup

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2. What's next on Senate Ag-FDA appropriations

We made it to Thursday, gang. Here's a look at takeaways from today's big Senate HELP markup of its primary care-workforce bill, and the bumpy road ahead for the package.

Programming note: There won't be a Monday newsletter since it's Yom Kippur and the House and Senate will be out. We'll be back on Tuesday, unless there's breaking news before then.

✅ Thank you for reading Axios Pro Policy, and thanks to editor Adriel Bettelheim and copy editor Amy Stern.

1 big thing: Behind the Medicaid disenrollment numbers

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2. First look: Bipartisan behavioral health access bill

3. Catch me up: Organ transplants, N.C. Medicaid

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Welcome back, gang. Today, we go behind the numbers and examine who's actually getting dropped from Medicaid as states unwind continuous enrollment, and how many could wind up uninsured.

🚨Situational awareness: Senate HELP Committee Ranking Member Bill Cassidy will send a request for information to stakeholders later today asking about ways to reform the CDC, including modernizing its use of public health data.

Axios Pro Policy

Vitals

Axios Vitals

The Department of Health and Human Services has released a contingency plan outlining what activities would continue in the event of a government shutdown. 

Plans for subagencies including the Centers for Medicare and Medicaid Services and the Food and Drug Administration were also published. 

42% of HHS staff, or 37,325 individuals, would be furloughed by the second day of a funding lapse, while the remainder would be retained to handle core functions. 

CMS will continue to have funding for Medicaid through the first quarter of FY2024 due to advanced appropriations. 

Excepted CMS employees will ensure Medicare keeps running. 

FDA's activities that are funded by carryover user fees will continue. 

Leftover supplemental COVID funding is being used to continue FDA's COVID response work, such as emergency use authorizations and supply chain issues. 

Excepted FDA staff can continue monitoring food-borne illnesses and some inspection surveillance activities. 

NIH staff working with patients in clinical trials are excepted from furloughs. 

CDC staff will remain on the job working on outbreak response, laboratory functions, running PEPFAR and emergency operations. 

The Administration for Strategic Preparedness and Response will also retain staff who are awarding contracts for medical countermeasures and flu preparedness. 

Centers for Medicare and Medicaid Services

HHS releases shutdown contingency plan

The Department of Health and Human Services has released a contingency plan outlining what activities would continue in the event of a government shutdown.

Department of Health and Human Services (HHS)

The Department of Health and Human Services has released a <a class="gtmContentClick" data-vars-link-text="contingency plan" data-vars-click-url="https://www.hhs.gov/about/budget/fy-2024-hhs-contingency-staffing-plan/index.html" data-vars-content-id="4949d532-78f5-49cc-ab01-0dd0d286ebc2" data-vars-headline="HHS releases shutdown contingency plan" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://www.hhs.gov/about/budget/fy-2024-hhs-contingency-staffing-plan/index.html" target="_blank">contingency plan</a> outlining what activities would continue in the event of a government shutdown. <ul><li>Plans for subagencies including the <a class="gtmContentClick" data-vars-link-text="Centers for Medicare and Medicaid Services" data-vars-click-url="https://www.hhs.gov/about/budget/fy-2024-cms-contingency-staffing-plan/index.html" data-vars-content-id="4949d532-78f5-49cc-ab01-0dd0d286ebc2" data-vars-headline="HHS releases shutdown contingency plan" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://www.hhs.gov/about/budget/fy-2024-cms-contingency-staffing-plan/index.html" target="_blank">Centers for Medicare and Medicaid Services</a> and the <a class="gtmContentClick" data-vars-link-text="Food and Drug Administration" data-vars-click-url="https://www.hhs.gov/about/budget/fy-2024-fda-contingency-staffing-plan/index.html" data-vars-content-id="4949d532-78f5-49cc-ab01-0dd0d286ebc2" data-vars-headline="HHS releases shutdown contingency plan" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://www.hhs.gov/about/budget/fy-2024-fda-contingency-staffing-plan/index.html" target="_blank">Food and Drug Administration</a> were also published. </li></ul>Here are some highlights: <ul><li>42% of HHS staff, or 37,325 individuals, would be furloughed by the second day of a funding lapse, while the remainder would be retained to handle core functions. </li><li>CMS will continue to have funding for Medicaid through the first quarter of FY2024 due to advanced appropriations. </li><li>Excepted CMS employees will ensure Medicare keeps running. </li><li>FDA&#x27;s activities that are funded by carryover user fees will continue. </li><li>Leftover supplemental COVID funding is being used to continue FDA&#x27;s COVID response work, such as emergency use authorizations and supply chain issues. </li><li>Excepted FDA staff can continue monitoring food-borne illnesses and some inspection surveillance activities. </li><li>NIH staff working with patients in clinical trials are excepted from furloughs. </li><li>CDC staff will remain on the job working on outbreak response, laboratory functions, running PEPFAR and emergency operations. </li><li>The Administration for Strategic Preparedness and Response will also retain staff who are awarding contracts for medical countermeasures and flu preparedness. </li></ul>

A bipartisan group of six House lawmakers on Tuesday introduced a plan aimed at integrating behavioral health services for Medicare beneficiaries in a primary care setting. 

Why it matters: It's part of a broader trend of rolling mental health care into primary care practices, but aimed specifically at seniors. 

Details: The bill is cosponsored by Reps. Michelle Steel, Lizzie Fletcher, Gus Bilirakis, August Pfluger, Susie Lee and Dan Kildee. 

It encourages the integration of behavioral health services by increasing Medicare reimbursement rates via specific CPT codes for three years. 

The increased reimbursement rates are supposed to help offset the startup costs of integrating mental health care into doctors' offices. 

The bill would also make the Health and Human Services secretary create quality measurement reporting requirements for integrating behavioral health with primary care. 

Of note: A Senate version of the legislation was introduced in April by Sens. Catherine Cortez-Masto and John Cornyn. 

The big picture: 20% of people ages 65 and older reported having symptoms of anxiety or depression, according to a February 2023 survey from KFF. 

First look: Bipartisan behavioral health access bill

A bipartisan group of six House lawmakers on Tuesday introduced a plan aimed at integrating behavioral health services for Medicare beneficiaries in a primary care setting.

Health care

A bipartisan group of six House lawmakers on Tuesday introduced a plan aimed at integrating behavioral health services for Medicare beneficiaries in a primary care setting. Why it matters: It&#x27;s part of a broader trend of rolling mental health care into primary care practices, but aimed specifically at seniors.

We're back again with another lunch feature, this time with Coherus BioSciences vice president of government affairs and public policy David Sanders.

He recently sat down with Axios at Zaytinya over roasted Brussels sprouts and chicken skewers to chat about biosimilars and the drug supply chain.

Coherus recently launched a low-cost Humira competitor. Beyond his work on biosimilars, Sanders also is executive director of Securing America's Medicines and Supply, a group of pharmaceutical companies pushing for domestic manufacturing of products.

He previously worked at Teva, where he helped push for the creation of the biosimilars approval pathway within the Affordable Care Act, and for Sen. Marsha Blackburn when she was a House member.

Biggest challenge for biosimilars industry: The pathway that we envisioned 15 years ago is not quite the pathway that we've got today. 

Unless we make improvements to Medicare, but also to the way commercial payers and middlemen treat these low-cost alternatives, we're gonna see the [drug] development program across the U.S. industry dry up. That's the real warning right now, is that you're going to see people get out of the business.

The PBM reform legislation he's pushing: The Blackburn-Menendez PBM legislation. I think that's the core of what's going to end up being passed ... but we need to add some things to it, to make it more meaningful, such as either banning rebates for originators with competition or creating a biosimilars-only tier for the biosimilars with the lowest wholesale acquisition cost. 

On addressing cancer drug shortages: I wouldn't give the FDA more authority. They have enough authority but they should increase inspections. I do think Congress should consider giving them more money for more inspections. I would add that to the framework that [Rep. Cathy McMorris Rodgers] put together. 

We're also endorsing the RAPID Reserve Act ... as well as giving construction authority to the assistant secretary for preparedness and response. 

(The RAPID Reserve Act would contract with generic drug companies in the U.S. and OECD member countries to keep certain reserves of drug supplies on hand. Construction authorities would allow for an increase of domestic manufacturing.)

Predictions for PAHPA: PAHPA is probably going to get delayed. PAHPA could be a December or March bill. So PAHPA could become a vehicle for a lot of these things [drug shortage issues] and/or the PBM reform. 

Best memory of working on the Hill: I was given the distinct honor by Rep. Marsha Blackburn to write her floor speech for the day we honored the life and legacy of Johnny Cash. It meant a lot to me because I knew Johnny. I grew up with Waylon Jennings' son so I met Johnny that way.

1 fun thing: Lunch with David Sanders

We sit down with Coherus BioSciences vice president of government affairs and public policy David Sanders.

Health lobbyist David Sanders shares lunch with Axios at Zaytinya. 

Sanders snacking on Brussels Sprouts and cheese at Zaytinya. Photo: Victoria Knight/Axios 

We&#x27;re back again with another lunch feature, this time with Coherus BioSciences vice president of government affairs and public policy David Sanders.<ul><li>He recently sat down with Axios at Zaytinya over roasted Brussels sprouts and chicken skewers to chat about biosimilars and the drug supply chain.</li></ul>

House Republicans are reviving Medicaid work requirements and other conservative health policy goals with a 2024 blueprint that House Budget Chairman Jodey Arrington unveiled and the panel marked up today. 

Why it matters: The budget document may be nonbinding and largely symbolic, but it could form the basis of a GOP health platform for next year's elections.

Details: It proposes balancing the federal budget in 10 years while sparing Medicare benefits. But to make the numbers all work, it would implement Medicaid work requirements and per capita caps, roll back Affordable Care Act subsidy expansion and enact site-neutral hospital payment measures. 

It proposes setting discretionary spending at $1.471 trillion, which is an 8% reduction or $131 billion below FY23 levels. There's also a proposed cap for spending growth at 1% for FY 2024. 

While Arrington has specifically said he doesn't want to cut Medicare benefits, he is proposing a bipartisan fiscal commission that would look at "drivers of U.S. debt, including entitlement spending such as Social Security and Medicare."

That could open the door to a host of provider payment changes that antagonize powerful health interests. 

The document sets Medicaid work requirements at 80 hours per month, similar to a proposal in Speaker Kevin McCarthy's original debt ceiling bill that fell out in the final deal in the face of Democratic opposition. 

It also envisions a Medicaid per capita cap for states rather than an open-ended federal match. 

Outside of Medicare and Medicaid, the budget resolution calls for rolling back $57 billion of ACA subsidies which were expanded under the Inflation Reduction Act. 

The resolution has a section devoted to returning to a "patient-centered health care system" with shout-outs to health policies that have already been gaining momentum in the House, including site-neutral payments, PBM reform, transparency for hospitals and insurers and 340B drug pricing reform.

Between the lines: The document didn't specify how targeted the site-neutral measures would be. 

As Caitlin Owens noted in her Monday column, the one that's moved in the House transparency package is limited to equalizing Medicare payments for drugs administered at outpatient facilities and doctor's offices, which saves less money than more wide-ranging site-neutral proposals. 

The other side: Despite some bipartisan support for site-neutral measures, Budget Committee Democrats didn't hold back criticism in a report released Tuesday. 

"It includes various payment cuts to providers, such as lower payments for certain outpatient hospital services and lower hospital reimbursements for uncompensated care. In the past, the most common cost-shifting response from hospitals to such proposals has been to reduce unprofitable services, which disproportionately hurt minority and low-income patients," the Democratic report reads. 

The intrigue: Arrington during a Tuesday press conference acknowledged the perils of reducing spending without touching Medicare benefits. 

"No party is going to strike that balance on their own. It's just not practical. It's too politically sensitive," Arrington said in response to a question from Axios. "As soon as one party or the other comes out with their grand plan to save Social Security or Medicare, it will be used as a baseball bat against the other." 

"It needs to be done on a bipartisan basis, because that's the only sustainable path to that consensus," Arrington added. 

But Democrats may not be so on board for such a commission. 

"I really have to say, I am very skeptical on any sort of Republican-led commission that wouldn't just be a backdoor way to bring about cuts," House Budget Ranking Member Brendan Boyle said. 

Of note: It's also clear that health care spending is definitely going to continue to be a target of the House Budget Committee, evidenced by the attention paid to Rep. Michael Burgess' new health care task force this week.   

Reality check: This GOP-led budget resolution comes amid a messy appropriations fight in the House where Republicans can't even agree on spending levels or pass appropriations bills on the floor. 

Plus, a budget resolution with such spending cuts stands no chance in the Senate. 

Yes, but: "I have full confidence we will get it to the floor in due time," Arrington told reporters last week. 

House budget resolution hits Medicaid once again

The budget document could form the basis of a GOP health platform for next year's elections.

House Budget Committee Chairman Jodey Arrington unveils a proposed budget for FY2024 on Sept. 19. (Photo by Chip Somodevilla/Getty Images)

House Republicans are reviving Medicaid work requirements and other conservative health policy goals with a <a class="gtmContentClick" data-vars-link-text="2024 blueprint" data-vars-click-url="https://docs.house.gov/meetings/BU/BU00/20230920/116397/BILLS-118pih-FY24ConcurrentResolutionontheBudget.pdf" data-vars-content-id="6a408f32-cb3e-4159-ad62-53c44b1fb53f" data-vars-headline="House budget resolution hits Medicaid once again" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://docs.house.gov/meetings/BU/BU00/20230920/116397/BILLS-118pih-FY24ConcurrentResolutionontheBudget.pdf" target="_blank">2024 blueprint</a> that House Budget Chairman Jodey Arrington unveiled and the panel <a class="gtmContentClick" data-vars-link-text="marked up" data-vars-click-url="https://budget.house.gov/the-markup-of-the-concurrent-resolution-on-the-budget-for-fiscal-year-2024" data-vars-content-id="6a408f32-cb3e-4159-ad62-53c44b1fb53f" data-vars-headline="House budget resolution hits Medicaid once again" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://budget.house.gov/the-markup-of-the-concurrent-resolution-on-the-budget-for-fiscal-year-2024" target="_blank">marked up</a> today. Why it matters: The budget document may be nonbinding and largely symbolic, but it could form the basis of a GOP health platform for next year&#x27;s elections.

While the House remains in appropriations limbo, the Senate is trying to move forward with a three-bill minibus that includes Agriculture-FDA, after hitting a roadblock in the form of Sen. Ron Johnson last week. 

Why it matters: The Senate wants to pass its bipartisan appropriations bills in order to maintain an upper hand in eventual negotiations over funding the government. 

What's happening: Last week, Johnson protested bundling the three bills by lodging a procedural objection that halted the minibus' consideration. 

Senate Democrats tried to get around this by putting forward a motion to suspend the Senate rules but that vote failed on Wednesday.

Johnson did signal this week he could be open to lifting his hold if he gets a vote on the "Prevent Government Shutdowns Act" as part of an amendment agreement. 

Sen. Roger Marshall has also insisted that he get a vote on a controversial bill about credit card competition. 

What they're saying: Senate Appropriations Ranking Republican Susan Collins told reporters on Wednesday night that "we certainly made progress today, but we still have a ways to go." 

"We're continuing to work with those that have holds. Most of the holds have been cleared, and we've been able to secure votes on Republican amendments, which has always been our goal. So I hope we can keep going," she added. 

On Thursday, the Senate spent floor time confirming several members of the Joint Chiefs of Staff that had been held up by Sen. Tommy Tuberville over the Defense Department's abortion travel policy. 

What's next: Once an amendment agreement is struck, the chamber can move on to the minibus, which could be a lengthy process.

Remember, too, there are significant differences between the House and Senate versions of the Ag-FDA bill that lawmakers would have to iron out.

Funding for the FDA itself is relatively stable: Senate appropriators opted for $6.63 billion, while House appropriators allotted the agency $6.58 billion.

But the House's bill has several controversial policy riders, including a provision that would return the abortion pill mifepristone to in-person dispensing requirements. 

Of note: House Labor-HHS Appropriations Chair Robert Aderholt told reporters on Thursday afternoon that there are discussions of  "maybe bringing in three or four bills together" next week in the lower chamber, including possibly Ag-FDA, Axios' Andrew Solender reported. 

The bottom line: Time is ticking. Government funding runs out on Oct. 1. And with the House floor chaos, a government shutdown may be unavoidable.

What's next on Senate Ag-FDA approps

The Senate is trying to move forward with a three-bill minibus that includes Agriculture-FDA, after hitting a roadblock last week.

Sens. Patty Murray and Susan Collins at an Appropriations hearing. Photo: Andrew Caballero-Reynolds / AFP

Congress

While the House remains in <a class="gtmContentClick" data-vars-link-text="appropriations limbo" data-vars-click-url="https://www.axios.com/2023/09/21/kevin-mccarthy-house-republicans-shutdown-likely" data-vars-content-id="bce79992-4788-4bc1-87e9-f0c5865a7333" data-vars-headline="What&#x27;s next on Senate Ag-FDA approps" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://www.axios.com/2023/09/21/kevin-mccarthy-house-republicans-shutdown-likely" target="_self">appropriations limbo</a>, the Senate is trying to move forward with a three-bill minibus that includes Agriculture-FDA, after hitting a roadblock in the form of Sen. Ron Johnson last week. Why it matters: The Senate wants to pass its bipartisan appropriations bills in order to maintain an upper hand in eventual negotiations over funding the government.

Victoria Knight

Stories

First look: Bipartisan behavioral health access bill

HHS releases shutdown contingency plan

What's next on Senate Ag-FDA approps

House budget resolution hits Medicaid once again

1 fun thing: Lunch with David Sanders

Newsletter editions

⚕️Health Care: Behind Medicaid disenrollments

🩺 Health Care: HELP markup takeaways

🎯Health Care: Budget targets Medicaid

🏛Health Care: Transparency bill outlook

💵 Health Care: House budget maneuvering