Every election is consequential, but the 2020 election turned out to be consequential in ways that were not expected going into Election Day. Turnout eclipsed all-time highs in raw vote totals and may be the highest turnout percentage since the election of 1900. However, the end result of all those ballots largely maintains the status quo for 2021, with the exception of President-Elect Joe Biden. Minimal power shifts—near historic lows across almost every level of government—hold implications for the ACR’s advocacy agenda moving forward.
The Congressional Landscape
There will be many new faces in Congress, including at least seven new members of the Senate and close to 60 new members in the House. Educating the freshman crop of legislators about the issues facing rheumatology providers and patients will be extremely important to achieve ACR legislative goals. Additionally, given the Republican gains in the House and the narrow Senate margins (regardless of the election outcomes in Georgia), every vote will be incredibly important to move legislation through either chamber.
The Democratic majority in the House narrowed its vote lead, but maintained leadership. This lends itself to smooth reintroduction of many priorities from the 116th Congress to the 117th. Popular legislation, such as prior authorization reform under Medicare and limits to step therapy use, as well as policies supporting growth in the medical workforce, can get a headstart with early reintroduction by sponsors who are continuing to serve in the House.
The Senate is harder to predict due to its tighter margins and possible flip, where we won’t know who the majority leaders will be until January. If Senate Majority Leader Mitch McConnell (R-KY) maintains his position, we can expect he will continue to be incredibly selective about what legislation passed by the House that he allows to be considered in the Senate. The tighter majority margin means any legislation taken up will have to appeal to at least centrist Republicans to have a chance of passing. If Sen. Chuck Schumer (D-N.Y.) becomes majority leader after the Georgia runoffs, we are likely to see a smoother pipeline of legislation from the House to the Senate and a higher likelihood of passage. However, even if both chambers are led by one party, the small margins in the Senate mean that any legislation from the House will have to be further moderated to get through the Senate.
We expect 2021 and the new Congress and administration to bring a fresh perspective on our current issues. A more comprehensive response to COVID-19 and the pandemic’s medical and financial demands will be top of mind. In this process, we are likely to see renewed discussion of major healthcare overhauls, which would not pass through a McConnell-led Senate and would need to be carefully worded to get through a narrow Schumer-led Senate. It is more likely that popular measures from the 116th Congress, such as utilization management policies and workforce support, will be taken up, while the larger picture continues to be negotiated by elected officials and stakeholders.
The Regulatory Landscape
As the nation faces another surge in the SARS-CoV-2 pandemic, President-Elect Biden has signaled his focus on coordinating federal efforts to get the U.S. through this public health emergency and to successfully administer an approved vaccine to the population. The ACR anticipates most regulatory activity in the first six months of the year will be dedicated to pandemic response.
The Trump administration has been working on aspects of the president’s executive order on drug pricing. However, with only two months left, it is unlikely that any meaningful regulations will be finalized before the transition of power. We know the president-elect has indicated a need to address drug pricing and has voiced support for allowing Medicare to negotiate drug prices with manufacturers. This approach will likely be addressed in the legislative branch prior to any regulatory activities. The ACR team will be closely monitoring this issue.
Lastly, the calendar year 2021 Medicare Physician Fee Schedule reaffirmed the Centers for Medicare and Medicaid Services’ (CMS) finalized policy to revalue evaluation and management (E/M) codes that will yield an approximate average 16% increase in reimbursement for rheumatology, depending on the mix of services provided and where a practice is located. Specialties that face a decrease in reimbursement have undertaken significant efforts to influence legislative activity that would alter the reimbursement of E/M codes during this pandemic.
The ACR supports waiving budget neutrality to minimize the financial concerns of the procedural specialties while ensuring the much-needed improvements to E/M revaluation important to rheumatologists.
As this is being written, the E/M improvements are slated to take effect on Jan. 1. We don’t expect the Biden administration to rescind these code revaluations and look forward to working with the CMS in the new administration to ensure these improvements are made permanent to recognize the work of cognitive care specialties.
The State Landscape
The 2020 election had little impact on the balance of power in state legislatures. Republicans previously held 59 legislative chambers, while Democrats controlled just 39. Republicans added two chambers to their total and now control 61 legislative chambers, compared with the 37 now held by the Democrats. That change in party control is the smallest in state chambers since 1944. Neither a Democratic blue wave nor a Republican red wave materialized.
This unprecedented level of stability adds some predictability to the coming legislative session. We can be reasonably sure our priority legislation that failed to pass last session will be reintroduced in the coming year. Step therapy efforts in Tennessee and Massachusetts will most likely continue, along with the reintroduction of workforce legislation in Georgia and Washington. However, with COVID-19 continuing to weigh on state budgets, any legislative ask that comes with a price will be difficult to move forward.
One of the most active areas of activity will likely be copay accumulator ban legislation. The UnitedHealthcare policy proposal that would have required physicians to report when patients use copay assistance for specialty drugs raised awareness of the importance of this issue. Although the policy has been placed on hold, it still looms large as a warning of things to come. Current estimates suggest 20 or more accumulator bills may be introduced in the coming session.
Drug prices will continue to be an issue on which states are increasingly active. Recently, pharmacy benefit manager (PBM) legislation has been at the center of state cost control efforts. However, in the past year-and-a-half, a marked decline has been seen in proposals that would aggressively regulate PBMs. Instead, we see more ad hoc measures that are chipping away at PBMs from the edges. The outcome of Rutledge v. PCMA in the U.S. Supreme Court could reignite aggressive PBM regulation at the state level. The case was heard by the court in October, but will not be decided until next year.
In addition to PBM regulations, states have increasingly sought to increase transparency throughout the drug supply chain. Proposals to monitor and cap price increases by pharmaceutical companies, as well as premium and out-of-pocket cost increases imposed on patients by payers have been set forth. Whether any of these proposals will be successful in the current environment remains unclear, but these proposals likely represent the coming wave of transparency reform.
Final Thoughts
Across the political landscape, 2021 promises to be another interesting year. To maximize our impact, we need your help. Your advocacy is essential to our success. Now more than ever, we need both the time and financial commitment from ACR/ARP members to bring about positive change in health policy. Continue to complete VoterVoice campaigns, email and call your legislators, and give to RheumPAC. If we can help you with any advocacy-related issues, contact our advocacy team at [email protected].
