Three health policy stories to watch in 2023

Considering the country’s divided Congress, Americans shouldn’t hold their breath for major health reform legislation this year. On the other hand, 2023 is shaping up to see some incredibly consequential health policy changes that could impact millions.

Here’s a quick look at three of them: State officials are looking to pass new abortion laws and restart Medicaid eligibility checks. And at the federal level, Medicare is beginning to flex its new power to negotiate drug prices.

Medicaid eligibility checks return  

Throughout the COVID pandemic, states have avoided kicking people off Medicaid, in order to help them get through the emergency.

But now, Congress is directing states to run three years of backlogged eligibility checks on more than 90 million people in less than a year. One estimate from the Urban Institute and Robert Wood Johnson Foundation finds that up to one in five people, nearly 18 million, could be dropped from Medicaid rolls, though many could find coverage through their employers or ACA marketplaces.

Still, people like Cindy Mann are worried. “The concern really is whether people will become uninsured, even though they are eligible for Medicaid…or for marketplace coverage,” said Mann, a partner with the legal and consulting firm Manatt Health.

Mann is talking with state officials about how to pull off this massive renewal process that begins April 1. One big concern is the paperwork involved. Since 2014 states have been required to check eligibility, including people's income and addresses through databases. Sending eligibility forms through the mail was to be a last resort.

“Paperwork has always led to coverage losses among eligible people,” Mann said. “If a state sends paperwork through the mail and the mail is returned undelivered, the state can terminate coverage.”

Paperwork issues led to more than 200,000 kids losing coverage in Tennessee between 2016 and 2019.

Studies have shown when people are uninsured, they’re more likely to delay getting care. “It can also lead to other issues…medical debt, credit issues, even trouble getting jobs or renting an apartment,” Mann said.

Once states finish Medicaid eligibility checks in mid-2024, an estimated four million people are expected to end up without coverage.

There’s some good news: South Dakota, for instance, will be able to mitigate some of its coverage losses through the state’s Medicaid expansion that goes into effect this summer. It will join 38 states and the District of Columbia in expanding coverage to include people making slightly more than the federal poverty level, or about $18,000 a year for a single adult.

There are also signs lawmakers in a few of the 11 remaining holdout states, including North Carolina, Kansas and Wyoming, are considering expansion this year.

Abortion in the balance

In this post-Roe era, there’s a tug of war as states are busy passing new laws to restrict – or in other cases expand – access to the procedure.

About half of the states are trying to seal off access to abortion care. Meanwhile, the other half, along with the Biden administration, are working to make it easier to get abortions.

“The rubber's hit the road and what they do on abortion really matters,” said Elizabeth Nash, state policy analyst for the Guttmacher Institute, an abortion rights health research group.

Currently it’s difficult for people to get an abortion in 19 states – because it's illegal, barriers are high or providers have left.

Nash projects that number will increase in 2023, as states like Nebraska, Ohio and Florida may move to pass bans.

This year she’s expecting more debates around exceptions for the life of the mother or rape or incest. That’s because, while a portion of the Republican base may want total bans, polling shows most Americans support some abortion rights.

“Legislators thread that needle through exceptions,” Nash said. “How many exceptions could they add into these bills in order to still pass them.”

The next frontier of the abortion fight is medications. In 2020 more than half of abortions were through medications. That’s only expected to increase.

Eighteen states already limit how patients can use telemedicine to complete medication abortions, but Nash anticipates that number also will rise. “We're anticipating states to pass laws like banning the mailing of pills,” she said. “Or requiring the manufacturers and distributors to be licensed in their state.”

On the other hand, the Food and Drug Administration recently determined patients can now use telehealth to get these prescriptions, and pick them up at retail pharmacies or get them sent through the mail.

As women continue to travel to the 18 states that enacted a record 77 provisions expanding or protecting access to abortion care last year, Nash is expecting anti-abortion lawmakers to go after the businesses and aid groups – often called abortion funds – that pay for that travel.

“They probably won't pass travel bans,” she said. “But they will try to limit how businesses can provide abortion care and support patients who need abortion care or how the abortion funds can operate.”

Texas lawmakers have already filed a bill to eliminate tax breaks for the businesses that pay for employees to travel for abortion care.

In the 18 states that have already expanded access through abortion funds and increased capacity, Nash is looking for more action to protect providers through so-called shield laws.

“Putting that sort of legal bubble wrap around providers,” she said, “protecting them from legal action from states that have banned abortions. We will not extradite the provider to you. We will not participate in a summons, those sorts of things.”

Prescription drug dances  

After decades of little to no movement, Americans are starting to see some progress from last summer’s Inflation Reduction Act (IRA) to lower prescription drug prices. One example: Diabetic seniors on Medicare are now paying a maximum of $35 per month for insulin.

As other parts of the IRA are implemented, 2023 promises to be a year of behind-the-scenes action to shape what consumers pay at the pharmacy counter in the future. This year Medicare is building out its 95-person Medicare Drug Rebate and Negotiations Group.

And by September the agency will reveal the 10 high-cost outpatient prescription drugs it plans to negotiate lower prices on.

“I am most interested to see what drugmakers’ reaction is going to be when there's actually a list,” said Rachel Cohrs, Washington Correspondent for STAT News. “It's been Wall Street's favorite parlor game since the Inflation Reduction Act passed to guess which drugs might be on this list.”

Patients won’t see these newly hammered out prices until 2026, but in the coming months and years Cohrs expects drugmakers to challenge the process. “This is a big hit to the industry,” she said. “I wouldn't be surprised in the slightest to see the industry take an aggressive stance in court.”

Medicare officials are also facing a big question around coverage of a newly approved Alzheimer’s drug, Leqembi.

Normally the agency covers all FDA-approved medications, but that hasn’t been the case for these new drugs. Medicare officials were concerned that another Alzheimer's drug, Aduhelm, did little to improve health and carried real safety risks, so the agency decided to limit coverage of it to only those people included in clinical trials.

That restriction on payments applies to all similar Alzheimer's drugs, including Leqembi, even though the data on this new drug has shown more promising results.

“I think there's a good chance that we could see a reconsideration here,” said Cohrs. “There's going to be pressure on CMS to make a decision based on this new data, not cover this new drug based on old data.”

It’s not clear when Medicare officials will make a decision.

“The stakes are very high,” she said. “Drugmakers really need a win in the Alzheimer's space. And if this drug gets fully approved, shows some clinical benefit for patients and is able to get some substantial coverage… I think that would be a very good signal for other drugs in the pipeline.”

This story comes from the health policy podcast Tradeoffs, a partner of Side Effects Public Media. Dan Gorenstein is Tradeoffs’ executive editor, and Alex Olgin is a reporter/producer for the show, which ran this story on Jan. 19, 2023.

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