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PBM and transparency riders left on the sidelines

Cassidy in the Capitol

Cassidy in the Capitol. Photo by Anna Moneymaker/Getty Images

Backers of health price transparency and PBM overhaul efforts are searching for a path forward after both issues were left out of a prospective government funding deal.

Why it matters: Barring a last-minute change, the advocates may have to wait for a lame duck session, when they will be competing with dozens of other interests trying to jam provisions into a year-end deal.

  • The passage of a CR buys a little more time, with deadlines extended to March 8 and 22. In theory, some health care items could ride on the March 22 package.

Yes, but: A good deal of disagreement and frustration remains between committees that have to sign off on any deal.

  • One friction point among GOP lawmakers is whether PBM reforms would apply to the commercial market or just Medicare.
  • "Why should we not protect a beneficiary in the commercial market?" Senate HELP Ranking Member Bill Cassidy told Axios yesterday.
  • Rep. Brett Guthrie, chair of the House Energy and Commerce health subcommittee, countered yesterday, saying "There's a number of people on our side [who think] the commercial market should not be part of a PBM [package]."

What they're saying: Senate Finance Chair Ron Wyden expressed frustration and puzzlement this week that PBM changes remained on the sidelines.

  • "I wouldn't want to go home and say 'Here's why we didn't do a PBM bill,' because the top issue in the country is holding down pharmaceutical prices, and central to that is dealing with middlemen," he said.
  • Seemingly referencing the House, he added: "I'm making some calls over there, [saying] what am I missing here? What are the real reasons this is not happening?"

Between the lines: Hospital price transparency and at least some PBM changes were seen as lower-hanging fruit, so it is noteworthy Congress has not been able to come to an agreement even on those items.

  • The talks never even seriously got to more challenging policy changes like site-neutral payments to hospitals.

What's next: The items most likely to catch a ride on the March funding deal are funding for community health centers, paired in the talks with partial relief for a Medicare payment cut to doctors.

  • Sources said Thursday that there is no final number on either of those items, but they are expected to be folded into next week's funding bill, considering there's a March 8 deadline for health center funding to expire.

The big picture: One of the main complications has been the sheer number of people who need to sign off on any deal, since four committees on both sides of the Capitol are involved.

  • "There was not an ability to get an agreement, you had to get a four-corner, actually an eight-corner [deal], and we just didn't get it," Senate Finance Ranking Member Mike Crapo told Axios yesterday.

The bottom line: The CR creating an additional, later deadline of March 22 has at least jolted a bit of life into reviving talks. But lawmakers had months leading up to this to come to a deal, and didn't come very close.

  • "It's not dead," Guthrie said. "It's just we're trying to come up with the right answer."

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