[House Hearing, 119 Congress]
[From the U.S. Government Publishing Office]
LEGISLATIVE PROPOSALS TO SUPPORT PATIENT
ACCESS TO MEDICARE SERVICES
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED NINETEENTH CONGRESS
SECOND SESSION
__________
JANUARY 8, 2026
__________
Serial No. 119-51
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Published for the use of the Committee on Energy and Commerce
govinfo.gov/committee/house-energy
energycommerce.house.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
62-884 PDF WASHINGTON : 2026
COMMITTEE ON ENERGY AND COMMERCE
BRETT GUTHRIE, Kentucky
Chairman
ROBERT E. LATTA, Ohio FRANK PALLONE, Jr., New Jersey
H. MORGAN GRIFFITH, Virginia Ranking Member
GUS M. BILIRAKIS, Florida DIANA DeGETTE, Colorado
RICHARD HUDSON, North Carolina JAN SCHAKOWSKY, Illinois
EARL L. ``BUDDY'' CARTER, Georgia DORIS O. MATSUI, California
GARY J. PALMER, Alabama KATHY CASTOR, Florida
NEAL P. DUNN, Florida, Vice PAUL TONKO, New York
Chairman YVETTE D. CLARKE, New York
DAN CRENSHAW, Texas RAUL RUIZ, California
JOHN JOYCE, Pennsylvania SCOTT H. PETERS, California
RANDY K. WEBER, Sr., Texas DEBBIE DINGELL, Michigan
RICK W. ALLEN, Georgia MARC A. VEASEY, Texas
TROY BALDERSON, Ohio ROBIN L. KELLY, Illinois
RUSS FULCHER, Idaho NANETTE DIAZ BARRAGAN, California
AUGUST PFLUGER, Texas DARREN SOTO, Florida
DIANA HARSHBARGER, Tennessee KIM SCHRIER, Washington
MARIANNETTE MILLER-MEEKS, Iowa LORI TRAHAN, Massachusetts
KAT CAMMACK, Florida LIZZIE FLETCHER, Texas
JAY OBERNOLTE, California ALEXANDRIA OCASIO-CORTEZ, New York
JOHN JAMES, Michigan JAKE AUCHINCLOSS, Massachusetts
CLIFF BENTZ, Oregon TROY A. CARTER, Louisiana
ERIN HOUCHIN, Indiana ROBERT MENENDEZ, New Jersey
RUSSELL FRY, South Carolina KEVIN MULLIN, California
LAUREL M. LEE, Florida GREG LANDSMAN, Ohio
NICHOLAS A. LANGWORTHY, New York JENNIFER L. McCLELLAN, Virginia
THOMAS H. KEAN, Jr., New Jersey
MICHAEL A. RULLI, Ohio
GABE EVANS, Colorado
CRAIG A. GOLDMAN, Texas
JULIE FEDORCHAK, North Dakota
------
Professional Staff
MEGAN JACKSON, Staff Director
SOPHIE KHANAHMADI, Deputy Staff Director
TIFFANY GUARASCIO, Minority Staff Director
Subcommittee on Health
H. MORGAN GRIFFITH, Virginia
Chairman
DIANA HARSHBARGER, Tennessee, Vice
Chair
GUS M. BILIRAKIS, Florida DIANA DeGETTE, Colorado
EARL L. ``BUDDY'' CARTER, Georgia Ranking Member
NEAL P. DUNN, Florida RAUL RUIZ, California
DAN CRENSHAW, Texas DEBBIE DINGELL, Michigan
JOHN JOYCE, Pennsylvania ROBIN L. KELLY, Illinois
TROY BALDERSON, Ohio NANETTE DIAZ BARRAGAN, California
MARIANNETTE MILLER-MEEKS, Iowa KIM SCHRIER, Washington
KAT CAMMACK, Florida LORI TRAHAN, Massachusetts
JAY OBERNOLTE, California MARC A. VEASEY, Texas
JOHN JAMES, Michigan LIZZIE FLETCHER, Texas
CLIFF BENTZ, Oregon ALEXANDRIA OCASIO-CORTEZ, New York
ERIN HOUCHIN, Indiana JAKE AUCHINCLOSS, Massachusetts
NICHOLAS A. LANGWORTHY, New York TROY A. CARTER, Louisiana
THOMAS H. KEAN, Jr., New Jersey GREG LANDSMAN, Ohio
MICHAEL A. RULLI, Ohio FRANK PALLONE, Jr., New Jersey (ex
BRETT GUTHRIE, Kentucky (ex officio)
officio)
C O N T E N T S
----------
Page
Hon. H. Morgan Griffith, a Representative in Congress from the
Commonwealth of Virginia, opening statement.................... 2
Prepared statement........................................... 4
Hon. Diana DeGette, a Representative in Congress from the State
of Colorado, opening statement................................. 7
Prepared statement........................................... 9
Hon. Brett Guthrie, a Representative in Congress from the
Commonwealth of Kentucky, opening statement.................... 11
Prepared statement........................................... 13
Hon. Frank Pallone, Jr., a Representative in Congress from the
State of New Jersey, opening statement......................... 16
Prepared statement........................................... 18
Witnesses
Susan Van Meter, President, American Clinical Laboratory
Association.................................................... 20
Prepared statement........................................... 23
Connie Sullivan, President and Chief Executive Officer, National
Home Infusion Association...................................... 37
Prepared statement........................................... 39
Tom Ryan, President and Chief Executive Officer, American
Association for Homecare....................................... 52
Prepared statement........................................... 54
Additional material submitted for the record................. 64
Answers to submitted questions............................... 314
David Lipschutz, Co-Director/Attorney, Center for Medicare
Advocacy....................................................... 82
Prepared statement........................................... 84
Legislation\1\
H.R. 1703, Choices for Increased Mobility Act of 2025
H.R. 2005, DMEPOS Relief Act of 2025
H.R. 2172, Preserving Patient Access to Home Infusion Act
H.R. 2477, Portable Ultrasound Reimbursement Equity Act of 2025
H.R. 2902, Supplemental Oxygen Access Reform (SOAR) Act of 2025
H.R. 5243, To amend title XVIII of the Social Security Act to
increase data transparency for supplemental benefits under
Medicare Advantage
H.R. 5269, Reforming and Enhancing Sustainable Updates to
Laboratory Testing Services (RESULTS) Act of 2025
H.R. 5347, Health Care Efficiency Through Flexibility Act
H.R. 6210, Senior Savings Protection Act
H.R. 6361, Ban AI Denials in Medicare Act
Submitted Material
Inclusion of the following was approved by unanimous consent.
List of documents submitted for the record....................... 150
Letter of January 6, 2026, from Daniel Buning, Chief Executive
Officer, TridentCare, to Mr. Guthrie, et al.................... 153
Letter of January 7, 2026, from Dominick V. Spatafora, President,
Neuropathy Action Foundation, to Mr. Griffith and Ms. DeGette.. 155
----------
\1\ The bills have been retained in committee files and are available
at https://docs.house.gov/Committee/Calendar/
ByEvent.aspx?EventID=118798.
Letter of January 7, 2026, from Marc Yale, Research and Policy
Advisor, International Pemphigus & Pemphigoid Foundation, to
Mr. Griffith and Ms. DeGette................................... 157
Statement of AHIP, January 8, 2026............................... 159
Letter of January 8, 2026, from Anders Gilberg, Senior Vice
President, Government Affairs, Medical Group Management
Association, to Mr. Griffith and Ms. DeGette................... 162
Letter of January 7, 2026, from Wayne Grau, Executive Director,
National Coalition for Assistive & Rehab Technology, to Mr.
Griffith and Ms. DeGette....................................... 164
Letter of January 7, 2026, from Beth Gore, Chief Executive
Officer, Oley Foundation, to Mr. Griffith and Ms. DeGette...... 166
Letter of January 8, 2026, from Luba Sobolevsky, President and
Chief Executive Officer, and Amy E. Clarke, Chief Clinical
Officer, Immunoglobulin National Society, to Mr. Griffith and
Ms. DeGette.................................................... 167
Letter of January 7, 2026, from the Council for Quality
Respiratory Care to Mr. Guthrie, et al......................... 169
Letter January 7, 2026, from Tom Ryan, President and Chief
Executive Officer, American Association for Homecare, to Mr.
Griffith and Ms. DeGette....................................... 173
Letter of January 7, 2026, from Sara Struwe, President and Chief
Executive Officer, Spina Bifida Association, to Mr. Griffith
and Ms. DeGette................................................ 175
Letter of January 7, 2026, from the Academy of Cardiovascular &
Pulmonary Physical Therapy, et al., to Mr. Griffith, Ms.
DeGette, and Subcommittee Members.............................. 177
Statement of the American Lung Association by Harold P. Wimmer,
President and Chief Executive Officer, January 8, 2026......... 180
Statement of the Advanced Medical Technology Association, January
8, 2026........................................................ 182
April 1, 2025, letter from the Independence Through Enhancement
of Medicare and Medicaid (ITEM) Coalition, to Mrs. Miller-
Meeks, et al................................................... 184
Letter of January 8, 2026, from Shane Bare, Roan Mountain, TN, to
Mr. Griffith and Ms. DeGette................................... 187
Letter of January 8, 2026, from Alicia Barron, Executive
Director, Infusion Access Foundation, to Mr. Griffith and Ms.
DeGette........................................................ 189
Letter of November 19, 2025, from Alliance for Aging Research, et
al., to Hon. Mike Johnson, Speaker of the House, et al......... 191
Letter of January 8, 2026, from Jen Brull, Board Chair, American
Academy of Family Physicians, to Mr. Griffith and Ms. DeGette.. 194
Letter of January 8, 2026, from Brian Scarpelli, Executive
Director, Connected Health Initiative, to Mr. Griffith and Ms.
DeGette........................................................ 202
Letter of January 8, 2026, from Tom Kraus, American Society of
Health-System Pharmacists, to Mr. Griffith and Ms. DeGette..... 206
Article of December 4, 2025, ``2025 KFF Marketplace Enrollees
Survey,'' by Lunna Lopes, et al., Kaiser Family Foundation\1\
Letter of January 7, 2026, from Nancy A. LeaMond, Executive Vice
President and Chief Advocacy & Engagement Officer, AARP, to
Hon. Mike Johnson, Speaker of the House, and Hakeem Jeffries,
House Minority Leader.......................................... 210
Article of September 30, 2025, ``ACA Marketplace Premium Payments
Would More than Double on Average Next Year if Enhanced Premium
Tax Credits Expire,'' by Justin Lo, et al., Kaiser Family
Foundation..................................................... 212
Statement of the American College of Physicians, January 8, 2026. 221
Press release of December 10, 2025, ``ACS CAN Urges Congress to
Immediately Extend the Enhanced Premium Tax Credits to Avoid a
Health Care Affordability Crisis,'' American Cancer Society
Cancer Action Network.......................................... 223
Article of September 11, 2025, ``Congress Must Preserve Access to
Affordable Marketplace Coverage,'' by Lindsay Copeland,
Medicare Rights Center......................................... 224
Article of October 15, 2025, ``Damage From Inaction On ACA Tax
Credits Has Begun And Will Grow With Further Delays,'' by Jason
Levitis, et al., Medicare Policy Initiative.................... 229
----------
\2\ The article has been retained in committee files and is included in
the Documents for the Record at https://docs.house.gov/meetings/IF/
IF14/20260108/118798/HHRG-119-IF14-20260108-SD003.pdf.
Article of October 2025, ``Eligibility Cliff on ACA Tax Credits
Would Make Health Care Unaffordable for Middle-Class
Families,'' by Jason Levitis, et al., Urban Institute.......... 239
Fact Sheet of the Center for Medicare Advocacy, ``The Affordable
Care Act (ACA) Helps Medicare''................................ 247
Fact Sheet of the American Hospital Association, ``Enhanced
Premium Tax Credits,'' July 2025............................... 248
Article of November 3, 2025, ``Health Insurance Premium Spikes
Imminent as Tax Credit Enhancements Set to Expire,'' Center on
Budget and Policy Priorities................................... 250
Letter of January 7, 2026, from Elizabeth S. Watson, Director of
Federal Government Affairs, American Federation of State,
County and Municipal Employees, to Representatives............. 263
Article of December 4, 2025, ``How to Evaluate Proposals to
Address Expiring Premium Tax Credit Enhancements,'' by Jennifer
Sullivan, Center on Budget and Policy Priorities............... 264
Article of December 12, 2025, ``Older Adults Face Spike in Health
Insurance Costs as ACA Tax Credits Expire,'' AARP.............. 267
Letter of September 15, 2025, from American Medical Association,
et al., to House Speaker Mike Johnson, et al................... 276
Article of July 29, 2025, ``Marketplace Enrollees Tell Congress:
Extend the Enhanced Premium Tax Credits,'' by Claire Heyison,
Center on Budget and Policy Priorities......................... 279
Letter of November 18, 2025, from Jon Godfread, President,
National Association of Insurance Commissioners, et al., to
Senate Majority Leader John Thune, et al....................... 283
Article of October 30, 2025, ``Older Adults at Risk if ACA
Subsidies Expire,'' by Lindsey Copeland, Medicare Rights Center 285
Article of January 5, 2026, ``Policy Changes Bring Renewed Focus
on High-Deductible Health Plans,'' by Michelle Long, et al.,
Kaiser Family Foundation....................................... 289
Article of December 4, 2025, ``Poll: 1 in 3 ACA Marketplace
Enrollees Say They Would `Very Likely' Shop for a Cheaper Plan
If Their Premium Payments Doubled; 1 in 4 Say They `Very
Likely' Would Go Without Insurance,'' Kaiser Family Foundation. 300
Letter of August 21, 2024, from Alpha-1 Foundation, et al., to
House Speaker Mike Johnson, et al.............................. 305
Letter of December 11, 2025, from Ramsey Alwin, President and
Chief Executive Officer, National Council on Aging, to Hon.
Lisa Blunt Rochester, et al.................................... 308
Article of November 5, 2025, ``The Importance of Premium Tax
Credits: Affording Health Insurance Coast to Coast,'' Families
USA............................................................ 312
LEGISLATIVE PROPOSALS TO SUPPORT PATIENT
ACCESS TO MEDICARE SERVICES
----------
THURSDAY, JANUARY 8, 2026,
House of Representatives,
Subcommittee on Health,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 10:20 a.m., in
the John D. Dingell Room 2123, Rayburn House Office Building,
Hon. H. Morgan Griffith (chairman of the subcommittee)
presiding.
Members present: Representatives Griffith, Harshbarger,
Bilirakis, Carter of Georgia, Crenshaw, Joyce, Balderson,
Miller-Meeks, Cammack, Obernolte, Bentz, Houchin, Langworthy,
Kean, Rulli, Guthrie (ex officio), DeGette (subcommittee
ranking member), Ruiz, Dingell, Barragan, Schrier, Trahan,
Veasey, Fletcher, Ocasio-Cortez, Auchincloss, Carter of
Louisiana, Landsman, and Pallone (ex officio).
Also present: Representatives Evans, Matsui, and McClellan.
Staff present: Christian Calvert, Press Assistant, Press;
Jessica Donlon, General Counsel; Sydney Greene, Director of
Finance and Logistics; Jay Gulshen, Chief Counsel, Health;
Annabelle Huffman, Clerk, Health; Megan Jackson, Staff
Director; AT Johnson, Special Advisor; Sophie Khanahmadi,
Deputy Staff Director; Sarah Meier, Counsel and
Parliamentarian; Joel Miller, Chief Counsel; Seth Ricketts,
Special Assistant; Chris Sarley, Member Services/Stakeholder
Director; Timothy Trimble, Staff Assistant; Matt VanHyfte,
Communications Director; Nick Wooldridge, Professional Staff
Member, Health; Lydia Abma, Minority Policy Analyst; Jacquelyn
Bolen, Minority Counsel; Keegan Cardman, Minority Staff
Assistant; Tiffany Guarascio, Minority Staff Director; Jackson
Hall, Minority Intern; Perry Hamilton, Minority Deputy
Director, Member Services and Outreach; Brent Langellier,
Minority Health Fellow; Una Lee, Minority Chief Counsel,
Health; Andrew Souvall, Minority Director of Communications,
Outreach, and Member Services; Hannah Treger, Minority Staff
Assistant; and Laurel Uhomba, Minority Health Fellow.
Mr. Griffith. The subcommittee will come to order.
The Chair recognizes himself for 5 minutes for an opening
statement.
OPENING STATEMENT OF HON. H. MORGAN GRIFFITH, A REPRESENTATIVE
IN CONGRESS FROM THE COMMONWEALTH OF VIRGINIA
In today's hearing, we will discuss 10 bills aimed at
improving patient access in Medicare. As our population ages,
it is critical that Medicare policies keep pace with patient
needs. Ensuring beneficiaries can obtain timely, cost-effective
services is essential to fulfilling Medicare's promise.
A handful of bills we are discussing today help increase
access to durable medical equipment, or DME, which include
wheelchairs, oxygen equipment, walkers, diabetic supplies, just
to name a few. However, the way Medicare reimburses for these
products can be improved.
Dr. Joyce from Pennsylvania is leading H.R. 1703, the
Choices for Increased Mobility Act, which creates a new billing
code to improve Medicare coverage for ultra-lightweight
wheelchairs, particularly those made from titanium or carbon
fiber. Currently, an individual must pay full price for the
upgrade to a lighter, more functional wheelchair and then hope
to get reimbursed by Medicare later. This bill would allow
Medicare to cover a portion of the cost upfront to ease the
financial burden on individuals.
Another bill, H.R. 2477, the Portable Ultrasound
Reimbursement Equity Act, led by Representative Van Duyne from
Texas, provides Medicare reimbursement for portable ultrasound
transportation and services, which will help seniors get the
care they need.
Representative Miller-Meeks from Iowa champions H.R. 2005.
The DMEPOS, also known as DMEPOS Relief Act, would establish a
fairer rate for DME supplies. The way DME products get priced
is through a process known as competitive bidding. This is
where DME suppliers bid to be the sole contractor in a certain
area of the country, with the winning bid prices used to
determine supplier reimbursement. These prices are not one-
size-fits-all, and suppliers, especially in some areas,
struggle to stay open due to these low rates. This bill aims to
help mitigate that impact.
The last bill in the DME space is H.R. 2902, the
Supplemental Oxygen Access Reform Act, led by Representative
Valadao from California. Among other things, this bill removes
supplemental oxygen and its supplies from the competitive
bidding program, and creates a new reimbursement rate for
supplemental and liquid oxygen.
We will also be considering H.R. 2172, the Preserving
Patient Access to Home Infusion Act, led by Representative
Buchanan from Florida. This bill would make updates to the home
infusion therapy benefit and support patient access to this
benefit. The current reimbursement structure is not aligned
with how these therapies are currently administered in the
home. This bill will modernize the model, ensure adequate
provider reimbursement, and support patient access to home
infusions.
Another bill being considered today is H.R. 5269, the
Reforming and Enhancing Sustainable Updates to Laboratory
Testing Services Act, led by our own Richard Hudson from North
Carolina. This bill would update how CMS establishes
reimbursement rates for clinical laboratory services paid under
Medicare Clinical Lab Fee Schedule. This important bill aims to
create a less burdensome process for CMS to determine private
payer-based rates for lab services.
A few other bills being considered today include H.R. 5243,
led by Representative McClellan from Virginia, that brings more
transparency in the supplemental benefits provided by Medicare
Advantage plans.
The Healthcare Efficiency Through Flexibility Act, also led
by Representative Buchanan--this bill would extend certain
methods for collecting Accountable Care Organizations' quality
measurement data as well as establish a digital quality measure
pilot program.
H.R. 6210, the Senior Savings Protection Act, led by
Representative Matsui from California, reauthorizes and funds
certain programs under the Medicare Improvements for Patients
and Providers Act. These programs help low-income beneficiaries
understand and access their benefits.
Lastly, we will discuss H.R. 6361, the Ban AI Denials in
Medicare Act, led by Representative Landsman from Ohio. This
bill prohibits the Center for Medicare and Medicaid Innovation,
or CMMI, from implementing the Wasteful and Inappropriate
Service Reduction model, or the WISeR model. While I understand
the concerns around AI and prior authorization, the CMMI
statutory mission is to lower healthcare costs and improve
outcomes for patients. The WISeR model does not change Medicare
coverage policy but will focus on ensuring that, for a set of
nonemergency services, seniors are getting safe, effective, and
appropriate care.
I look forward to hearing from our witnesses today and
working to advance these bills to a markup.
[The prepared statement of Mr. Griffith follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Griffith. I now recognize the subcommittee ranking
member, Representative DeGette, for 5 minutes for an opening
statement. Representative DeGette.
OPENING STATEMENT OF HON. DIANA DeGETTE, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF COLORADO
Ms. DeGette. Thank you very much, Mr. Chairman. And I will
say I am glad that this committee is finally having another
hearing, and I am glad we are bringing up some bills that
overall we can agree on in a bipartisan way, but I hate to tell
you: Rome is still burning. Alarm bells have been ringing for
healthcare affordability for months. And with the expiration of
enhanced premium tax credits at the end of 2025, we knew that
premiums would skyrocket in 2026.
Millions of Americans who get health insurance through the
ACA were notified last year that their premiums were doubling
or more. They are now trying to figure out how to pay for
coverage this year or if they are going to take the terrifying
step of going without insurance that has become too expensive,
and they are also wondering if Congress will finally step in to
save them from these skyrocketing premiums.
In my district, for example, a family of four making
$128,000 a year--this is teachers, nurses, farmers, small
business owners--got hit with an average $14,000 increase in
their Silver plan premiums, but the majority has done nothing
to help.
Now, enhanced premium tax credits aren't, on their own, the
long-term fix for healthcare affordability that we need, but
they have been a critical part of lowering premiums since we
passed them during COVID, and they have expanded healthcare
coverage even more than we expected. So, while Republicans let
the Federal tax credits expire, States like Colorado--but not
all States--have stepped in with a short-term fix. But States
like Florida and Texas, they might be forced to pay more than
20 percent of their income in healthcare premiums, if they keep
insurance at all.
This crisis did not appear overnight. For over a year, the
Democrats on this subcommittee and everyday Americans have been
warning Donald Trump and the majority about the healthcare
affordability crisis and the impending expiration of the tax
cuts. We asked for hearings to consider legislation and to do
something--anything--to be able to help people afford their
health insurance.
But rather than have a serious conversation about
affordability, the majority wasted precious time on legislation
that will only raise costs and kick people off their coverage.
Instead of extending premium tax credits, meaningfully lowering
healthcare costs, or expanding access to affordable coverage,
Republicans' Big, Bad Bill that they spent the first half of
the year passing sent 15 million people to cause their health
insurance--to lose their health insurance so that they could
pay for tax breaks for the ultra-wealthy. And now the
Republicans are doing everything they can to ignore the
necessity of extending ACA premium subsidies and lowering
costs.
Democrats literally had to force the majority to bring up
the tax credit extension for a vote this week because--at the
same time Republicans are bringing up bills to police shower
heads. Also, they are trying to change the subject to House
savings accounts and, really, abortion restrictions. For once,
I would encourage the majority to take Donald Trump's advice.
Just this week, Donald Trump implored congressional
Republicans to, quote, ``be flexible on abortion restrictions
so we can actually focus on lowering costs.''
Only time will tell if the majority will listen, but I am
not too hopeful. They have completely avoided the topic of
affordability, canceling town halls, holding as few Health
Subcommittee hearings as possible, and simply allowing the
crisis to unfold, which is why Democrats, with the help of four
GOP members who are actually listening to the three-quarters of
Americans who support extending the tax credits have stepped up
to bypass the Speaker and put a 3-year enhanced ACA subsidy
extension on the House floor which will be voted on later
today. The extension will cut premium spikes by 80 percent on
average. It will wipe out increases for lower-income families.
It will save 5 million people from losing their insurance.
While short term, it is a straightforward fix.
To those watching at home, I will say this: If your
Representative truly wants to lower your healthcare costs, they
will vote in favor of this bill on the floor later today. If
your Senators truly want to lower your insurance premiums, they
will vote in favor of this bill when it goes to the Senate. And
if President Trump truly wants to put money in your pockets, he
will sign this bill into law. Republicans refused to act last
year, and now we will see if they have the backbone to truly
help lower costs.
[The prepared statement of Ms. DeGette follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Ms. DeGette. I yield back.
Mr. Griffith. The gentlelady yields back.
I now recognize the chairman of the full committee for 5
minutes for an opening statement, Mr. Guthrie.
OPENING STATEMENT OF HON. BRETT GUTHRIE, A REPRESENTATIVE IN
CONGRESS FROM THE COMMONWEALTH OF KENTUCKY
Mr. Guthrie. Thank you, Mr. Chairman. I appreciate the
recognition, and I want to thank all of our witnesses for being
here today to this hearing. Today's hearing is important. We
will explore potential solutions to strengthen the Medicare
program and enhance seniors' access to care.
For example, in 2014 Congress enacted Protecting Access to
Medicare Act, which reformed Medicare payments for lapsed
services, but it has become clear the law is not exactly
operating as intended, and Congress has frequently modified or
delayed aspects of this reform. Today, the subcommittee will
examine potential solutions for payment stability and
consistency for lapsed services, encourage innovation in
diagnostic lab testing, and protect seniors' ability to receive
these services, all while ensuring Federal taxpayers' dollars
are used responsibly and sustainably.
The subcommittee will also hear testimony about several
bills related to durable medical equipment, or DME, and home
infusion therapy. These are critical items and services for
seniors, particularly for beneficiaries in rural and
underserved areas. We will also examine the WISeR model, which
is focused on promoting high-quality care for medical
beneficiaries by ensuring that certain services are provided in
alignment with existing CMS coverage policies.
While I know many patients and providers have frustrations
with the traditional prior authorization processes, I also
appreciate that our current Medicare spending trajectory is
unsustainable. CMMI was created for the express reason of
trying new payment models that might make our healthcare
programs more efficient and effective. Therefore, we must think
creatively to see how CMMI can harness cutting-edge
technologies that aim to help beneficiaries avoid unnecessary
care.
Despite all these reservations, I look forward to a robust
discussion on all of the bills before us today, but our work
cannot just end here. As we look forward to all the important
work we have coming this year, we do need to take a broad
examination of healthcare costs. As members of this committee
know well, we do not shy away from tackling tough issues within
our wide-ranging jurisdiction. And I am pleased to announce
that, over the next few months, we will hold a series of
hearings to examine healthcare affordability.
While some want to talk solely about a small subset of the
population, I believe we have to take a broader look as to what
is driving costs for all Americans. On January 22, we will hold
a Health Subcommittee hearing with CEOs of some of the largest
health insurance companies representing a cross section of the
marketplace.
I am hopeful that we can have a productive discussion about
what is truly driving increased healthcare costs and premiums
for everyone.
From there, we need to look at the entire healthcare
system, why prices and costs are going up, and what we can do--
hopefully, much of it in a bipartisan way--to address these
issues. We have the greatest healthcare system in the world. We
just need to examine how we can make it more affordable for all
Americans.
I thank the witnesses for their participation today, and I
will yield back.
[The prepared statement of Mr. Guthrie follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Griffith. The gentleman yields back. I agree with him,
and glad we are doing a lot of hearings on affordability.
And I will take a point of personal privilege and recognize
the former chairman of this committee. Mr. Walden is in the
room. We appreciate him being here.
For those who don't know, it is not a mirror. That is his
portrait. That is him.
I now recognize for an opening--I now recognize for 5
minutes for an opening statement the ranking member of the full
committee, Mr. Pallone, for an opening statement.
OPENING STATEMENT OF HON. FRANK PALLONE, Jr., A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF NEW JERSEY
Mr. Pallone. The former chairman still looks good. He looks
like the portrait.
Anyway, thank you, Mr. Chairman.
Today, committee Republicans are holding a hearing on
Medicare to supposedly strengthen the program and enhance
access to care. Yet, congressional Republicans have spent the
last year decimating our healthcare system, cutting more than
$1 trillion for the Medicaid program, and--the biggest cuts in
this country's history, and all to fund giant tax cuts for big
corporations and billionaires.
At the same time, Republicans refuse to extend the
Affordable Care Act's enhanced premium tax credits that help
low- and middle-income Americans afford their healthcare
coverage. And last year, Democrats repeatedly pressed
Republicans to take action, but they refused, and so the tax
credits expired at the end of 2025. Now, here we are on January
8 with insurance premiums skyrocketing by two, three, and even
four times for 24 million Americans.
This is a major failure of leadership to address the
affordability crisis. In fact, it is such a failure that even
members of our own party have joined--of their own party, the
Republican Party--have joined Democrats in forcing a vote on
the House floor to extend the tax credits through the discharge
petition that we are going to be voting on, or we are voting on
this week.
Rather than addressing the healthcare affordability crisis
that seniors and all Americans are facing, Republicans are
holding this hearing on Medicare bills that will mostly raise
payment rates for certain classes of providers in Medicare.
Now, some of these bills, like the RESULTS Act and the
Preserving Patient Access to Home Infusion Act, address known
payment issues in the Medicare program that we need to fix.
And, while I support these efforts, I also believe that fixing
minor payment issues in Medicare does nothing to fix the
broader crisis Americans are facing in paying for healthcare
and their rising cost of living across the board.
The failure to extend the enhanced premium tax credits are
particularly harmful to older Americans preparing for
retirement. Over half of all enrollees who are losing all
support to purchase ACA coverage are between the ages of 50 and
64. Take, for example, a 60-year-old couple in Texas with a
household income of $85,000. They rang in the new year facing a
more than $26,000 premium increase just to keep their
healthcare. Undoubtedly, older Americans like them will either
go without coverage or they will purchase worse coverage that
leaves them on the hook for thousands of dollars of medical
costs when they get sick or need routine medical care. And,
without these enhanced tax credits, they will become less
healthy and face the possibility of financial ruin.
And the failure to extend these tax credits is compounded
by the devastating cuts in the Big, Ugly Bill that rips
healthcare away from 15 million Americans, increases out-of-
pocket costs for millions of Americans, and is already forcing
hospitals, maternity care units, and clinics across the country
to close their doors and cut services. The Big, Ugly Bill even
directly attacks seniors and people with disabilities who rely
on Medicare. The Republican law makes it harder to enroll in
coverage for programs like the Medicare Savings Program that
make it possible for seniors struggling to afford healthcare
costs to pay for their prescriptions and doctors' visits.
So we must do better for the American people, Mr. Chairman.
Fortunately, today, we can support an extension of the premium
tax credits by passing Leader Jeffries' discharge petition. If
Republicans are serious about making healthcare more affordable
and ensuring access to care, they will support the discharge
petition today.
And with that said, I support some of the bills we will
discuss today, including H.R. 5243, led by Representative
Jennifer McClellan--I mean, by Representative McClellan--H.R.
6210, led by Representative Matsui, and H.R. 6361 led by
Representative Landsman of our committee as well.
Representative Landsman's bill would prohibit the Trump
administration from implementing its so-called WISeR model,
which would impose prior authorization in traditional Medicare
by allowing for-profit companies to use AI to perform prior
authorization reviews and then give them a cut of the savings
if care is denied. And this model threatens beneficiaries'
access to timely and necessary medical care, and that is why I
support this legislation to halt it and any future model that
imposes this type of coverage restrictions on seniors who rely
on traditional Medicare to get the care they need.
They don't need to face even more barriers. There are
enough barriers out there without having to deal with this kind
of a barrier as well.
[The prepared statement of Mr. Pallone follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Pallone. And, with that, Mr. Chairman, I yield back the
balance of my time.
Mr. Griffith. The gentleman yields back.
We now conclude with Members' opening statements. The Chair
would like to remind Members that, pursuant to the committee
rules, all Members' opening statements will be made a part of
the record.
We want to thank our witnesses for taking their time to
testify before the subcommittee. Although it is not the
practice of this subcommittee to swear in witnesses, I would
remind our witnesses that knowingly and willfully making
materially false statements to the legislative branch is
against the law under Section--Title 18, Section 1001 of the
United States Code.
You will have the opportunity to give an opening statement
followed by questions from Members.
And our witnesses today are Susan Van Meter, president of
American Clinical Laboratory Association. Welcome.
Connie Sullivan, president and CEO of National Home
Infusion Association. Welcome.
Mr. Thomas Ryan, president and CEO of American Association
for Homecare.
And David Lipschutz, attorney and codirector of law and
policy, Center for Medicare Advocacy.
Per committee custom, each witness will have the
opportunity for a 5-minute opening statement followed by a
round of questions from Members. The light on the timer in
front of you will turn from green to yellow when you have 1
minute left, and, of course, from yellow to red when your time
is up.
Mr. Griffith. I now recognize Ms. Susan Van Meter for her 5
minutes to give an opening statement. Ms. Van Meter.
STATEMENTS OF SUSAN VAN METER, PRESIDENT, AMERICAN CLINICAL
LABORATORY ASSOCIATION; CONNIE SULLIVAN, PRESIDENT AND CHIEF
EXECUTIVE OFFICER, NATIONAL HOME INFUSION ASSOCIATION; TOM
RYAN, PRESIDENT AND CHIEF EXECUTIVE OFFICER, AMERICAN
ASSOCIATION FOR HOMECARE; DAVID LIPSCHUTZ, CO-DIRECTOR/
ATTORNEY, CENTER FOR MEDICARE ADVOCACY
STATEMENT OF SUSAN VAN METER
Ms. Van Meter. Chairman Griffith, Ranking Member DeGette,
Vice Chair Harshbarger, Ranking Member Pallone, thank you for
the opportunity to testify today. My name is Susan Van Meter. I
am the president of the American Clinical Laboratory
Association. ACLA is a trade association representing leading
laboratories that develop and deliver essential diagnostic
tests for patients and providers across the country.
Ensuring innovation in diagnostics and broad patient access
to necessary testing requires a Medicare payment system that is
fair, accurate, and predictable. Regrettably, the Clinical
Laboratory Fee Schedule, the only Medicare payment system which
statute requires be based on commercial market rates, suffers
from significant foundational flaws. Current payment rates are
inaccurate, artificially low, and still based on incomplete
data from 2016.
We are now 23 days away from Medicare cuts to about 800
tests--of as much as 15 percent--hitting laboratories across
the country, impacting most significantly routine tests used
every day to care for Medicare patients. ACLA strongly endorses
the RESULTS Act as a commonsense, smart-policy approach to
reforming the Clinical Laboratory Fee Schedule and preventing
deep Medicare cuts from taking effect January 31.
America's clinical laboratories are an indispensable part
of the healthcare system, delivering tremendous value to
patients and clinicians. Laboratory tests screen for disease,
prevent diagnostic--or provide diagnostic information that
informs clinical care, support increasingly personalized
medicine, contribute to the discovery of new therapies, and
help identify emerging pathogens. From routine tests used to
diagnose and monitor a wide range of diseases, to biomarker
testing that enables clinicians to better target treatments,
particularly in cancer care, laboratory testing helps patients
avoid ineffective therapies while improving outcomes and
reducing unnecessary costs.
Laboratory test results serve as the GPS for healthcare
decision making, informing roughly 70 percent of medical
decisions, while payments to the Clinical Laboratory Fee
Schedule account for less than 1 percent of total Medicare
spending, or approximately $8 billion annually.
Despite this value, the Clinical Laboratory Fee Schedule
lacks the stability and predictability laboratories need to
maintain access to testing services that are relied upon by
millions of patients and clinicians and continue investing in
innovation.
The primary challenges lie in the foundational flaws of the
Protecting Access to Medicare Act, or PAMA. When PAMA became
law in 2014, Congress intended Medicare laboratory rates to
reflect the commercial market by using a weighted median of
private payer rates reported to CMS. However, the goal was not
achieved.
PAMA's challenges fall into three core areas.
First, CMS lacks access to timely and comprehensive
commercial market data that reflect all segments of the
laboratory market--hospital outreach, independent, and
physician office laboratories--resulting in rates based on
incomplete and outdated information. During the only data
collection period since enactment of PAMA, CMS based rates on
private payer data reported by fewer than 1 percent of
laboratories. Hospital and physician office laboratories were
significantly underrepresented, resulting in Medicare payment
rates that did not accurately reflect the broader market, and
absent further congressional action, laboratories soon will be
required to report private payer data from 2019. Those data,
collected before the COVID pandemic, will be used to set the
Clinical Laboratory Fee Schedule for rates for 2027 through
2029.
Second, because of flawed data, Medicare payment reductions
have been far greater than Congress intended, and current law
allows those reductions to continue. Between 2018 and 2020,
Medicare payments to laboratories were cut by nearly $4
billion. That is about four times the $1 billion reductions
projected by the Congressional Budget Office for that period.
Congress has appropriately delayed further reporting
requirements and additional cuts several times, for which the
ACLA is grateful, but without further intervention, deep cuts
begin again on January 31.
Third, reporting requirements impose a significant
administrative burden on both laboratories and CMS,
discouraging participation of reporting and contributing to
low-quality data. PAMA requires clinical laboratories to report
each and every payment rate from each private payer and the
associated volumes for all 1,600 codes on the CLFS. The RESULTS
Act fixes these problems. It would base CLFS rates on current,
comprehensive, and representative commercial market data,
establish guardrails to mitigate rate reductions, and prevent
deep destabilizing payment cuts while dramatically reducing
administrative burden on laboratories and CMS.
I thank you for the opportunity to testify. The ACLA looks
forward to continuing to work with this committee to advance
commonsense legislation that ensures Medicare beneficiaries
continue to have access to the diagnostic services they rely on
every day. I welcome your questions.
Thank you.
[The prepared statement of Ms. Van Meter follows:]
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Mr. Griffith. I thank the gentlelady for yielding back.
I now recognize Ms. Sullivan for her 5 minutes of
testimony. Thank you.
STATEMENT OF CONNIE SULLIVAN
Ms. Sullivan. Chairman Griffith, Ranking Member DeGette,
and members of the subcommittee, thank you for the opportunity
to testify today. My name is Connie Sullivan, and I serve as
the president and CEO of the National Home Infusion
Association, and I am also a licensed pharmacist.
NHIA represents pharmacies that coordinate and deliver home
infusion care to patients across the country. Home infusion is
the mainstream part of modern healthcare delivery. Every year,
over a million patients rely on home infusion to treat serious
infections, immune disorders, cancer, heart failure, and other
complex conditions.
Home infusion is strongly preferred by patients because it
helps them get the IV medications they need with the least
disruption to their daily lives, allows earlier discharge from
the hospital, and lowers the risk for complications, such as
drug-resistant infections.
Despite these well-established benefits, home infusion has
largely been out of reach for patients with traditional
Medicare. The Medicare home infusion benefit only covers a
handful of available drugs and is limited to a set of
professional services that occur face to face in the home. As a
result, Medicare beneficiaries remain significantly underserved
compared to these insured under commercial or other government
plans.
Despite clear evidence of safety, patient preference, and
systemwide cost savings, Medicare's restrictive and incomplete
benefit design impedes access to home infusion. This assessment
was confirmed in a 2010 study conducted by the Government
Accountability Office. Their report accurately summarized the
differences between Medicare and the commercial market and is
still relevant today.
Today, I am here to urge your support for H.R. 2172, the
Preserving Patient Access to Home Infusion Act. This bill
matters because Medicare still does not have a complete home
infusion benefit, and this bill addresses a real access problem
for America's seniors and people with disabilities.
Without home infusion access, seniors must travel back and
forth to facilities or extend their hospital stay to receive
these necessary and often lifesaving treatments. Here is a
common example. A patient develops a serious infection due to
an injury and is hospitalized. After a few days of IV
antibiotics, the patient stabilizes and is ready to be
discharged but must finish the 14-day course of daily IV
antibiotics to ensure the infection doesn't reoccur.
If this patient has commercial insurance, they would most
likely be discharged to home because it is a safe, effective
way to finish therapy using the least intensive medical
resources. For Medicare beneficiaries, discharge to home,
especially for IV antibiotics, is more difficult because the
Medicare structure does not support the home-based model.
As a result, patients are directed to higher-cost
institutional pathways, having to make daily trips back to a
hospital for infusions, or be admitted to a long-term care
facility for the duration of therapy, even when the patient has
the appropriate caregiver support to complete that treatment at
home.
This challenge is especially notable in rural communities,
where the closest facility that can perform infusions may be
hours away. For many patients, daily travel may be unrealistic,
especially for someone who is medically fragile, has mobility
issues, or is dependent on a family member for transportation.
Without a workable home option, rural patients may be more
likely to end up in a long-term care facility simply because
there is no alternative supported by Medicare.
The Preserving Patient Access to Home Infusion Act fixes
this coverage gap by modernizing the Medicare benefits so that
more patients can access home infusion. The bill addresses gaps
in the current Medicare benefit by establishing appropriate
coverage for the supplies and full scope of professional
services needed to support home infusion care. The bill also
expands coverage for home infusion of IV anti-infectives, which
represent by far the most common situation where home infusion
can prevent avoidable facility use. With these changes, more
home infusion providers will be encouraged to participate in
the benefit, which would then expand access across the country
for patients with a variety of needs.
In closing, the Preserving Patient Access to Home Infusion
Act is a commonsense solution that strengthens access for
Medicare beneficiaries, supports rural and underserved
communities, and avoids unnecessary facility-based care.
Thank you for your attention to this issue. I appreciate
your consideration of this important legislation, and I look
forward to your questions.
[The prepared statement of Ms. Sullivan follows:]
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Mr. Griffith. I thank the gentlelady. She yields back.
I now recognize and welcome Mr. Thomas Ryan for his 5-
minute opening statement.
STATEMENT OF THOMAS RYAN
Mr. Ryan. Thank you. Chairman Griffith, Ranking Member
DeGette, and members of the subcommittee, thank you for the
opportunity to testify today. My name is Tom Ryan, and I serve
as the president and CEO of the American Association for
Homecare. Before joining AAHomecare, I spent 25 years running a
home medical equipment company in Long Island, New York, so I
know firsthand how Medicare policy affects patients, families,
and the small businesses that they serve.
AAHomecare represents the Nation's home medical equipment
suppliers and manufacturers--most of them are small
businesses--who support millions of Americans with oxygen
therapy, mobility equipment, hospital beds, diabetes supplies,
home infusion, and other essential medical products. Home
medical equipment is a critical part of the care continuum. It
keeps people healthier, more independent, and in the setting
that they overwhelmingly prefer, their homes, while reducing
costly hospitalizations and emergency room visits.
Today, I want to speak to three bipartisan bills that are
essential to protecting Medicare beneficiaries' access to care:
H.R. 1703, H.R. 2005, and H.R. 2902. But first, I must raise
serious concerns about CMS' recently announced plans for the
next round of competitive bidding. CMS is proposing to include
ostomy and neurological supplies in competitive bidding,
despite clear congressional intent that these items should not
be included. CMS also plans to include new technology, like
continuous glucose monitors, and change their payment category
in a way that will sharply reduce reimbursement. This threatens
beneficiary access and undermines innovation in diabetes care.
Even more troubling, CMS intends to reduce the number of
suppliers of these key product categories to fewer than 10
nationwide. This would devastate small businesses, it will
destabilize the national home medical equipment infrastructure
that patients rely on. And, finally, the proposed bidding
methodology will artificially drive payment rates to
unsustainable levels, leaving too few suppliers to meet the
needs of our Medicare beneficiaries.
Now, I will discuss the bills. H.R. 1703 addresses a 2016
policy that effectively eliminated beneficiaries' ability to
upgrade to titanium or carbon fiber wheelchairs unless they pay
the full cost out of pocket. This is contrary to long-standing
Medicare policy that has severely restricted access to these
lighter, more durable chairs. The bill restores the ability for
the beneficiary to pay the difference for the upgraded
materials without adding any cost to Medicare. Individuals with
disabilities deserve the ability to choose the equipment that
best supports their mobility needs and their quality of life. I
want to thank Representatives Joyce, Buchanan, and Schrier for
their leadership on the support and legislation.
Next is H.R. 2005, relief for nonbid, nonrural areas. Since
2016, CMS has applied competitive bidding rates that never
participated in competitive bidding to these areas. These cuts
often were more than 50 percent. They have been devastating,
especially in rural and suburban communities. Congress has
repeatedly stepped in with temporary relief, most recently
through the 2022 omnibus bill, but that relief expired at the
end of 2023. As a result, suppliers in these areas are, again,
facing cuts of more than 30 percent.
H.R. 2005 restores a 75/25 blended rate for nonbid,
nonrural areas through 2025. We are going to work with the
committee on changing that, obviously. This is essential to
maintaining access to home medical equipment and preventing
further supplier choices. We appreciate the bipartisan
leadership of Representatives Miller-Meeks, Tonko, Feenstra,
and Panetta, and we look forward to working with the committee
to update the timeliness as this bill advances.
And finally, H.R. 2902, the Supplemental Oxygen Access
Reform Act. Finally, H.R. 2902 addresses long-standing access
problems in the Medicare oxygen benefit, especially for
patients who require liquid oxygen. Competitive bidding has
produced savings, but it has also pushed reimbursement for
liquid oxygen far below the cost of providing it. As a result,
many patients cannot get the type of oxygen systems that their
physicians prescribe. The bill creates a sustainable payment
methodology for liquid oxygen, strengthens program integrity
for a national electronic template, recognizes the essential
role of respiratory therapists, and, of course, reimbursing the
services for individuals with COPD, pulmonary fibrosis, heart
disease, and other diseases. We strongly support this
legislation and thank Representatives Valadao, Brownley, Smith,
and Evans for championing it.
In conclusion, home medical equipment keeps people safe,
independent, and in their home, and it saves Medicare money.
These three bipartisan bills before you today--H.R. 1703, H.R.
2005, and H.R. 2902--are practical, targeted solutions that
will protect access to care for millions of Medicare
beneficiaries. AAHomecare really looks forward to working with
the committee to move these bills forward.
Thank you very much.
[The prepared statement of Mr. Ryan follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Griffith. The gentleman yields back.
I now recognize Mr. David Lipschutz--welcome--for his 5
minutes for an opening statement.
STATEMENT OF DAVID LIPSCHUTZ
Mr. Lipschutz. Thank you. Chairman Griffith, Ranking Member
DeGette, Chairman Guthrie, Ranking Member Pallone, and
distinguished members of the committee, thank you for the
invitation to testify today. My name is David Lipschutz, and I
am director--codirector of the Center for Medicare Advocacy. We
are a national, private, nonprofit, nonpartisan law
organization that works to advance access to comprehensive
Medicare coverage and quality healthcare. Our policy work is
based on the real-life experiences of the beneficiaries and
families we hear from every day. We appreciate the committee's
focus on improving access to care for Medicare beneficiaries.
I would like to express support for three bills at issue in
this hearing today which I will discuss in turn.
First, H.R. 6210, the Senior Savings Protection Act, would
provide a 5-year reauthorization of critical funding for State
Health Insurance Assistance Programs, Area Agencies on Aging,
Aging and Disability Resource Centers, and the National Center
on Benefits Outreach and Enrollment.
First established under the Medicare Improvements for
Patients and Providers Act, or MIPPA, since 2008 this funding
has provided essential outreach and enrollment assistance for
millions of low-income older adults and individuals with
disabilities, including help with enrollment into programs
which provide assistance with Medicare premiums and costs.
Reauthorizing funding for 5 years will help ensure the
community-based organizations can continue their important work
helping older adults and individuals with disabilities access
needed care and lower their healthcare costs.
This critical work includes helping people enroll in
Medicare Saving Programs, or MSPs, in the Part D Low-Income
Subsidy. MSPs are Medicaid programs that help with Medicare
costs for those who qualify. These programs, though, are
significantly underutilized, with roughly half of individuals
eligible actually enrolled. The need for education about and
assistance with enrollment in MSPs is even more important
following passage of H.R. 1, which delays implementation of a
rule streamlining eligibility and enrollment in MSPs, which
will result in fewer people accessing this financial help.
Reauthorization of MIPPA funding will help these vital
community organizations, SHIPs, AAAs, ADRCs, and others
continue to provide needed assistance in their communities.
Second, we offer our support for H.R. 5243 to amend Title
18 of the Social Security Act to increase data transparency for
supplemental benefits under Medicare Advantage. Due to
significantly higher payment to Medicare Advantage plans that
Medicare spends on enrollees in traditional Medicare, virtually
all Medicare Advantage plans provide supplemental benefits:
items and services that are not covered in the traditional
program. However, such benefits are not standardized and vary
considerably by plan.
Research demonstrates that, while beneficiaries value
supplemental benefits in theory, and these benefits are a major
driver in planned marketing and beneficiary selection, many
enrollees do not utilize the full range of supplemental
benefits available to them. The data collection outlined in
this bill--particularly at a granular enrollee level--along
with the required public reporting requirements would make
available essential information about how specific supplemental
benefits vary across plans, how and whether they are used, and
how much they cost enrollees. With more than half of Medicare
beneficiaries enrolled in MA plans, this bill would provide
needed transparency and oversight of the MA program.
Finally, we offer our strong support for H.R. 6361, the Ban
AI Denials in Medicare Act. This bill would prohibit HHS from
proceeding with the Wasteful and Inappropriate Services
Reduction, or WISeR, model, which began in six States just last
week and would also prohibit the implementation of payment
models testing prior authorization in traditional Medicare.
Currently, prior authorization requirements are applied to
a very limited set of services in traditional Medicare, while
virtually all Medicare Advantage enrollees are subject to prior
auth, particularly for more expensive services. Extensive
research and studies and our own experience have found that
prior authorization requirements can result in inappropriate
denials and delays in obtaining medically necessary care. When
appealed, over 80 percent of MA denials are partially or fully
overturned, but too few people appeal, meaning millions of
beneficiaries are forgoing their right to appeal and going
without necessary care.
In recent years, problems with prior authorization in
Medicare Advantage have been exacerbated by insurance companies
or their vendors using AI or algorithmic software to aid their
decision making. The WISeR model borrows some of the worst
elements of Medicare Advantage with respect to accessing care
and injects them into traditional Medicare.
The model employs private vendors using AI or algorithmic
tools to review and approve or deny coverage. Such vendors are
compensated in part based on a share of averted expenditures--
in other words, a reduction in improved services creating
financial incentives to deny care.
Prior authorization is often dangerous for beneficiaries,
far too burdensome from providers, and has no place in
traditional Medicare. We strongly support this legislation that
would halt the deeply flawed WISeR model and prohibit future
models that would incorporate harmful prior authorization
requirements in traditional Medicare.
Thank you again for the opportunity to testify, and I look
forward to your questions.
[The prepared statement of Mr. Lipschutz follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Griffith. Thank you very much.
We will now begin our questioning period. I ask that
Members not begin a new question to our witnesses as their 5
minutes expire and would encourage Members to submit written
questions for the record if they have additional questions when
their time is up.
I now recognize myself for 5 minutes.
Let me start with some good news. We always need some good
news. I was able to attend a ribbon cutting on Monday for the
Stuart Community Hospital in Patrick County, Virginia. It was a
reopening of one of my rural hospitals that had previously
closed down back in 2017, and that is just really good news. I
was very, very pleased to be there.
All right. Ms. Van Meter, I have concerns, particularly
about routine tests that patients rely on every day. In your
testimony, you mentioned one such test, a complete blood count
test that regularly is furnished by these smaller labs. That is
currently reimbursed under the Clinical Lab Fee Schedule at
$7.77. However, you say that it is scheduled to be cut by 11
percent on January 31, absent a change in the law.
What does this mean for patient access to this test and
others like it if we don't take action?
Ms. Van Meter. Thank you, Mr. Chairman, for the question.
CBC is a very commonly ordered test. It can tell us quite a lot
about monitoring a patient's condition, diagnosing it, the
health of their immune system. It can also be the first sign
that there may be a blood cancer like a leukemia.
You are exactly right. The Medicare program currently
reimburses $7.77 for this extraordinarily valuable test. That
means the blood draw, the transportation to the laboratory, the
medical laboratory professionals who assess that sample, run
the test, and deliver the results to the patients and their
clinicians, and that is done for $7.77. It is a perfectly
illustrative test of the value of clinical laboratories.
Now, that test is among the most common tests ordered, and
common tests are subject to a disproportionate level of
reductions under PAMA. Those cuts take place on January 31. For
smaller laboratories in rural or frontier communities, for
example, that have more narrower menus that focus really on
those essential common tests, we have significant concerns
about them being able to weather these deep Medicare cuts,
again, that are disproportionately hitting those common tests
that Medicare beneficiaries rely on every day.
Mr. Griffith. And let me see if I--correct me if I have got
my translation wrong, but if you are in a big city and you are
doing a thousand of those tests a day, you might be able to
justify the 7.77--maybe a little bit of a cut, but if you are
in a rural area where you are doing five of those tests a day,
there is no way you can possibly manage it for that amount of
money.
And so you have either got to decide whether you close up
shop or whether you just stop doing that test. Is that what I
am hearing?
Ms. Van Meter. Well, I think the impact could be profound
for smaller laboratories in particular, but I must say, even
larger laboratories, whether it be in urban areas or small
communities--there can be large laboratories in small
communities--it is extraordinarily difficult to have the
professional laboratory and staff and the infrastructure--these
labs run 24/7--to be able to carry out that service in a timely
fashion for $7.77. They are committed to doing so. ACLA members
are committed to doing so, but we worry profoundly about the
impact of those reductions.
Mr. Griffith. All right. I appreciate that.
Mr. Ryan, I appreciate you being here today. You raised a
couple questions in your testimony, but I want to go to my
second question first, and then we will see if we have time to
get to the others.
My district is considered very rural by many metrics. I
represent southwest Virginia and Southside Virginia, the
Appalachian region of the commonwealth. According to the
competitive bidding process that CMS implements, CMS determined
that a good portion of my district is nonrural. Can you briefly
explain how CMS decides this designation? Because I am looking
at the map here of what is considered nonrural, and I can't
figure it out.
Mr. Ryan. Thank you, Mr. Chairman. A lot of people can't
figure that out. Medicare uses a set of ZIP Codes, and in the
ZIP Codes they chose what areas of the country were going to be
competitively bid to see the areas of the country--what areas
of the country would be rural areas of the country and then
what areas of the country would be nonbid, nonrural areas.
So your district probably has a lot of these nonbid,
nonrural areas. Obviously, H.R. 2005 would help with that. The
SOAR Act would help with that, because you get increased
reimbursement for those product categories if that, in fact,
comes into play. But that is a common question that is asked,
and people are questioning CMS' methodology on that ZIP Code
application, and it is just one of the flaws of the program.
Mr. Griffith. Well, and I will have to check into that
further. And I appreciate your answer because I have got a
couple of counties--some of them, I understand, but then I have
got a couple of counties and a couple of communities that I
just can't figure out how Duffield or New Castle in Craig
County, a county that has about 4,000 people and is owned by
the National Forest Service--about half of it is owned by the
National Forest Service--how that is not rural. I don't
understand that, but c'est la vie.
For the people back home, can you please explain what has
already been done to help rural areas subject to competitive
bidding?
Mr. Ryan. Yes. We have worked with Congress in the past,
and we have enacted the 75/25 blended rate, which I said was in
effect essentially until the end of 2023, and we have also
worked with Congress and worked with the administration. And in
that rural area of America, which originally was being
reimbursed at 110 percent, we made it--well, it is not
permanent. Nothing with CMS is permanent. But we have a fix now
that we get paid a 50/50 blended rate. Now, these percentages
we talk about are essentially the adjusted amount or the bid
amount and the unadjusted amount, so----
Mr. Griffith. All right. I appreciate it.
Mr. Ryan [continuing]. This needs some help.
Mr. Griffith. I will apologize to the committee. I violated
my own rule and asked a question as time was running out but
didn't realize it until after I asked the question. So I
apologize for that, and I will have more questions for the
record.
I now recognize the ranking member, Ms. DeGette, for her 5
minutes of questioning.
Ms. DeGette. Thank you so much, Mr. Chairman.
I want to thank all of the witnesses for coming today, and
I particularly want to single out Ms. Sullivan because she is
my neighbor to the north in Lyons, Colorado, and--welcome--and
also because the home infusion benefit in the bill that she is
talking about was originally in 21st Century Cures Act that
was--and anybody who was here then voted for that bill, and it
allowed beneficiaries to be administered infused drugs in a
home setting to begin with. So this is a commonsense expansion
of that, and I want to thank you.
One of the themes that goes through all of these bills is
an attempt to reduce costs for beneficiaries and for Americans,
and so I just want to talk about one thing the Democrats have
done to bring down costs.
On January 1, thanks to our bill that we passed under the
Inflation Reduction Act, negotiated drug prices went into
effect under Medicare Part D, and now Medicare is going to
negotiate the prices of certain high-cost drugs.
Mr. Lipschutz, what reduction in list price did this first
round of negotiations achieve?
Mr. Lipschutz. Thank you, Ranking Member. When the prices
were first announced, the discounts depended on the drug and
ranged from roughly 40 percent to 80 percent discounts.
Ms. DeGette. Because of the negotiations?
Mr. Lipschutz. Exactly.
Ms. DeGette. And how much is this projected to save people
on Medicare?
Mr. Lipschutz. It is projected to save Medicare
beneficiaries about $1.5 billion in out-of-pocket expenses this
year.
Ms. DeGette.Wow. Now, that is tangible savings that
American seniors will feel in their pocketbooks.
In the meantime, President Trump threatened extreme tariffs
on drug companies if they didn't make deals with him. So let me
ask you--this is a little out there, but does that sound sort
of like extortion to you?
Mr. Lipschutz. It kind of sounds like it, yeah.
Ms. DeGette. And why is that?
Mr. Lipschutz. Well, it is--I believe the negotiation
tactics were exchanging the lack of pursuing tariffs in order
to extract promises from different companies.
Ms. DeGette. Now, are the deal details public that you know
of?
Mr. Lipschutz. No.
Ms. DeGette. And companies that have made deals with the
Trump administration, they haven't significantly revised their
revenue projections so far. Does that seem like the behavior of
companies that have agreed to take a revenue hit in this
country?
Mr. Lipschutz. It doesn't sound like it.
Ms. DeGette. No. OK. So I want to say that what we need to
do--as we are reforming healthcare in this country and looking
at lowering costs, we need to do things that actually will
lower costs, like this Medicare price negotiation. And if the
majority really wanted to truly bring down costs for consumers,
they would vote to extend enhanced premium tax credits and to
strengthen the model of negotiating drug prices as well as
other issues. I know Congressman Carter has worked on PBM
reform and many, many other issues that we could work on to
actually reduce the price of healthcare in this country.
I yield back.
Mr. Griffith. The gentlelady yields back.
I now recognize the vice chairwoman of the Health
Subcommittee, Mrs. Harshbarger of Tennessee.
Mrs. Harshbarger. Thank you, Mr. Chairman.
Thank you to the witnesses for being here today, and I want
to turn to you first, Ms. Sullivan.
Being a pharmacist myself, we know how important it is for
patients to get care in the right setting, and for many
patients, especially in rural areas like mine in east Tennessee
and Chairman Griffith's in southwest Virginia, you know, home
infusion can improve outcomes and the quality of life while
avoiding unnecessary trips to the hospitals or extended
facility stays. Because I have done this home health, I have
done hospice respiratory companies, I have done it all as a
pharmacist. So that is why I helped introduce the Preserving
Patient Access to Home Infusion Act, and this bill updates
Medicare's home infusion benefits so the patients can actually
receive the care they need at home when appropriate.
Before I get to my questions, though, I wanted to ask
unanimous consent to submit into the hearing record this letter
from one of my constituents, Mr. Shane Bare, who stands to
benefit from this legislation.
When you have people with chronic debilitating disease
states, the best remedy for them most of the time is to be at
home when they get immunoglobulin therapy or whatever. So, if
we could do that, Mr. Chairman.
Mr. Griffith. And the date of the letter is?
Mrs. Harshbarger. January the 8th.
Mr. Griffith. January the 8th. Without objection, so
ordered.
[The information appears at the conclusion of the hearing.]
Mrs. Harshbarger. Thank you, sir.
When a Medicare patient needs IV antibiotics after
discharge, what happens today if home infusion isn't an option,
and how would this bill change that for rural patients and
families?
Ms. Sullivan. Thank you, Vice Chair, for the question and
for acknowledging our patient that has been very supportive of
this bill and illustrates how important this service is for
patients like him who--he is bound in a wheelchair and relies
on these services----
Mrs. Harshbarger. Absolutely.
Ms. Sullivan [continuing]. And for lifesaving treatment.
Basically, what happens today, unfortunately, is that if a
patient needs IV antibiotics, the first question that is asked
by the physician or the discharge planner is not what does this
patient prefer, or is this patient safe to be at home. The
first question is, Does this patient have Medicare?
Mrs. Harshbarger. Yeah.
Ms. Sullivan. Because it completely rules out home
infusion, in most cases, for those particular patients. If the
patient has commercial insurance, they work through the process
of establishing the proper treatment in the home setting
whenever possible. Unfortunately, because that is not available
to Medicare patients, they start looking at the alternatives
and what is going to be workable for that patient. Do they have
someone that can drive them? In some cases, in Mr. Bare's case,
it would be several hours through the mountains----
Mrs. Harshbarger. Yeah.
Ms. Sullivan [continuing]. In inclement weather to reach an
infusion center, which is a very difficult thing for a lot of
patients to do, particularly our seniors and those with
disabilities.
Mrs. Harshbarger. Totally. And, you know, he is in a
wheelchair. I mean, not only do you fight the weather and
everything else when you are in a mountainous region, but you
have to deal with the prior approvals from the insurance or the
out-of-pocket costs. It is ridiculous. And I have had to deal
with all that in the pharmacy, so thank you for that answer.
Mr. Ryan, I am a cosponsor of H.R. 2005, the DMEPOS Relief
Act, and I know that when patients can't get timely access to
oxygen, mobility equipment or diabetes supplies, their
conditions will worsen. And so how do these reimbursement cuts
undermine Medicare's goal of keeping safely at home and
avoiding costly emergency room visits and hospital stays,
especially in rural communities with limited hospital access?
Mr. Ryan. Well, the service model has changed over the
years because the reimbursement model has been devastating.
Mrs. Harshbarger. Yeah.
Mr. Ryan. It has been cut by over 60 percent since
competitive bidding came into place. And we have thwarted
technology. We have seen that technology has really gone down
over the years. Patents decreased significantly, so innovation
has been problematic.
The service model has changed tremendously. When I was a
respiratory therapist back in the 1980s and the 1970s, we would
be in patients' homes following up on oxygen therapy and some
of the things that the SOAR Act would offer.
Mrs. Harshbarger. Yeah. Absolutely.
Mr. Ryan. But the reimbursement has changed that dynamic,
and patients are getting their equipment later. Repairs have
gone up significantly because the quality of the equipment is
not the same. And the reality is these--the H.R. 2005 and the
SOAR Act, you know, essentially put some of those savings back
in place that makes some sense, particularly for access to
liquid oxygen, which has been devastating.
Mrs. Harshbarger. Yeah.
Mr. Ryan. These patients who are on high-flow oxygen need
to have this technology. It is actually old technology. One
cubic foot of liquid oxygen converts to 860 cubic feet of
gaseous oxygen. So, with a very small container, you could have
a much greater amount of oxygen.
Mrs. Harshbarger. Yeah. True.
Mr. Ryan. When I was a therapist, we put liquid out all the
time, but the Medicare reimbursement system taking oxygen and
making it modality-neutral essentially--getting one payment
model for different types of oxygen therapy that are very
different--that whole infrastructure and that whole drug has
gone away. It seems like an orphan drug now.
Mrs. Harshbarger. Well, they used to be able to do a
nebulizer and the breathing medication that went in at the--the
respiratory therapy companies used to be able to do that. Then
they said, ``No, we are not going to do it,'' so they had to
get the medication at a pharmacy or a different place. It is
just----
Mr. Ryan. Right. It is all about reimbursement. When I was
at my company in New York for 25 years, we had a different
model.
Mrs. Harshbarger. You can't keep up with the change. I
gotcha. I feel your pain. I understand. I have had to deal with
that too.
Let me go to Ms. Van Meter. In your testimony, you warned
that sustained Medicare cuts threaten not only testing capacity
but also skilled laboratory workforce, and you also note that
CMS has provided little education to laboratories about the
mechanics and requirements for reporting their data.
Absent statutory reform, do you expect the next data
collection cycle to be materially better or more representative
results than the last one, and why or why not?
Ms. Van Meter. Thank you, Vice Chair, for the question. It
is a terrific question. I mean, a fundamental flaw within PAMA
right now has to do with CMS' lack of access to robust and
representative commercial market data. And if we were to move
forward with that data reporting period come February 1, it is
data from 2019 that labs would have to report for every payer
with whom they do business, for every test on their menu, what
those rates are, and the associated volumes.
Not only are systems old--computer systems from which those
data would have to be gathered, and that is a fundamental
challenge--but you are exactly right. The training on what data
and what mechanics need to be used to get those data in have
not really been done in any sufficient way, so we are
tremendously concerned that the reporting would be lackluster.
The first time the data were reported--2016 data--fewer than 1
percent of laboratories across the country reported data, and
those data were used to set rates.
Mrs. Harshbarger. Yeah.
Ms. Van Meter. So, without that comprehensive, robust, you
know, representative data, you have got artificially low data
that we have been living with.
Mrs. Harshbarger. Well, I have got more questions, and I
know my time is up, so I yield back. Thank you so much.
Mr. Griffith. The gentlelady yields back.
I now recognize Dr. Schrier of Washington for her 5 minutes
of questioning.
Ms. Schrier. Thank you, Mr. Chairman. Thank you, Ranking
Member DeGette. Thank you to all of the witnesses for this
really--for being here for this interesting hearing.
I just want to note before we get into today's topics that
we are ignoring some gigantic elephants in the room right now.
On Monday, Secretary Kennedy's CDC gutted the childhood
immunization schedule recommendations without any substantive
evidence or recommendations. He shocked CDC career staff and
scientists. And, in fact, his changes were so radical that he
even did a runaround his own handpicked vaccine advisory
committee that is stacked with antivaccine activists. That is
how extreme this was.
And I have to just say, again, as the only pediatrician in
Congress, that this decision is going to harm children, it is
going to cost lives, and it is going to make their families
sicker as well. And I have asked again and again to hold an
oversight hearing about Secretary Kennedy's recklessness and
antivaccine and antiscience decisions.
And I just want to remind our chairman, you are not
powerless here. You can call a hearing. We can do oversight.
And if you really care about children, I will urge you to do a
hearing on this issue.
Turning to today's hearing, I consistently hear a couple
things from my constituents. First, I just hear that healthcare
is unaffordable, health insurance is unaffordable. And I also
want to remind my colleagues that today we will have an
opportunity to vote to extend the tax credits that help people
afford health insurance, and I would urge my Republican
colleagues to vote with us for that bill.
Now, the other thing I hear constantly from constituents is
that the health insurance that they do have, that they pay a
lot of money for, is not holding up their end of the bargain,
and that their insurance companies are delaying or denying care
due to, really, abuse of prior authorizations. And I hear the
same thing, by the way, from physicians and from hospitals, and
they are forced to hire more staff to deal with this
bureaucracy and appeals than nurses.
And the most egregious of these is Medicare Advantage,
which is a type of Medicare plan, as you know, that contracts
with private insurance companies to deliver care. About half of
seniors are enrolled in Medicare Advantage because they are
often a bit more affordable. And they seem great until a
patient gets sick and then can't get the care that they need.
In 2023, traditional Medicare beneficiaries, the usual kind
of Medicare, saw about 40,000 prior authorization requests. In
that same year, Medicare Advantage beneficiaries saw nearly 50
million prior authorization demands. And I want you to keep in
mind that this is about a 50/50. Half of seniors choose
Advantage and half choose traditional.
So this seems so egregious. And then on top of that, the
use of AI by insurance companies, you can dial that to deny
more or to approve more. And it is causing more abuses and more
denials. And healthcare decisions, as I said many times, should
be guided by doctors and worked with patients and not be
decided by insurance companies.
And so, I am so supportive of Representative McClellan's
bill to increase data transparency in Medicare Advantage and
Representative Landsman's bill to stop the use of AI and prior
authorization and the expansion of that true traditional
Medicare. Our seniors deserve better.
Mr. Lipschutz, in your testimony, you point out that
Medicare is projected to spend about 20 percent more for
Medicare Advantage enrollees than it would spend if those
enrollees had traditional Medicare, and yet Medicare Advantage
plans say that they have to use all of this prior authorization
in order to keep costs down.
Can you explain that contradiction, please?
Mr. Lipschutz. I don't know if I can.
Ms. Schrier. I don't know if I can either.
Mr. Lipschutz. Medicare Advantage plans have the ability to
employ prior authorization, ostensibly to weed out medically
unnecessary care. But in our experience, far too often they
weed out medically necessary care. And as cited in my written
testimony, plenty of studies, including the HHS Office of
Inspector General, have found widespread problems with
inappropriate denials. And their own assessment of claims
found, I think, an inappropriate denial rate, about 13 percent
of claims that were denied that, in fact, were medically
necessary in their estimation.
Ms. Schrier. That is right. I believe 95 percent of the
appeals are ultimately approved. It is just that that care was
delayed, and so it is unnecessary. It is denying care. Our
seniors deserve better. We need further oversight of this too.
So thank you. I yield back.
Mr. Griffith. The gentlelady yields back.
I now recognize the chairman of the full committee for 5
minutes for his questioning, Mr. Guthrie of Kentucky.
Mr. Guthrie. Thank you, Mr. Chair. I appreciate that.
And questions--Ms. Van Meter, how are you today? In 2014,
Congress passed reforms to Medicare's clinical APV schedule to
help lower costs, basing Medicare rates for those services on
private market rates because, at the time, Medicare rates were
significantly exceeding the private market. Under current law,
CMS is required to collect data from laboratories about what
they are paid by private payers.
Can you describe the data collection and reporting process
for lab? And how does this administrative burden ultimately
affect the accuracy of private payer-base Medicare payments?
Ms. Van Meter. Thank you for the question, Mr. Chairman.
And I would say that the original data upon which that
assumption that Medicare rates were significantly higher than
commercial market rates was--there was a dearth of data to
suggest such system analysis looking at three FEHBP plans and
only 20 tests.
Be that as it may, the collection of comprehensive
commercial market data that is also representative of the three
segments of the market--that is, physician office labs,
hospital outreach labs, independent labs--is critical to
ensuring that CMS actually understands commercial market rates
and can appropriately set the Medicare rates based on those
commercial market data.
The RESULTS Act would be the step in the right direction to
ensuring that CMS actually had access to that commercial market
data. Without it, you cannot accurately set Medicare rates.
Mr. Guthrie. Thank you. And so there is legislation
considered in this hearing, the RESULTS Act, which would
require CMS to contract with an independent claims database to
obtain private payer data to calculate the Medicare payment
rates.
Can you speak to this idea of using independent claims
database? And how would it improve accuracy?
Ms. Van Meter. Yeah. Certainly. Thank you.
The legislation would request that CMS contract with an
independent, not-for-profit database that has privacy and
security policy in place, and that--the data would be--come
directly from private health plans. It would be claims data
with volumes associated. It would be representative of the
entire laboratory field: physician office, hospital outreach,
and independent laboratories.
That would give CMS tremendously robust data for the most
widely available tests. Under the bill, widely available tests
comprise 98 percent of the volume of tests paid for by the
CLFS.
One database that could meet the criteria is the FAIR
Health Database out of New York State. Currently, 20 States
across the country use the FAIR Health database for any number
of reimbursement-related policies, including no surprise
billing, for example. And CMS considers the FAIR Health
database, which has 54 billion claims in it, to be a qualified
entity and have statistically significant data across the
country.
Mr. Guthrie. You know, the most important thing for us in
solving this issue is how it affects the patient.
Ms. Van Meter. Yes.
Mr. Guthrie. That is how the patients get the care that
they deserve. And so, as more personalized and targeted
treatments come to market, can you discuss the importance of
innovation in the clinical space and how payment reform impact
will affect the patient's access to care and innovation?
Ms. Van Meter. Absolutely. Innovation and diagnostics is
really driving personalized medicine. It is changing healthcare
as we know it. Diagnostics are truly the GPS of healthcare. We
are able to determine in a cancer, for example, exactly the
mutation that a patient may have in a solid tumor, to determine
precisely the right therapy for that patient and to monitor
that treatment. That is because there has been longstanding
innovation, investment, and research and development.
With an unstable payment system and a threat of reductions
that constantly hangs over the head--hangs over the head of
clinical laboratories, you compromise the capacity to have
long-range R&D. And while labs are investing today, if we were
able to move towards the RESULTS Act, you would take away that
threat of constant reduction and uncertainty, and thereby allow
for greater investment and more advances to benefit patients.
Mr. Guthrie. OK. Thank you. And then I will close with
this. I appreciate Dr. Schrier bringing it up--preauth. We have
to figure that out. I've sat with providers. I am not a doctor,
and I know you are doctors, so you can read the information but
I can't. But they presented to me cases that got approved and
cases that didn't get approved. And from what I could tell,
there was little difference between what was approved and what
wasn't approved.
And so, some of the muses, well, why have preauthorization
at all because--if the doctor makes the decision, let them make
it. What we do have to be concerned about, people setting up
entities and taking advantage of not having any
preauthorization whatsoever.
So that is something we have to get right, though, because
people are being denied care they will get eventually, or
people--providers are denied payment that they will get
eventually because of this process. And so, I know Texas has
done something called the gold standard. As long as you operate
within parameters--there's ways to fix it.
And hopefully, Dr. Schrier, all of us can work together to
figure that out, because we want patients to get the care that
they need that the providers determine they need, and providers
get paid for doing the care. So hopefully there will be
opportunity--we have insurance agent--managers--or CEOs in
front of us recently--to bring that up as well.
So thank you for bringing that up, and it is something we
need to deal with. I am sorry. My time is expired.
Mr. Griffith. The gentleman yields back.
I now recognize the gentleman from California, Dr. Ruiz,
for his 5 minutes of questioning.
Mr. Ruiz. Thank you, Mr. Chairman.
This is the first time this subcommittee has met in months.
Months. And while I don't want to underplay the importance of
the bills under consideration today, I think we need to first
acknowledge how out of touch it is that while our constituents
are suffering from the Republican-fabricated healthcare
affordability crisis, they refuse to hold a hearing about it.
Many of my constituents have been faced with overwhelming
spikes in their ACA premiums because this Republican-majority
Congress refuses to extend the enhanced premium tax credits.
This politicking impacts real people. In fact, I am going
to read you a letter from my constituent, Frank--who wrote to
me--that shows the kind of affordability crisis Americans are
facing across the country. Here is Frank's story from Indio,
California.
Quote: ``For my family, the change is immediate and severe.
Our marketplace monthly premium would jump from $704.20 to
$1,869 for the highest deductible, least desirable coverage
available. That kind of increase forces families like mine to
make impossible choices.''
You know, Frank is not alone. His story is reflected in the
stories of millions of people across our country. And we have
to put people over politics. We have to put people--we have to
take care of them right now.
So getting back to the focus of this hearing, I would like
to express my support for the bipartisan H.R. 2172, the
Preserving Patient Access to Home Infusion Act, which is
sponsored by Representatives Buchanan and also Dingell and
Harshbarger here in this committee.
This bill removes the physical presence requirement for the
Medicare Part B home infusion benefit and acknowledges the full
scope of professional services provided in home infusion into
the reimbursement structure. I cosponsored this bill because of
its potential to improve access to care for seniors and help
keep them in their own homes and out of nursing facilities.
I represent a large rural area of southern California where
many patients have to travel up to an hour or more to receive
medical treatment. And like many underserved communities,
transportation and geographic distance are considerable
barriers, including the lack of nursing facilities in these
communities. If a patient has to travel back and forth to a
facility every day or every week for IV therapy, that barrier
can be the deciding factor that pushes a patient into a nursing
home, or leads them not to receive care at all. But receiving
treatment in their own home is a game changer.
Ms. Sullivan, from your perspective, what does that look
like for patients and families on the ground? And how would
this bill, the Preserving Patient Access to Home Infusion Act,
make home infusion a more dependable option for Medicare
beneficiaries, reducing repeated travel, caregiver strain, and
unnecessary time in facilities?
Ms. Sullivan. Thank you so much, Congressman, for the
question.
You state the problem very clearly. And I wish I could say
it was a rare problem, but it is not. Every home infusion
company throughout the country gets a call every day from a
physician or a hospital saying, ``I have a Medicare patient. I
really need them to get home infusion because I don't know how
else they are going to get this treatment.''
And it just puts everyone in an impossible position.
Families have to then make decisions about whether to be
separated by hours from a loved one who needs to go to a
skilled facility. And physician--you know that when you need an
IV therapy, you need an IV therapy. There is not simply an
easier oral option that will take care of the problem. These
issues are more urgent, more critical, and the IV is necessary.
And so, home infusion simply removes those barriers. It
removes that stress. It removes the burden on the family to be
able to bring that care to the home and provide all of the
services that make it possible for that family to perform the
infusions confidently, safely, and effectively and cost
effectively.
Mr. Ruiz. Thank you very much. I yield back my time.
Mr. Griffith. I thank the gentleman. The gentleman yields
back.
I now recognize the gentleman from Florida, Mr. Bilirakis,
for his 5 minutes of questions.
Mr. Bilirakis. Thank you, Mr. Chairman, and thanks for
convening this very important hearing.
Improving Medicare is such a pressing issue for seniors in
Florida and across the country, obviously. I am proud to
support many of the bills on the agenda today, including the
Senior Savings Protection Act, which reauthorizes critical
programs for low-income Medicare beneficiaries. I have heard
testimony from volunteers and program participants, and the
impact of the Medicare improvement program is felt in my
district.
I also colead the RESULTS Act with Mr. Hudson, of course
Mr. Peters as well, and other cosponsors. Strong clinical
laboratories are vital to delivering high-quality care,
especially for seniors who depend on timely testing to maintain
their health.
I am glad we are discussing this key legislative initiative
to protect access to essential clinical laboratory testing,
services and help ensure that families in Florida and, of
course, across the country have the benefit of the crucial
information those test results offer.
You all know that one of my top priorities, of course, is
improving access to cutting-edge medical innovation. So my
first question is, Ms. Van Meter, your testimony speaks to the
importance of clinical lab tests and delivering care.
Can you elaborate more on this role, particularly for
patients with rare diseases, please?
Ms. Van Meter. Thank you, Mr. Bilirakis.
Yes. Absolutely. It is incredibly important that a patient
and their physicians have access to a comprehensive set of
tests. That does, of course, include routine tests but also
tests for rare diseases.
Let me give an example of a disease--rare disease:
autoimmune encephalitis. A patient that has autoimmune
encephalitis may present with symptoms of confusion, memory
loss, maybe psychiatric symptoms. Those types of symptoms
really clearly mimic common conditions like a dementia, for
example. But that patient with autoimmune encephalitis, that
is, an autoimmune-triggered swelling of the brain, that is a
disease that is treatable. And if that patient gets steroids
and other therapies, they can overcome that disease. If they
don't get that rare disease test, they aren't clearly
diagnosed, that disease can be fatal.
Other examples of rare disease testing that apply to
Medicare beneficiaries but also our youngest patients include
rapid whole genomic sequencing. These types of technologies are
uniquely situated to discern, diagnose unique and rare
conditions. Rapid whole genomic sequencing can diagnose
hundreds, thousands of conditions, can help patients and their
family end diagnostic odysseys. And this yields actionable
results in 50, 60 percent of the time. That is the kind of
information that patients and their families deserve.
So testing for rare disease is extraordinarily important,
and we worry about innovation being curtailed by deep and
persistent reductions.
Mr. Bilirakis. Thank you. Well put.
Mr. Chairman, I ask unanimous consent to enter into the
record a letter from over 30 leading organizations representing
patients with cancer, diabetes, kidney disease, sepsis,
autoimmune disorders, and a myriad of other conditions, urging
Congress to act, stating that access to timely and accurate
diagnostic information is foundational to patient healthcare
and well-being, of course.
So thank you, and I ask for this to be admitted into the
record.
Mr. Griffith. Does the gentleman have a date on the letter?
Mr. Bilirakis. Yeah. It is November 19th, 2025.
Mr. Griffith. Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Bilirakis. Thank you. And I yield back, Mr. Chairman.
Mr. Griffith. The gentleman yields back.
I now recognize Ms. Barragan for her 5 minutes of
questioning--of California.
Ms. Barragan. Thank you, Mr. Chairman.
Mr. Lipschutz, I want to start with you. First of all,
thank you for the work that you do for the Center for Medicare
Advocacy.
Last year, Republicans' priority was to give tax cuts to
the rich and take away healthcare through Medicaid. And even
though the bill doesn't mention the word ``Medicare,''
according to the Congressional Budget Office, absent future
congressional action, the bill will trigger $490 billion in
cuts to Medicare from 2027 to 2034 due to the Statutory Pay-As-
You-Go Act of 2010.
Can you talk about what it will mean for recipients of
Medicare if there are $490 billion of cuts to the program?
Mr. Lipschutz. That would be a significant cut. That would
require, perhaps, cuts to benefits, cuts to provider payments,
reorganization of the way people access healthcare.
If you will permit me, I would like to address the impacts
of H.R. 1 on Medicare. In addition to the cuts that providers
will face as a result of significant cuts to Medicaid--the same
providers that treat Medicare beneficiaries--and in addition to
potential cuts that States will have to make to their Medicaid
programs because of these cuts, services that people who are
duly eligible for Medicare and Medicaid both use, H.R. 1, for
the first time, strips away Medicare eligibility and coverage
for entire groups of people.
Now, undocumented individuals have never been eligible for
Medicare. But this bill strips away eligibility and coverage
for groups of lawfully present individuals regardless of how
long they have worked and paid into the system.
As previously mentioned, this bill also delays changes that
were meant to streamline enrollment and accessibility for the
Medicare Savings Programs, which helps people afford their
Medicare programs to the tune of, according to CBO, $66 billion
in savings, which is money that otherwise--going to come out of
people's pockets.
In addition, if you will permit me one more point about
H.R. 1, it also has an impact on Medicare prescription drug
negotiation. The Inflation Reduction Act exempted certain
orphan drugs from negotiation. H.R. 1 expands that exemption so
that the Medicare program will be paying an estimated extra $8
billion over the next 10 years as a result of that change.
Ms. Barragan. Thank you.
The other topic, of course, that everybody has been talking
about, except for Republicans, has been the Affordable Care Act
tax credits expiring and people losing their coverage. So I
want to echo the concerns that have been raised that we haven't
had a hearing in this committee for months. And instead of
having a hearing on what we can do to make sure more people
have access to healthcare and keep their healthcare, we are
talking about Medicare, which is also, again, very important.
But what is before people right now is their inability to
afford their healthcare.
Mr. Lipschutz, I want to follow up with you. Nearly one-
fourth of the ACA enrollees are at least 55 years old. Many are
early retirees who have to purchase insurance on the
marketplace because they are not yet eligible for Medicare.
If older Americans are forced to delay care because they
can't afford it, doesn't that mean they are going to be more
sick and in need of more expensive care by the time they need
Medicare?
Mr. Lipschutz. Very likely. Right now, the expiration of
the enhanced subsidies, 50 percent of the people who will lose
it are between the age of 50 and 64, which means their premiums
are skyrocketing, particularly compared with other groups of
people. So yes, more people will go uninsured or underinsured,
will delay care, will defer care, will go into debt, and will
face bankruptcy because of healthcare costs.
Ms. Barragan. Thank you.
I would also like to--important bill I think is missing
from today's hearing called the Promoting Access to Diabetic
Shoes Act. This bill would authorize nurse practitioners to
certify a Medicare patient's need for diabetic shoes and refer
them to a podiatrist so patients with Medicare can more easily
get the care necessary to prevent diabetic foot ulcers and
other conditions. That is why I hope we can consider this
legislation and have a hearing on it, including--included on--
at a hearing I am proud to colead with Representative LaHood in
a hearing soon.
And with that, I yield back.
Mr. Griffith. The gentlelady yields back. I now recognize
the gentleman from Georgia, Mr. Carter, for his 5 minutes of
questioning.
Mr. Carter of Georgia. Thank you, Mr. Chairman. Thank all
of you for being here. We appreciate it very much.
And, Mr. Chairman, I want to thank you for holding this
legislative hearing on proposals to support patient access to
Medicare services, something that we are very dedicated to and
working diligently on.
There are, however, two bills that are noticeably absent
today that I want to mention because I believe they are
essential to ensuring Medicare beneficiaries have access to
critical services. One is called ECAPS, Ensuring Community
Access to Pharmacist Services Act, which will allow seniors to
access testing and treatment for common respiratory illnesses
at the most convenient and accessible site of care for many
Americans, and that is their local community pharmacy.
The bill does this by establishing permanent reimbursement
for pharmacists under Medicare in States where scope-of-
practice laws already allow pharmacists to deliver such
services. And this is very important because in many States
where such services are allowed under State scope of practice,
when scope of practice is determined by the States, the only
patients currently without coverage are seniors under Medicare.
And the very patients most likely to have severe cases of
common respiratory conditions are these patients.
Secondly, I want to mention the Preserving Patient Access
to Long-Term Care Pharmacies Act, which is a bipartisan piece
of legislation that provides a critical fix so seniors can
continue to access the safe, reliable, long-term-care pharmacy
services they deserve.
Again, let me remind you, these bills are especially vital
for seniors in rural areas. Pharmacists are the most accessible
healthcare professionals in America. Ninety percent of all
Americans live within 5 miles of a pharmacy. But many in the
rural areas have to drive long distances to the closest
physician office or emergency room, both which are much more
expensive and less accessible points of care.
Keep in mind, we all want the same thing whether you are
Republican or Democrat. You want accessible, affordable,
quality healthcare. That is what we are trying to achieve here.
Mr. Chairman, I know that you are a supporter of both of
these bills. In fact, you are a cosponsor of both of these
bills, and I appreciate that very much. But I want to just ask,
please, if we could have these two bills considered in the very
near future, in the next relevant legislative hearing, and then
in the next markup as well.
Mr. Griffith. Mr. Carter, I look forward to working with
you on both of those bills, and hopefully we will be able to
get a hearing set up soon.
Mr. Carter of Georgia. Thank you very much, Mr. Chairman.
Again, I appreciate your support of this, and I know you are a
cosponsor on both of them.
Ladies and gentlemen, as a pharmacist, I always try to pull
the conversation back to what patients deal with after they
leave the hospital, because treatment doesn't end in discharge.
We all know that. Many still need infused treatments. And the
question is, Where do they finish them and how hard is it on
the patient and the family?
Home infusion is about safe care at home, not just drug
delivery. But Medicare patients often struggle to access it,
pushing them back into hospitals or facilities, and that is not
what we want, options that are tougher on seniors and families
and use more resources than needed.
Ms. Sullivan, I want to ask you, can you describe what home
infusion pharmacies do to ensure patients receive safe support
at home over the course of treatment?
Ms. Sullivan. Thank you, Congressman Carter. I appreciate
the question. I am always happy to talk about the important
work that pharmacists across this country are doing on behalf
of patients.
You know, the Medicare benefit today has an unusual
restriction that does not exist in the commercial market, which
has a robust home infusion benefit. Medicare restricts the
services payments only to those that take place face to face in
the home, which essentially is nursing. But without the
essential pharmacy services that occur in the background in the
pharmacy, home infusion is just simply not available.
I like to kind of describe it as the Medicare benefit for
home infusion is kind of like a car without an engine. The
pharmacy is what makes home infusion actually a functioning
benefit. The pharmacy designs a plan of care that the patient
can do and the family can support on their own, with supportive
nurses when it is needed. But they also provide that continuous
support and 24/7 availability to answer questions, serve as a
point of contact for physicians, and ultimately prevent
patients from returning to the hospital or needing to visit the
emergency room for support.
Mr. Carter of Georgia. Good. We are considering now today
the Preserving Patient Access to Home Infusion Act.
Would that make home options better? Would that improve the
system?
Ms. Sullivan. It will change patients' lives dramatically
today that have Medicare. They simply do not have the same
benefit that everyone else in the country essentially enjoys
and has access to when they might need a home IV therapy
unexpectedly.
Mr. Carter of Georgia. Mr. Chairman, I just want to point
out, make sure committee members understand that what she is
saying here is that most of the private insurance are covering
this, but Medicare is not. And that is a big gap and something
we need to fill in. So thank you for pointing that out, Ms.
Sullivan. I appreciate it.
Again, we all want the same thing: accessible, affordable,
quality healthcare. Accessibility is extremely important.
So thank you, Mr. Chairman. And I yield back.
Mr. Griffith. I thank the gentleman for yielding back.
I now recognize Mrs. Fletcher of Texas for her 5 minutes of
questioning.
Mrs. Fletcher. Thank you, Mr. Chairman, and thank you to
all of the witnesses for your testimony here this morning. I do
appreciate this hearing today and the hearings that have been
announced this morning, but I do want to echo the concerns of
many of my colleagues that have already been raised about this
committee and this Congress's failure to address the healthcare
affordability crisis.
And it is important that we also understand how we got
here, because we have to connect the dots in this committee
that a driver of this affordability crisis that we are now
talking about comes from decisions that this Congress has made.
Cutting Medicaid funding and eliminating the Affordable Care
Act enhanced premium tax credits are a huge part of it. They
are not the only drivers, but they are important ones. And they
are things that we can actually change in here.
And so I really think it is important, as Mr. Pallone has
mentioned, as several other people mentioned in here today, we
could vote to restore those premium tax credits today, this
afternoon, and I intend to do that. And I think this is an
important hearing. And I think that, you know, as we talk about
improving patient access to Medicare services, we have to
understand what Mr. Lipschutz was talking about a little while
ago, that the cuts that are being made by this committee, by
this Congress right now. are also impacting Medicare
recipients, and they are--they are affecting their access to
Medicare services as well.
Cutting access to healthcare for millions of Americans,
which is indisputably what is happening right now, is
increasing costs for everyone across the country, and it is
hurting Medicare recipients.
So I have the privilege of representing many people who
work in the Texas Medical Center, the world's largest medical
complex, and many of the more than 120,000 people who work
there live in my district and have warned me about how
disastrous the actions of this Congress are for patients across
the healthcare system, and in this case letting the premium tax
credits expire.
Now, Texas already has the highest uninsured rate in the
country. It is estimated that Texas will experience the highest
coverage loss of any State with the expiration of the tax
credits. And last fall, when we were still working on this, the
Texas Medical Center institutions and our local Chamber of
Commerce, the Greater Houston Partnership, sent letters to me
and to everyone in our delegation outlining the impact that
that loss is going to have on our constituents. It is a
bipartisan concern in the medical community and the business
community and across our community that people are losing
access to healthcare that they desperately need.
And so, I know most people in this room know how all that
works, but the idea that hospitals are going to be forced to
reduce services and staff, that patients are going to have to
wait longer--this applies to Medicare recipients too. And so I
appreciate the importance of what we are talking about here,
expanding access to Medicare services. That is what we should
be doing. But we can't have this conversation without
acknowledging the harm that is currently being done by
decisions that are being made by this current Congress and
limiting access to healthcare for all Americans.
So Mr. Lipschutz, I appreciate the work that the Center for
Medicare Advocacy does to promote access to quality healthcare
for Medicare beneficiaries. I appreciated your answers earlier.
And I just want to know if you can talk about, with the time we
have--I will have another question to submit, I think, to you
for the record at the rate I am going. But could you discuss
how this increase and the overall number of people across the
country who are not insured impacts access to care for Medicare
beneficiaries?
Mr. Lipschutz. Well, if you have a significant group of
people that don't have insurance at all, it is going to be
unaffordable for them. And many people will defer care until
they absolutely need it. It will--it will increase pressure on
emergency rooms. It will increase pressure on, you know,
frontline providers. It affects the entire healthcare system
when you have people who are uninsured and underinsured. It
adds pressure across the board, including the providers who
provide care to everybody, not just Medicare beneficiaries or
Medicaid beneficiaries.
Mrs. Fletcher. OK. So it looks like you are going to give
me time to ask you my other question, but I may have to take
the answer off the record--or for the record. But I do want to
acknowledge one of the issues that you raised in your testimony
about the WISeR model because that is one of the things I have
heard about ever since I have been here from the physicians in
my district, are about the problems with prior authorizations
and prior authorization in Medicare Advantage in particular and
how it really slows down access to appropriate care, forcing
physicians to spend a ton of time on the phone with insurance
companies instead of caring for their patients. And they are
really concerned about the implementation of the WISeR model,
which is being implemented in Texas.
So I am going to submit a question for you on that for the
record. But I appreciate your insights. I appreciate all of
your time here today and all of the work that you do.
Thank you, Mr. Chairman. I yield back.
Mr. Griffith. The gentlelady yields back. I now recognize
the gentleman from Pennsylvania, Dr. Joyce, for his 5 minutes
of questioning.
Mr. Joyce. Thank you, Mr. Chairman. And thank you for
including my legislation, H.R. 1703, the Choices for Increased
Mobility Act, in this hearing. This is commonsense legislation.
It would give greater access to Medicare beneficiaries to
titanium and to carbon fiber wheelchairs.
There is one keyword in this legislation, and that is
``choice.'' This bill allows Medicare patients the opportunity
to decide whether a titanium or a carbon fiber wheelchair is
the right choice for them. And if it is, then patients with
Medicare B have the ability to pay out of pocket for wheelchair
upgrades if they so choose.
Mr. Ryan, with your background, can you speak to some of
the benefits that these lighter-weight wheelchairs will offer
for those with disabilities?
Mr. Ryan. Certainly. Thank you.
Yeah. These patients who are using these type of
wheelchairs are not just, you know, broken leg. These are
patients with serious diseases, spinal cord disease, and they
ambulate on their own the best they can if they have the
ability. And just the wear and tear on them, on their
shoulders, on their arms, trying to get around and be about and
lead a mobile life is just, you know, unfair.
Other insurances cover this. We haven't gotten Medicare to
cover it yet. But the ability to the patient if they have the
means to at least pay the upgrade amount makes perfect sense.
And that is the way it had been in Medicare previously, but
through subregulation, they made a change and is no longer in
effect.
Mr. Joyce. You bring out a great point. That is previously
what Medicare patients had the capabilities of having, to have
a lightweight wheelchair. And this legislation once again will
provide that for the patients. Thank you for those statements.
I urge all of my colleagues to support this commonsense,
zero-cost measure, which passed unanimously out of this
committee last Congress, so that it may be signed into law.
I would now like to turn to H.R. 5269, the RESULTS Act. As
a doctor, I know firsthand that accurate diagnostic testing is
critical for the precise patient care. And that is why I
strongly support the RESULTS Act, to improve patient access to
these necessary services. This is bipartisan legislation, and
it provides for stability, and it provides for predictability
and ensures that CMS has a comprehensive cost data for the
market-based Medicare payment structure that was originally
intended under PAMA for clinical laboratory services.
Since the passage of PAMA, we have seen drastic cuts in
reimbursement for lab tests, with cuts as high as 30 percent
from previous rates. These cuts across the board impact testing
for everything from a skin biopsy to a complete blood count.
This underreimbursement is a dire threat to access for seniors
across our country. And there are more cuts slated to occur if
we in Congress fail to act.
The payments reforms in the RESULTS Act has strong support
from a diverse coalition that includes doctors, laboratories,
hospitals, and diagnostic manufacturer organizations. I urge
all of my colleagues to support this legislation.
Ms. Van Meter, thank you for your testimony and your
leadership on this bill and building such broad consensus. I
would also like to thank Representative Hudson for his
leadership on this legislation. I urge the committee to advance
the reforms of the RESULTS Act and provide the relief for
compounding payment cuts.
Ms. Van Meter, can you speak briefly to the impact that
these sustained cuts will have on access?
Ms. Van Meter. Thank you, Dr. Joyce, for your question.
Yes. We are tremendously concerned that these sustained
cuts in an unstable payment system can lead to longer
turnaround time for patients to get the results they deserve,
to have test menus curtailed for those laboratories that
focused on the most common routine tests that are essential to
everyday care. Those tests disproportionately get cut. We worry
about the viability of those laboratories.
And then there is innovation. Innovation is tremendously
important in diagnostics to help reduce costs overall and to--
--
Mr. Joyce. And you and I recognize it, that innovation is
the cornerstone of American medicine. Thank you.
I would also be remiss if I didn't mention the compounding
cuts and underpayments under the Medicare physician fee
schedule that have continued to negatively impact seniors'
access to their doctors and have forced more consolidation and
even higher costs in our healthcare system. I have also become
very concerned over the utilization of tools like AI going
beyond the already onerous prior authorization process in both
Medicare Advantage and Part D delaying and restricting
necessary care. I look forward to working with my colleagues to
address these pressing issues in a bipartisan process.
And with that, my time has expired, and I yield back.
Mr. Griffith. The gentleman yields back.
I now recognize the gentlelady from New York, Ms. Ocasio-
Cortez.
Ms. Ocasio-Cortez. Thank you, Mr. Chairman. And thank you
to our witnesses for being here today.
I want to expand a bit on Representative Schrier's point
earlier. It is so important that we acknowledge what is
happening right now, particularly in the area of health. Just 3
days ago, Secretary Kennedy stopped recommending life-saving
childhood vaccines across the United States. And this includes
hepatitis A, hepatitis B, and other vaccinations, including
rotavirus, the leading cause of hospitalization in U.S.
infants.
Millions of babies across the United States are going to be
at greater risk now than they were 3 days ago. And, in fact, we
are already seeing the results of this. In 2025, just wrapping
up the end of this last year, the United States has recorded
more cases of measles than any year since 1993, in over 30
years.
And later this month, the United States in general may lose
its official measles elimination status. It is back. And yet we
are only cutting more vaccinations to allow increases and risk
in increases in hepatitis A and B in babies across the country.
These cuts are deeply concerning. But then on top of that,
Secretary Kennedy is instituting some of the most devastating
cuts to scientific research that we have ever seen. Independent
scientific research is what provides us with new medical
technologies and treatments and is critical to getting harmful
products off the market, products that corporations will
sometimes sell to consumers despite the fact that there are
serious safety and health concerns.
Mr. Lipschutz, you are a patient advocate, correct?
Mr. Lipschutz. Correct.
Ms. Ocasio-Cortez. And I imagine that patients you have
worked with have shared instances where corporations and
healthcare conglomerates have not always acted in their best
interests in mind, correct?
Mr. Lipschutz. Correct.
Ms. Ocasio-Cortez. And we have seen large circumstances of
this. And I want to break down why corporations stand to profit
from RFK's cutting scientific research.
Let's look at Johnson & Johnson, for example. They are
known to manufacture talcum powder, more commonly known as baby
powder. As early as 1971, top J&J executives knew that their
talcum powder contained asbestos, a carcinogen that can cause
ovarian cancer. But because they wanted to continue to profit
off this product, the company hid the evidence.
Or we can look at DuPont, which was dumping cancer-causing
chemicals into our drinking water. These chemicals contained--
these chemicals caused cancer and birth defects.
And both of these companies worked successfully to keep the
public in the dark from scientific research proving their
harms, all to protect their bottom line.
Mr. Lipschutz, are you aware that J&J released falsified
studies and suppressed and discredited research finding their
product could be dangerous?
Mr. Lipschutz. I am.
Ms. Ocasio-Cortez. And in 1976, Johnson & Johnson lied to
Federal regulators stating their talcum powder was not toxic.
And I use these examples because we even have instances of
this that may be going on today. In fact, RFK himself had a
personal history--allegedly had a personal history going after
Monsanto around Roundup and pesticides.
However, just after giving a closed-door--after giving
closed-door listening tours where his only guests were biotech
and pharma CEOs with products awaiting FDA approval, giving
them private access instead of patients with doctors. On top of
that, his AI-generated MAHA report has turned around on his own
personal history on Roundup and instead parroted pesticide
industry talking points rather than include any proposals to
hold chemical companies accountable.
He surrounded himself with top advisors who come from the
for-profit wellness industry that set up the same exact
conflict of interests that he says that he is rooting out.
So in other words, he has done nothing except completely
dismantle the system that provides independent public research.
RFK is not cutting these cancer research and purging these
scientists because they are corrupt. He is purging these
scientists because he is.
And I yield back.
Mr. Griffith. The gentlelady yields back.
I now recognize the gentleman from Ohio, Mr. Balderson, for
his 5 minutes of questioning.
Mr. Balderson. Thank you, Mr. Chairman. And thank you all
for being here this morning.
My first question is for Mr. Ryan. I have heard from
constituents and stakeholders alike that there is often
difficulty in finding an oxygen supplier that carries the
equipment and supplies for liquid oxygen, particularly portable
liquid oxygen. While patients may still be able to obtain
different equipment, they are often unable to leave their home
except for a very limited period. Some do not have the
appropriate equipment that would allow them to travel, even for
something like a doctor's visit.
Can you discuss how the SOAR Act would help address this
problem?
Mr. Ryan. Yes, certainly. And you are correct. Usage of
liquid oxygen has gone down significantly over the years.
Portable liquid oxygen is down 77 percent. Stationary liquid
oxygen is down 80 percent.
And the reason for this is the reimbursement. Reimbursement
under the competitive bidding program would not allow suppliers
to provide liquid oxygen. And there are a certain subset of
patients that have high-liter flow needs that cannot be met
with traditional portable oxygen concentrators, and certainly
they have a high-liter flow need, it couldn't be met with the
gaseous tanks. Those tanks wouldn't last quite as long.
The SOAR Act would take all oxygen out of competitive
bidding, which would be very helpful to get more technology in
the sector, and it would treat liquid oxygen differently, and
it would give it a much higher rate that would hopefully add to
some expansion of the product category if necessary, set up a
group that would kind of look together to see how this should
be reimbursed in the future.
It is a small group of patients, but these patients are the
most, you know, fragile, and they can't get out and about, and
they are--sometimes they are very young--even a younger
population--pulmonary fibrosis requires such a high-liter flow
that it can't be met. So they are tethered to their home.
The SOAR Act would make an effort to take that away, give
liquid a separate reimbursement, figure out what is the best as
it goes in the future. And who knows? If we took oxygen out of
competitive bidding like the SOAR Act is saying, we might put
more technology back in that sector and have the technology in
years to come with a portable oxygen concentrator provide
higher-liter flow. So it is an excellent bill.
Mr. Balderson. I agree. Thank you.
My next question is for Ms. Van Meter. Thank you for being
here this morning today.
According to the Department of Health and Human Services
Office and Inspector General, Medicare paid between 18 and 30
percent more than other insurers for 20--for 20 high-volume
and/or high-expenditure lab tests in 2011. I apologize. The
Protecting Access to Medicare Act and its reform to the
clinical laboratory fee schedule adjusted the rates to stop
this excessive Medicaid spending. The RESULTS Act would address
concerns with the underlying data collection and rate
adjustment.
If we continue to postpone data collection and
reimbursement adjustments, do we risk returning to a situation
like 2011, where Medicare is paying significantly higher rates
for clinical tests than other insurers?
Ms. Van Meter. Thank you for your question.
That OIG report focused on, as you mentioned, 20 high-
volume tests, but looked at only three plans within the FEHBP.
I would suggest that is a dearth of data from which we could
draw broad generalizations about the differentiation between
rates between Medicare and private payers.
What the RESULTS Act would effectively do is establish
reforms to the current CLFS and allow CMS to pull in
comprehensive commercial market data, representative of all
three segments of laboratory industry to give a much greater
picture about if there is any difference between the Medicare
rates and the commercial market rates and allow for Medicare
rates to be more appropriately and accurately set.
Mr. Balderson. Thank you. I will follow up with you. Rural
hospitals act as a backbone for thousands of seniors living in
the district that I--the 12th congressional district that I am
fortunate enough to represent, providing them with timely,
accessible, and affordable care. The RESULTS Act would prevent
a 15 percent Medicare reimbursement cut for nearly 800 common
clinical laboratory tests.
How could this 15 percent cut in reimbursement impact rural
hospitals and patients around the country? I have 30 seconds
left.
Ms. Van Meter. It would dramatically curtail access, reduce
the--or increase turnaround time, and suppress innovation. But
particularly for communities like the ones that you were
mentioning, we worry significantly about any reduction in
access to those patients within those communities that are
served by rural hospitals. That infrastructure will be harmed
by persistent reductions of that magnitude.
Mr. Balderson. Thank you. Mr. Chairman, I yield back.
Mr. Griffith. The gentleman yields back.
I now recognize the gentleman of Texas, Mr. Veasey, for his
5 minutes of questioning.
Mr. Veasey. Thank you, Mr. Chairman.
And I am going to pivot away from these bills for a moment
because I want to ask a question that Donald Trump posed to my
colleagues yesterday: What have you done for America's health
lately? The President asked my colleagues to look in the mirror
and ask themselves, ``What have you done lately on
healthcare?''
Well, I am going to answer it for them. Just this week they
stood by while RFK Jr. unilaterally revoked recommendations for
vaccines against deadly diseases like flu, hepatitis, and
meningitis. Even the very conservative Review and Outlook in
the Wall Street Journal talked about some of these crazy moves
that RFK is making.
These are deadly diseases, and yet my colleagues have let
the lunacy of pseudoscience overtake long-standing, objective
medical truth, and that is the truth that children will die
without these vaccines.
And they are doing this as Texas and other States battle
the worst measles outbreak that we have seen in decades, with
more than 2,000 cases in 2025 alone. And this outbreak has
killed children.
Also this past week, Donald Trump--they allowed Donald
Trump to freeze more than $10 billion in childcare funding. Not
because of waste, not because of fraud, but because daycare
workers refused to let a YouTuber harass babies and toddlers. A
YouTuber. Damn. Let that sink in. Working families across the
country won't be able to take their kids to daycare because of
a YouTuber trying to be an influencer so they can put some
money in their pocket. That was just this past week.
Last year they terminated dozens of billions of dollars in
cancer research. Then they led the charge and gleefully gouging
more than $800 billion in Medicare dollars from children,
mothers, and working families. And as if this weren't enough,
my colleagues refuse to negotiate to lower insurance premiums
for more than 22 million Americans. Add to that the reckless
Medicaid cuts, and Republicans have robbed Americans blind of
almost $1 trillion in healthcare dollars.
And these are not coincidences. This is not incompetence.
This is a Republican-manufactured health crisis. And let me be
clear: This crisis was manufactured by my Republican
colleagues, decision by decision, vote by vote.
Now, despite my colleagues' obstruction, this afternoon
Democrats will vote to protect the Affordable Care Act's
premium tax credits because healthcare is not a game. Repeat:
This is not a game. We have children's lives that are at stake.
So I have to ask, how can we sit here today and talk about
how Congress should support Medicare while Republicans do
everything in their power to make sure America's children don't
live long enough to even become Medicare beneficiaries?
I appreciate that we are here to talk about serious
policies that will improve Medicare for our seniors, but I
can't separate that work from the reality that Republicans are
actively undermining our healthcare system. Republicans are
dismantling the system dollar by dollar, program by program,
piece by piece, and it seems they won't be satisfied until
nothing--nothing--is left.
These assaults on America's healthcare are antichild. They
are antifamily. They are anti-American. And so when the
President told you to ask yourselves what have you done lately,
I hope you will look hard in the mirror and that you are honest
with yourselves about the reality of why we are here. You
created this crisis, and American children are paying the
price. American families are paying the price.
Thank you, Mr. Chairman. Thank you, witnesses, for bearing
with me. I yield back.
Mr. Griffith. The gentleman yields back.
I now recognize the gentlelady from Iowa, Dr. Miller-Meeks,
for her 5 minutes of questioning.
Mrs. Miller-Meeks. Thank you, Mr. Chairman, and thank you
to the witnesses for testifying before this subcommittee today.
I appreciate the Health Subcommittee's focus on ensuring
Medicare beneficiaries have reliable access to durable medical
equipment, prosthetics, orthotics, and supplies, commonly known
as DMEPOS, because for millions of patients, these items are
essential to daily living and ongoing care.
As a physician and nurse, I have seen firsthand how
critical, timely access to oxygen equipment, mobility devices,
and home medical supplies is to keep patients healthy and out
of hospitals. When access to these services is disrupted,
patient outcomes suffer and costs to the healthcare system
increase. That is why I introduced H.R. 2005, the DMEPOS Relief
Act. D
MEPOS supplies, particularly small, independent providers
and those serving rural communities, are under growing
financial pressure due to inflation, workforce shortages,
supply chain disruption, and Medicare reimbursement rates that
have not kept pace with real-world costs. In many cases,
suppliers are being forced to limit services or exit the
Medicare program altogether, leaving beneficiaries with fewer
options and longer wait times. The DMEPOS Relief Act provides
targeted temporary payment relief to stabilize the supplier
market and preserve beneficiary access without undermining
program integrity or patient protection.
The goal is simple: to ensure seniors and individuals with
disabilities can continue receiving the equipment and supplies
they need, where and when they need them.
Today's hearing is an important opportunity to hear
directly from providers and experts about how current payment
policies are affecting patients and care delivery. I look
forward to hearing more from our witnesses and how Congress can
act responsibly to address these challenges and prevent further
erosion of access, especially in rural and underserved areas.
I hope this discussion will help inform bipartisan
solutions that protect patients, strengthen home-based care,
and ensure Medicare policies that reflect the realities facing
providers and beneficiaries alike.
Mr. Ryan, from the perspective of home medical equipment
suppliers across the country, particularly small, independent
providers and those serving rural communities, how are current
Medicare DMEPOS reimbursement rates affecting beneficiary
access to care? And how would targeted relief in H.R. 2005, the
DMEPOS Relief Act, help stabilize access for patients who
depend on these services?
Mr. Ryan. Yeah. Thank you, Congresswoman.
Let me just say, you know, when those rates cuts came into
effect, again, we did a survey around the country of our
membership, and some of the key findings were finding out that
65 percent of the companies reduce the amount or type of
products they offered, 46 percent reduced their service areas,
53 percent laid off staff, 35 percent used personal savings to
maintain that business. I know that route, did that myself. And
over one in 10 surveyed said they will be out of business
probably within a year.
So those areas of the country, the nonbid, nonrural areas
of the country, they woke up overnight and got a significant
decrease, a 30 percent decrease, without getting an increase in
market share.
When I had my company in New York, I bid responsibly, and I
lost 32 contracts and essentially went out of business. But at
least when I bid, I had the option of potentially getting more
market share. These areas of the country, those suppliers of
the country didn't get any increased market share. In fact,
competitive bidding for those legacy items is not, at this
point, in effect. But they see these tremendous rates.
So what has to happen is they have to look for less
expensive equipment. Technology is going to be thwarted. At the
end of the day, we are taking the patient-preferred, cost-
preferred setting in the home and bringing it down to a
commodity. We used to spend 2.2 percent of Part B on DMEPOS.
Now we are 1.3 percent.
Mrs. Miller-Meeks. Thank you, sir.
Mr. Ryan. That number should be higher.
Mrs. Miller-Meeks. Thank you. I have a question for Ms.
Sullivan on H.R. 2172, Preserving Patient Access to Home
Infusion Act, that I will submit for the record for you to
answer. And also one on Medicare reimbursement rates affecting
timely access to diagnostic testing for beneficiaries.
Mr. Lipschutz, you were asked some questions about the ACA
premium. So let me ask you, are the premiums for those who are
not on the ACA exchanges, are those premiums increasing for
those 130 to 160 million Americans?
Mr. Lipschutz. Well, Congresswoman, I am more of an expert
on Medicare than I am on the ACA----
Mrs. Miller-Meeks. The ACA is Medicaid and not Medicare,
but the answer to that question would be yes. And so can you
tell me the COVID-enhanced era tax credits with no income
limits with subsidies that are going directly to profitable
insurance companies--do extending those COVID-era tax credits
lower premiums for those 130 to 160 million Americans?
Mr. Lipschutz. I think it should be Congress's goal to
lower premiums for people across the board and----
Mrs. Miller-Meeks. I wholeheartedly agree with you. Our
goal should be to lower premiums. It is why we passed Lowering
Health Care Premiums for All Americans Act, which my colleagues
on the other side of the aisle voted against and, while in
control of government for 4 years, did nothing to pass
legislation to lower premiums for Americans. So the answer to
the question is no, it does not lower premiums for 130 to 160
Americans not on the ACA.
With that, Mr. Chair, I yield. Thank you.
Mr. Griffith. The gentlelady yields back. I now recognize
the gentleman from Massachusetts, Mr. Auchincloss, for his 5
minutes of questioning.
Mr. Auchincloss. Thank you, Chairman. I want to begin by
lifting up the poignant remarks from the gentleman from Texas,
Mr. Veasey, about this committee's failure to do one of its
fundamental jobs, which is to exercise oversight and
accountability over Secretary Kennedy and Health and Human
Services.
We are whistling past the graveyard right now. He is, as he
said he was going to do--there is no surprise here--gutting the
childhood vaccination schedule. This will lead to an increase
in morbidity and mortality from infectious disease for
children. This is preventable. This is predictable. And it is
going to be a tragedy.
Shame on this committee for not acting. We have requested
repeatedly oversight hearings over the Secretary, over FDA,
over his actions with ASIP. There has been nothing. That needs
to change in 2026.
There is action that we can take, though, that is immediate
and bipartisan, including with Secretary Kennedy, and that is
on community health center funding. The community health
centers are bipartisan priorities. And they are struggling
through a period of acute financial uncertainty, with their
Federal funding scheduled to expire in just 22 days on January
30th, repeated short-term funding extensions that limit
community health centers' ability to plan for their patients'
needs and exacerbate the difficulty of working on already very
tight margins.
I know that this is true for Members on both sides of the
aisle, that we value the work of our community health centers
in our districts and we should take action to ensure they have
the funding they need to be successful. And indeed we should be
working on legislation to expand that funding and help them
triple their reach across the United States. I hope we can work
in a bipartisan way to provide long-term health center funding
that protects patients' access to comprehensive primary care
before the January 30th deadline.
Moving to the issues at hand with this hearing: Mr.
Lipschutz, I want to address my questions to you. You have
talked in depth in both your written and oral testimony about
the use of AI, how it can be instrumental and lifesaving, also
dangerous if used inappropriately or excessively, and that is
the case with the use of AI to evaluate prior authorization
requirements. There's ongoing class action lawsuits from Cigna,
UnitedHealthcare, and Humana about improperly denying claims,
which is why I am working on legislation that would place
guardrails around the use of AI for prior auth determinations
in Medicaid-managed care plans and Medicare Part D plans.
My legislation would require these plans to establish an
electronic prior auth program, enabling them to meet the new
timelines--timeliness--excuse me--requirements for plans' prior
auth determinations. It would require full transparency about a
plan's prior auth requirements and the clinical criteria used
for decision making with public reporting to ensure audit
capabilities and annual review of plans' utilization management
trends.
It will eliminate unnecessary prior auth reviews for
certain providers, items or services for patients with
conditions that require ongoing care. And it would implement
guardrails by requiring only qualified physicians to make prior
auth determinations, prohibiting retroactive denials, requiring
a standardized appeals process, and mandating a 60-day advance
notice for any changes in prior auth requirements.
Mr. Lipschutz, recognizing your expertise in Medicare and
understanding that you haven't been able to review the text of
what I am proposing, but just hearing those broad outlines, do
you think that could be an effective addition to prior auth
legislation for Medicaid MCOs and Medicare Part D?
Mr. Lipschutz. Yes. It would be an important start in
trying to rein in inappropriate use of AI.
Mr. Auchincloss. Anything I am missing that I should be
considering?
Mr. Lipschutz. I think we should ask the question of
whether or not these tools actually do learn from their own
mistakes. I can elaborate unless you have further questions.
Mr. Auchincloss. If I could, let me try to--what I think I
hear you saying is whether the models are purely tokenized LLMs
where they are making just predictions or whether they actually
have a worldview, whether they are world models that actually
feel like they have inherent logic and are learning.
Mr. Lipschutz. Let me give an example. So, in the Medicare
Advantage context, we often see plans deny care--ongoing care
in a skilled nursing facility. Say, initially, care is
authorized. The plan will come back and prematurely terminate
coverage. A person, if they appeal--they often win, but then
the next day or a few days later, they get another denial----
Mr. Auchincloss. So it is just a----
Mr. Lipschutz [continuing]. And no change in condition. So
we are unconvinced that the machine learning tools are learning
from their own mistakes and accounting for them.
Mr. Auchincloss. Helpful. Thank you, sir.
I yield back.
Mr. Griffith. The gentleman yields back.
I now recognize the gentleman from Louisiana, Mr. Carter,
for his 5 minutes of questioning.
Mr. Carter of Louisiana. Thank you, Mr. Chairman, and thank
you to the witnesses for participating today.
We are in this committee today discussing various proposals
that would improve access to healthcare services covered by
Medicare while seniors, families, and small business owners
across the country saw their premiums skyrocket last month
after Republicans failed to extend the ACA tax credit--premium
tax credits before January 1. These tax credits are a lifeline
and help make healthcare coverage affordable at times when the
cost of living continues to climb.
I stand with Leader Jeffries and my Democratic colleagues
on this committee as we continue to fix and fight for an
extension of the tax credits to make healthcare affordable for
all Americans--and I underscore all Americans. Not Democrats,
not Republicans, not independents, but all Americans. The
fallacy that this only impacts some and doesn't impact others
is something that we must at all costs dismiss.
Mr. Lipschutz, thank you for joining us. Louisiana has one
of the highest percentage of MA enrollees in the country, many
of whom live in my district. Given how many of my constituents
get their healthcare through MA plans, it is important to me
that they have the information they need to make the best
decision about their healthcare, which also includes choosing
the supplemental benefits that best meets their needs.
Can you talk more about how collecting supplemental benefit
data from MA plans help seniors and why it is important for
these plans to notify beneficiaries of their benefits?
Mr. Lipschutz. Thank you for the question. So Medicare
Advantage plans use their considerable payments in part to
offer supplemental benefits to their enrollees. They often use
these supplemental benefits heavily in marketing to try to
entice people to enroll. Oftentimes, for example, we will hear
about people drawn to so-called flex cards that are essentially
debit cards that, among other things, could be used to purchase
over-the-counter items.
And we hear stories of people contacting the SHIP programs,
State Health Insurance Assistance Programs, asking what plan
will give them the highest-value card while disregarding all
the more important considerations like do my doctors contract
with the plan, what services are covered, what kind of prior
authorization will I be subject to?
We also hear from folks who are drawn to supplemental
benefits--say, a dental benefit, for example--but when they are
enrolled in the plan, they find out that they have trouble
getting--finding a provider that will take their plan, or their
services are capped at a far lower level than they believed.
So what this bill would do would help gather information to
give the public and give the Medicare program a better idea of
what services are being offered, who is using them and to what
extent, how much it is costing folks, and if people are
actually getting value out of these services for which we pay
plans considerably.
Mr. Carter of Louisiana. So how do we better educate?
Because we know that many people are either hoodwinked into
going into, as you suggested, a plan that has greater variables
that may not very well be the best fit for their true medical
coverage. How do we--listening from this committee and working
with our other agencies back home, how do we do a better job at
making sure that we educate people on these MA options?
Mr. Lipschutz. So we just discussed one of the bills being
evaluated today that would increase requirements for collection
of data on supplemental benefits. I will pivot to the other
bill that would extend MIPPA funding for key community health
organizations like State Health Insurance Assistance Programs,
AAAs, ADRCs, and others. Part of that funding goes exactly
towards trying to provide people with information about their
Medicare coverage options primarily through the SHIP programs.
The best way, in my view, to help educate people is to
invest even more into the SHIP program, which is really the
only source of pure, unbiased information where counselors--
they have no stake in someone's decision. They have no
financial stake.
Contrast that with the billions of dollars spent annually
on marketing and commissions all aimed to try to convince
people to enroll in certain plans to the benefit of the people
who are paying those commissions and ads but not necessarily to
the benefit of enrollees.
So we need more unbiased, neutral information that can help
people understand their options, and that is where I would
suggest Congress focus its attention.
Mr. Carter of Louisiana. Hence the transparency measure
that my dear colleague Jennifer McClellan will be offering, and
I fully support the Representative's effort because it makes
all the sense in the world to create--we talk about
transparency all the time, but it seems to be more selective
than it should be.
Transparency should be universal. This measure will, in
fact, do that. It will save lots of money and opportunities for
people to be better educated and have the healthcare more
accessible.
Thank you very much. My time is up. I yield.
Mr. Griffith. The gentleman yields back.
I now recognize the gentleman from Ohio, Mr. Landsman, for
his 5 minutes of questioning.
Mr. Landsman. Thank you, Mr. Chairman, Ranking Member, for
this hearing. I thank all of you for being here and offering
your expertise. A lot of good bills.
I want to give a little bit of context for our bill. As you
know, Medicare provides healthcare for tens of millions of
seniors. It is one of the most significant things we do as a
community of Americans, is provide healthcare in general but in
particular to our seniors. And it is an earned benefit. Folks
pay into the system.
The WISeR pilot picked six States--Ohio included--to test
whether or not the following is a good idea: To use AI to deny
healthcare to seniors. Now, this is the first time to my
knowledge that Medicare is using AI for anything. And I have
been sitting here listening to all of you thinking of all kinds
of great uses of AI, the paperwork and billing and all kinds of
other things that would help you all provide better healthcare.
The first time they are going to use AI is to deny healthcare
to seniors.
And they will say, well, this is the low-hanging fruit, it
is really basic stuff, to which I would say, then why do you
need AI? Why not just say this is low-hanging fruit and we are
going to make these changes? There is something very suspicious
going on, which is to say they are going to use AI in this
context, hoping that no one would notice because it is low-
hanging fruit, and then expand it to the kind of healthcare
decisions that will lead to life-and-death decisions or
situations.
And that is why this is being called by many, many people
these AI death panels because AI is going to make decisions on
whether or not somebody gets the healthcare they need, and that
decision may lead to that person losing their life.
So, on top of that, there is an incentive to deny care that
for-profit companies get. They are going to get a percentage of
the money saved when they deny it. So very perverse. Very
problematic.
My bill prohibits HHS from doing WISeR, from testing WISeR,
using AI to deny care in Medicare. There is immediate confusion
and concern, just so you know, not surprisingly. There is no
transparency, or little transparency. So the big pieces here
are the financial incentive model. No one knows what is in it.
They do know that the burden will be on the provider.
So here I am a doctor and I am providing healthcare to a
senior using Medicare. It gets denied. I am now on the hook. So
you are going to have all these doctors who just stop providing
certain care.
And then the lines of code that will be deciding whether or
not somebody gets healthcare--which is insane--there is no
transparency for that either. We don't know whether or not it
is a learning model or if it is just, you know, pretty basic
stuff that is just denying what it is going to--what it has
been told to deny.
In any event, the--you know, one of the things that came up
is just how often people get denied claims wrongfully. Why not
use AI to stop that, to stop the wrongful, you know, denials of
claims? Instead, they are using AI to deny healthcare.
I would encourage all of my colleagues to think about how
important this is to bring this bill to the floor or to this
committee up for a vote and to make it unanimous, bipartisan.
There are lots of ways to deal with the denial situation.
Adding AI and for-profit companies and these financial
incentives is a disaster, and we should stop it.
I would ask any of you if you know of the coding or the
financial modeling behind this. I mean, is there--does anyone
know? Because my providers have no idea what is going on.
Mr. Lipschutz. Congressman, I think the only thing that we
do know is that these vendors that have been hired to
participate in the WISeR model, as you noted, have a financial
stake in denying care. They benefit when care is withheld,
which is exactly the wrong model to be using in healthcare,
particularly with the Medicare population.
Mr. Landsman. I couldn't agree more, and I yield back.
Thank you.
Mr. Griffith. The gentleman yields back.
I now recognize the gentleman from New Jersey, Mr. Kean,
for his 5 minutes of questioning.
Mr. Kean. Thank you, Mr. Chairman. I appreciate this
committee's efforts to educate all of us on legislation that
could help our seniors who rely on Medicare. I support H.R.
5269, the RESULTS Act.
The bill has been introduced by my colleague from North
Carolina, Representative Hudson. This bill would make vital
reforms to Medicare's Clinical Lab Fee Schedule, which pays for
lab tests New Jersey seniors rely on for routine care and for
diagnosis of more complex conditions like cancer. In New
Jersey, there are over 2,300 laboratories. In my district,
there are over 200.
Ms. Van Meter, can you articulate the urgency of reform
needed for Medicare's Clinical Lab Fee Schedule?
Ms. Van Meter. Yes. Thank you, Congressman. On January 31,
about 800 tests will get cut by up to 15 percent. The cuts are
going to hit tests that are among the most routine that
Medicare beneficiaries rely on every day. Those kinds of
reductions will have an impact on beneficiary access to
services and will also stifle innovation in the next generation
of diagnostics those same patients need and deserve.
Mr. Kean. Thank you. In New Jersey, as a followup on this,
we have several companies with great employees who are
developing new diagnostics to ease the process of diagnosing
suffering patients. These include companies like WuXi
Diagnostics or Thermo Fisher.
In your testimony, you mentioned innovations in biomarker
testing or rapid whole genome sequencing. First, can you
explain to us the exciting hope that these new tests can
promise patients, including those with rare diseases?
Ms. Van Meter. Absolutely. Biomarker tests can be used in a
variety of conditions and diseases--cardiac, neurological,
cancers, many others--and it is the foundation for precision
medicine; in other words, being able to plot a personalized
course for patients on the best medicines and best treatments
for their particular condition. We are seeing tremendous growth
in this field bringing treatments and improvements and saving
lives for patients.
With rapid whole genome sequencing, that technology is
uniquely situated to diagnose rare diseases. Thousands of rare
diseases can be diagnosed using this technology that is
essential for patients who are living with such diseases and
conditions.
Mr. Kean. And can you explain how the current Medicare
Clinical Lab Fee Schedule under PAMA is affecting the
development of these tests and the ability of these patients to
access them?
Ms. Van Meter. The key to ensuring that we have long-range
research and development is a stable and predictable Medicare
payment system, and we do not have that right now under PAMA.
There are years of cuts that have taken effect, and there is a
constant threat of deep reductions over the field.
While innovation has been happening, with that threat of
constant cuts, looking out for long-term research and
development certainly is compromised, and that includes the
work that we can do in biomarker testing and beyond.
Mr. Kean. So, currently, CMS would rely upon data from 7
years ago, 2019, to determine the reimbursement rates for lab
tests. In your testimony, you write that around one-third of
lab testing codes are new since 2019.
Without some type of changes to the current system, could
you give us your thoughts on how realistic it would be to
expect CMS to gather stakeholder input individually to
determine the price of each one of these codes, and what impact
would further delays on these repricings have?
Ms. Van Meter. It is an excellent question. So, yes,
because there is constant innovation, there's been hundreds of
new codes that have been established since the last data
collection period, but that would not be captured within the
2019 data that labs are due to report come February 1, and CMS
will not have any commercial market data upon which to make any
changes to those rates for those tests that have been
established since 2019.
We have consulted with CMS. We have encouraged them to use
the rates that have been set to date. We think it is beyond the
scope of what is reasonable for the agency to do to really
update those rates. They should be maintained. But, most
importantly, if we move forward with the RESULTS Act, that
becomes a moot issue.
Mr. Kean. Thank you to all of our witnesses for being here
today and your valuable insights.
I yield back, Mr. Chairman.
Mr. Griffith. I thank the gentleman for yielding back.
I now recognize the gentlelady from Massachusetts, Mrs.
Trahan, for her 5 minutes of questioning.
Mrs. Trahan. Thank you, Mr. Chairman, and thank you to the
witnesses for being here today.
You know, it is refreshing that this subcommittee is
finally doing the work that the American people expect us to
do. The last time that we met was September 18, 112 days ago.
Even as families were staring down the barrel of a healthcare
price hike that was entirely created by Republicans' failure to
meaningfully extend the ACA premium tax credits--nothing, not a
single official action from this subcommittee with direct
jurisdiction over Americans' healthcare, even as RFK Jr. puts
our children at risk of death, hospitalization, and illness as
he dismantles vaccine policy in our country.
Instead, House Republicans passed a bill to make this
crisis that they created even worse, increasing premiums for
millions of Americans, raising the number of uninsured by an
average of 100,000 people each year, according to CBO, and
ignoring the ACA tax credits altogether.
You know, Mr. Chairman, in 2025, 24 million individuals
obtained health insurance through the ACA marketplace, and it
is estimated that 22 million of them received tax credits that
helped reduce costs. Without these subsidies, premiums are
skyrocketing, increasing by an average of 114 percent. That is
hundreds or even thousands of dollars every month. And, like
all of my colleagues, my office is being inundated with
messages from constituents facing that massive sticker shock.
A 54-year-old woman on disability says that her cheapest
plan is jumping from $250 to $570 a month, forcing her to
considering dropping her coverage. A 61-year-old forced into
early retirement says his family's premiums are already $1,600
a month and rising another 11 percent next year with a $3,000
deductible on top of that, making healthcare his largest
household expense before he reaches Medicare age. And one
constituent who relies on premium tax credits says their
premiums are set to triple, from $300 to $900 per month.
This is all on top of the more than $1 trillion in Medicaid
cuts Republicans already passed last summer to pay for tax cuts
for the wealthy, cuts that will push millions off coverage and
make it harder for seniors, people with disability, and low-
income families to get the care they need.
So, Mr. Chairman, we all know that these policies will not
only push people off coverage, but it also exacerbates our
physician shortage and accelerates hospital closures. That is
why the authors of the Big Ugly Bill included a $50 billion
rural health fund to try to offset the expected 137 billion
reduction in Federal Medicaid spending in rural communities.
That is the very definition of a Band-Aid on a bullet wound.
And, if it hasn't been made clear already, it should be
now. House Republicans have shown that protecting Americans'
healthcare is just simply not a priority. Policies are pushing
people off coverage, driving up their costs, and destabilizing
the very providers that our communities rely on.
With that reality in mind, I want to turn to a couple of
specific Medicare payment policies where decisions we make in
this room in this committee can help stabilize care. The PURE
Act aims to improve access to portable diagnostic imaging for
seniors and medically fragile patients who can't easily travel
for care. These services allow clinicians to evaluate serious
conditions directly at the bedside. But, unlike portable x ray,
Medicare does not reimburse transportation costs for portable
ultrasounds, making it harder to bring timely diagnoses to
patients or provide diagnostics to patients.
Mr. Ryan, how important is timely access to diagnostic
services for seniors and medically fragile patients,
particularly when it comes to catching problems early, avoiding
unnecessary hospitalizations, and reducing long stays?
Mr. Ryan. Yeah. It is obviously very, very important. As I
continue to talk about today, care in the home is extremely
important. It is where the dollars should be going these days.
It is where the infrastructure should be building up. And,
certainly, knowing travel time and what it costs to do travel
time and using it as an example for, you know, repairing
wheelchairs, where you get wrench time, you only get paid for
the time you are in the home and actually fixing the chair. I
can certainly empathize with that industry for wanting to get
some sort of a reimbursement for that travel time.
Mrs. Trahan. Thank you. Seniors and other Medicare patients
must continue to have that access to vital testing used to
diagnose, monitor, and manage diseases such as diabetes, heart
disease, and cancer.
Ms. Van Meter, I am not sure if you will have time to
answer, but I will get my question on the record. Under current
law, Medicare reimbursements for lab testing continues to face
significant downward pressure.
How have those cuts already affected laboratories' ability
to serve seniors, and how would the RESULTS Act help protect
access to diagnostic tests patients rely on to detect and
manage disease?
Mr. Griffith. If you can do it quickly.
Ms. Van Meter. It is compromising access and stifling
innovation. Having a stable payment system that the RESULTS Act
would bring to bear would do a tremendous amount to ensure that
patient access.
Mrs. Trahan. Thank you.
I yield back, Chair.
Mr. Griffith. I thank the gentlelady. She has yielded back.
I now recognize the gentleman from New York, Mr.
Langworthy, for his 5 minutes of questioning.
Mr. Langworthy. Thank you, Mr. Chairman.
For millions of our seniors, access to Medicare services is
only as good as the payment policies behind them, and when
those policies fail to keep pace with modern care delivery, the
patients feel it first through delayed services, fewer provider
options, and reduced access to care in their communities.
Across the country, providers are telling us the same thing:
Outdated reimbursement rules and rigid payment schedules are
making it harder to deliver care where patients need it the
most, which is at home, close to family, and outside of
institutional settings.
And, with that, Ms. Sullivan, my district covers a large
stretch of rural communities where a simple infusion
appointment could easily turn into an all-day ordeal for
patients and caregivers, family that have to be responsible for
transportation, and in the winter especially. You know, I
represent western New York and the southern tier of New York,
where it is a harsh winter.
Weather and road conditions can make repeated trips to a
hospital outpatient department unrealistic. And missing doses
isn't just inconvenient. It can derail the treatment plan of a
patient. When Medicare doesn't make the home option dependable,
the system too often defaults patients into a more inconvenient
setting simply because it is the only workable way to complete
their treatment.
Ms. Sullivan, can you explain how the Preserving Patient
Access to Home Infusion Act would help keep Medicare patients
on track with treatment for patients that are a long ways away
from their next hospital campus or infusion center, so that
their care isn't determined by weather or logistics but by what
their doctor believes is safest for them?
Ms. Sullivan. Thank you, Congressman, for the question.
Home infusion operates on a model that is incredibly efficient
in that we rely on the pharmacy to provide that support and the
continuity of care for patients so that they can independently
infuse their medications at home. They don't rely on a nurse
regularly.
The nurse visits periodically to make sure things are on
track, to lay eyes on the patient. Maybe they have a wound or
something that needs to be assessed to make sure it is healing
properly. But the support really comes from the pharmacy on a
daily basis and largely happens behind the scenes.
The Medicare program's benefit is so fragmented, which was
confirmed by the GAO report that I mentioned in my opening
remarks, that they pay for only the services that happen in the
home, which are the most infrequent of the services that occur
with a home infusion patient. So the pharmacy is working behind
the scenes, communicating with the physician, monitoring the
labs, making sure everything is working properly for that
patient and can communicate with them without the patient
needing to travel, without needing to send resources to the
home. So it is an efficient model that has been widely adopted
in the commercial market.
And you would think with almost a million beneficiaries
under the Medicare program being sent to hospital outpatient
departments for these infusions, the hospitals would not want
to lose that. In fact, most health systems have signed letters
of support of this particular legislation because they
recognize these are not patients that need to be there, that
they have other patients that are--that would better benefit
from their resources. And so it is one of those commonsense
solutions that helps patients, helps our health systems, and
uses appropriate resources.
Mr. Langworthy. The keyword is common sense.
Ms. Van Meter, as you know, Medicare lab payments are still
based on outdated data that fails to reflect real costs, and in
just 25 days labs could be hit with payment cuts of up to 15
percent across hundreds of tests, making it harder to deliver
timely and accurate care. What are some of the unique
challenges that these payment cuts create for labs serving
rural communities or other vulnerable populations like those in
nursing homes?
Ms. Van Meter. Thank you for the question. The
infrastructure that exists in rural or frontier communities may
not be as robust as is ideal. Right now, we have patient
service centers, there are hospital laboratories, physician
office labs, and obviously large commercial labs that have
capacity to move samples around the country, but if the cuts go
into effect we worry that that infrastructure will be
compromised: fewer patient service centers, smaller menus,
longer turnaround time.
We need those tests to be timely in order to make clinical
judgments about the right pathway for care. So we are concerned
about patient access to those services across the country but
certainly in rural and frontier communities.
Mr. Langworthy. Thank you. I am a proud cosponsor of the
RESULTS Act, which is a commonsense fix to prevent these
payment cuts while reducing the administrative burden on
laboratories and CMS.
And, finally, Mr. Ryan, last year AAHomecare conducted a
survey on the impact of the 2024 payment cuts on durable
medical equipment. Could you briefly summarize your findings in
the remaining time?
Mr. Ryan. Well, we discussed this earlier today, Mr.
Congressman. But, certainly, when those 75/25 rate cuts went
into effect--again, this is in the nonrural, nonbid area of the
country that--when they woke up overnight and just saw a 50
percent cut, a 75 percent cut, and we had Congress intervene
twice to make sure those cuts were not in place and the 75/25
rate remained in place.
Well, since they have stopped, the key findings are that 65
percent of the products have been reduced. The companies are
offering fewer products. Forty-six percent reduced their
service area, 53 percent laid off staff, 35 percent used
personal savings to maintain the business, and one in 10
surveyed said they would be entirely out of business within a
year.
Mr. Langworthy. Well, thank you. Thank you for bringing
that up, and I yield back.
Mr. Griffith. The gentleman yields back.
We now enter into the next phase, where we go to Ms. Matsui
for her 5 minutes of questioning.
Ms. Matsui. Thank you very much, Mr. Chairman. I want to
thank the witnesses for being here today.
I am glad to be here discussing this bipartisan slate of
bills. I am especially excited to discuss my bill, the Senior
Savings Protection Act, but I would like to echo my colleagues.
This hearing misses the point. We are in a full-blown
healthcare crisis.
On January 1, over 20 million Americans saw their premiums
skyrocket. They are facing a dire choice: Pay crushing premiums
or risk going without coverage to afford other basic
necessities. They have been begging Congress to act. Instead,
House Republicans have refused to extend premium tax credits
and pushed a sham of a bill that would cut even more people off
care. That managed for what we are discussing today.
My bill focuses on helping Medicare beneficiaries afford
their care, but we can't ignore the millions of older Americans
who aren't yet eligible for Medicare. Nearly 5 million older
Americans age 50 to 64 rely on the ACA marketplace for their
healthcare. In my jurisdiction, a 60-year-old couple making
$150,000 annually just saw their premiums jump from about $800
a month to over $2,500 a month. Where are they supposed to find
another $20,000 a year to afford healthcare?
When premiums skyrocket, despite--when premiums skyrocket,
people just delay care. That means a sicker Medicare
population, more preventable ER visits, and higher costs down
the line. It is all connected, and we all need to govern like
it is, but Republicans are intent on ripping benefits from
hardworking Americans. It is even more important that we ensure
people maximize the benefits available to them.
That brings me to my bill, the Senior Savings Protection
Act. Congress has created programs to help low-income Medicare
beneficiaries afford their care. The IRA expanded and added new
programs to support seniors, but millions of Medicare
beneficiaries eligible for these programs aren't enrolled in
California, especially--I will bring that up because there are
over 2.3 million Medicare beneficiaries eligible for Extra
Help, but less than 300,000 are enrolled.
Mr. Lipschutz, how do programs like the Low-Income Subsidy
or Extra Help and the IRA smoothing provision help seniors
afford their healthcare?
Mr. Lipschutz. Thank you for the question, Congresswoman.
As you noted, Congress created these programs to help Medicare
beneficiaries afford some of their healthcare expenses. Part D
Low-Income Subsidy for those who meet the income and asset test
is able to pay for Medicare premiums and much of the cost
sharing under the Part D benefit. The smoothing provision that
you mentioned from the Inflation Reduction Act allows
beneficiaries to spread their prescription costs over the
course of the calendar year. It is most helpful for people who
have high out-of-pocket expenses earlier in the year.
Ms. Matsui. Right.
Mr. Lipschutz. I would add to that list the Medicare
Savings Programs as well----
Ms. Matsui. Yes. Right.
Mr. Lipschutz [continuing]. For folks who qualify for them.
Ms. Matsui. Well, that is why I introduced the Senior
Savings Protection Act along with Congressman Bilirakis. This
bipartisan bill reauthorizes funding for outreach in their own
activities to help low-income Medicare beneficiaries understand
all their options and enroll in the plan that works for them.
Mr. Lipschutz, how do State- and community-based
organizations use these funds to help low-income Medicare
beneficiaries?
Mr. Lipschutz. The MIPPA funds is spread between SHIP
programs--HICAP in California--AAAs, ADRCs, and benefit
enrollment centers. What these programs do is try to connect
people in the community with Federal, State, and local programs
that can help them pay for their daily needs.
Ms. Matsui. Right.
Mr. Lipschutz. That ranges from assistance with cost
sharing like the Medicare Savings Programs and Part D LIS, and
some of these other entities also help evaluate eligibility for
LIHEAP services, heating and cooling, and SNAP benefits.
Ms. Matsui. Well, absolutely. And programs like this are
really the only nonbiased way of--source of medical enrollment
assistance and especially as there is a lot of misleading and
fraudulent advertising that runs rampant.
I really, really do emphasize, Mr. Chair, how important a
bill like this is in order to make sure that Medicare
beneficiaries are protected and understand what their resources
are.
So thank you, Mr. Chair. I hope we can advance this
critical bipartisan bill to a markup soon, and I yield back.
Mr. Griffith. The gentlelady yields back.
I now recognize the gentleman from Texas, Mr. Crenshaw, for
his 5 minutes of questioning.
Mr. Crenshaw. Thank you. Thank you all for being here.
I will start with Mr. Ryan. You know, in a State like
Texas, there is a large share of nursing homes and assisted
living facilities located in rural areas. How does portable
ultrasound help ensure seniors receive that timely diagnostic
care without being transported long distances?
Mr. Ryan. I mean, I don't know much about your bill. I am
sorry, Congressman. But I, again, believe in care in the home.
I think it is, you know, patient preferred, cost effective. So
having the ability to have portable, you know, imaging in the
home would be something that is very, very important.
Mr. Crenshaw. OK. I thought you would have more of an
answer for that. Would you think that being able to bring it to
the patient would bring costs down?
Mr. Ryan. I am sorry. Could you repeat that, sir?
Mr. Crenshaw. Bringing this kind of technology to the
patient, would that overall bring costs down?
Mr. Ryan. Newer technology that could be done in a home
care setting, I think, at the end of the day, should certainly
be able to bring costs down, not being a subject matter on this
particular product.
Mr. Crenshaw. No problem.
Ms. Van Meter, what differences do you see in how current
payment policies affect hospital-based laboratories, physician
office laboratories, and independent laboratories, and why does
that matter for patients?
Ms. Van Meter. Well, the current Medicare payment system,
the Clinical Laboratory Fee Schedule, has suffered from years
of deep reductions. It is the only Medicare payment system that
is designed to be based on commercial market rates but has
failed to do so because it has collected lackluster data. Only
1 percent of laboratory data was used to set rates, and we are
still living under data that is from 2016.
So it has a compromising effect in terms of long-range
innovation--or investment in innovation. We appreciate that
Congress has stepped in and has halted reductions. We believe
that the RESULTS Act that has been discussed today is the right
approach to allowing there to be stability in that payment
system to ensure patient access, to have swift turnaround
times, innovation and testing, and broad patient access.
Mr. Crenshaw. OK. Thank you.
And, Ms. Sullivan, from the patients' perspective, how does
the availability of home infusion services influence where
seniors ultimately receive care, particularly when managing
complex and chronic conditions?
Ms. Sullivan. Thank you, Congressman. The range of
medications that are available to patients in the home if you
have commercial insurance reaches above 300 different
individual medications. Unfortunately for Medicare
beneficiaries, they are limited to a handful of drugs that
are--that use the--an item of DME or an infusion pump to be
administered. So they live with much more restricted access
under the Medicare program.
If they were to have access at least to IV antibiotics, we
estimate it would change the lives of many beneficiaries and
just open the options up for them to receive care at home
rather than driving back and forth to facilities or being
admitted to long-term care facilities.
Mr. Crenshaw. Can you comment on how that might effect
long-term cost savings? Do you think it remains neutral? Do you
think it saves costs?
Ms. Sullivan. Yes. Excellent question. Historically, the
Congressional Budget Office has scored home infusion
legislation as something that would generate savings. We are
still waiting for an updated score on the provisions in this
bill. However, you know, we have--when we look at care in a
setting such as hospital admission or in outpatient departments
or urgent cares, generally we feel confident that home would be
a more efficient model for those patients.
Mr. Crenshaw. OK. Thank you for those answers.
I yield back.
Mr. Griffith. The gentleman yields back.
I now recognize the gentlelady from Indiana, Mrs. Houchin,
for her 5 minutes of questioning.
Mrs. Houchin. Thank you, Mr. Chairman. Thank you to our
witnesses for being here today to discuss a fundamental
responsibility of this committee to ensure that the Medicare
program actually works for patients and the providers who rely
on it every day.
In States like Indiana where rural hospitals and community
health centers and independent providers are often the primary
source of care, Medicare payment policy determines whether
services are available at all. Community health centers and
rural providers are often the first to feel the downstream
effects of reimbursement cuts, the administrative burden, and
rigid coverage rules. These pressures also trickle down to
patients and show up in real and tangible ways,for example,
with our durable medical equipment providers as well.
During COVID, my State cut benefits to home health oxygen
and cut reimbursement rates for home health oxygen during a
time when people were required to stay home and even during
research that suggested that putting people on ventilators in
hospitals was maybe not the best course of treatment.
So I want us to--I want to thank the committee and the
chairman for bringing these issues to the attention of the
committee in a legislative manner. I know that some colleagues
have discussed home infusion therapy, so I want to touch on
that a little bit.
As we have heard, it allows seniors to receive medically
necessary treatment safely in their homes, helping them avoid
more costly or facility-based care. Yet the Medicare current
home infusion benefit often falls short of supporting the kind
of care patients deserve, much like we saw during the home
health durable medical equipment cuts that we saw during COVID.
Under current policy, Medicare generally only pays for home
infusion services on days when a clinician is physically
present in the home even though patients still require care
coordination, monitoring, and clinical oversight on noninfusion
days.
Ms. Sullivan, can you explain how the Preserving Patient
Access to Home Infusion Act helps make it more realistic for
Medicare patients to receive infusion therapy at home when
their doctor wants them to be treated there?
Ms. Sullivan. Thank you so much, Congresswoman. Basically,
the Preserving Patient Access to Home Infusion Act is going to
do a couple fundamental things.
Number one, it is going to eliminate some of the
fragmentation that exists in the current benefit and remove the
restriction for the face-to-face requirements. We find that,
basically, those restrictions are so limiting that there are
fewer than 70 providers across the country that are
participating in the benefit today, which essentially means
that patients in most areas are not accessing this benefit, and
in some States there are no patients accessing this benefit and
no providers offering the benefit. It is just simply
unsustainable and is not creating access.
Mrs. Houchin. Does that lead to--the face-to-face
requirements, does it lead to unnecessary treatment delays?
Ms. Sullivan. I think it is probably closer to no treatment
versus a delayed treatment. It is so limited in terms of the
scope that it leaves out--I have spoken a lot about IV
antibiotics, which is the largest subset of medications that
are the most common home infusion drugs today. Infections are
common. They happen. And we find that because those are just
off the table with Medicare that those patients just don't--
aren't presented with the option at all to go home, so they
have to go somewhere else to get that care.
Mrs. Houchin. Understood. Thank you.
And, to Ms. Van Meter, community health centers and other
providers in rural areas rely on local and independent
laboratories to deliver timely diagnostic services.
How have repeated delays and uncertainty around the
Clinical Laboratory Fee Schedule affected labs that serve rural
areas of the country in particular?
Ms. Van Meter. Thank you for the question. For small
independent laboratories, these are often laboratories that
offer the most common, routine tests upon which Medicare
beneficiaries and their physicians rely. Those are core
services, and it is those types of tests that are going to bear
the brunt of the next fourth round of reductions under PAMA
that will take place on December 31--or pardon me--January 31,
and that is after 3 years of reductions. So we worry about the
capacity of the laboratories to have as broad a menu as
possible and, in some cases, to really continue to operate in a
small community.
Mrs. Houchin. Thank you. I look forward to working when my
colleagues to provide long-term healthcare funding that
protects patients and their access to comprehensive primary
care that includes home healthcare.
Thank you so much. I yield back.
Mr. Griffith. The gentlelady yields back.
I now recognize the gentlelady from Florida.
She passes.
I recognize--actually, it goes over here. I recognize the
gentlelady from Virginia for her 5 minutes of questioning.
Ms. McClellan. Thank you, Chairman Griffith, and to Ranking
Member DeGette for holding this timely hearing.
As we have already talked about, across the country
millions of Americans are facing soaring healthcare premiums
and higher out-of-pocket costs as the new year is beginning,
and today approximately 22 million Americans who rely on the
Affordable Care Act marketplace coverage have lost their
enhanced premium tax credits that kept that coverage affordable
due to the Republicans' refusal to act before now.
In Virginia, this includes small business owners, their
employees, the self-employed, farmers, retailers,
restaurateurs, and people like my constituent Bobby Conner from
rural Brunswick County, who is 3 years away from Medicare. Last
year, he paid $34 a month for his premium. This year, with the
tax credit, it would have gone to $92 a month. Without the tax
credit, he is facing a premium that is $1,700 a month.
Lester and Yolanda Johnson and their 3-year-old daughter,
who are the owners of the Mama J's restaurant in Richmond, have
gone from paying $700 a month for their family of three to now
$1,400 a month. And this comes at the height of an
affordability crisis in the United States as groceries, gas,
rent, and now healthcare costs are rising, squeezing families'
budgets and prompting impossible choices between coverage and
basic necessities. More than half of American families lack the
resources to live securely in their communities, with grocery
prices up 32 percent since 2019 and the lowest-price ACA
marketplace Silver plan up 41 percent.
This affordability crisis isn't limited to working-age
Americans. Seniors enrolled in Medicare Advantage, which now
covers more than half of all Medicare beneficiaries, are also
navigating rising costs and making difficult choices to afford
prescriptions and provider visits.
I am glad the committee is considering my H.R. 5243, which
would require companies that offer Medicare Advantage plans to
submit enrollee-level data on supplemental benefits to the
Department of Health and Human Services, thereby increasing
transparency around Medicare Advantage supplemental benefits
and helping seniors make better-informed decisions amid this
ongoing affordability crisis.
So with that, Mr. Lipschutz, from your work with Medicare
beneficiaries, how often do seniors choose Medicare Advantage
plans because of promised supplemental benefits like dental,
vision, or transportation that they have seen advertised on
television only to later find out that those benefits are
difficult to access or far more limited than advertised?
Mr. Lipschutz. In our experience, quite often. Supplemental
benefits really drive a lot of decision making when it comes to
planned enrollment, but people don't realize that these
supplemental benefits are not standardized, and they vary
considerably by plan and they can change from year to year.
So, as you note, advertisements are full of articulating
the supplemental benefits as a means to draw people in, but
oftentimes, when people get in the plans, they find that they
have more difficulty than they anticipated trying to access
those benefits.
Ms. McClellan. And sticking with you, if Medicare Advantage
is going to continue to grow as a major part of Medicare, what
role should transparency and accountability around supplemental
benefits play in ensuring the program truly serves seniors and
not just insurers?
Mr. Lipschutz. I think transparency and accountability are
paramount when we look at the program. These are public dollars
going to private plans to administer benefits for the Medicare
population. We need a lot more accountability and transparency.
This is a start. So thank you for introducing this bill.
Ms. McClellan. I agree. Thank you.
And would requiring carriers to report enrollee-level data
on supplemental benefits to the Department of Health and Human
Services better align advertised benefits with what seniors
actually need and leading to greater participation, more
meaningful coverage, and better health outcomes for
beneficiaries?
Mr. Lipschutz. Agreed.
Ms. McClellan. Thank you.
And, with that, I will yield back.
Mr. Griffith. The gentlelady yields back.
I now recognize the gentleman from California, Mr.
Obernolte, for his 5 minutes of questioning.
Mr. Obernolte. Well, thank you very much, Mr. Chairman, and
thank you to our witnesses. This is a really critically
important topic, and we very much appreciate you contributing
your expertise.
Ms. Van Meter, I would like to start with you. I was really
interested in the part of your testimony where you were talking
about improving Medicare's payment structure for clinical labs
and the way that doing that could help foster innovation for
diagnosis. I have long been interested in the application of
artificial intelligence to that particular space.
I chaired the House Task Force on AI last Congress. This
is, you know, one--we always said--we had a whole chapter in
our task force report just on healthcare because we really
think that, of all of the applications of AI, really the low-
hanging fruit--the way it can most immediately contribute to
the well-being of people--is through the healthcare space and
certainly through the lab space as well.
So can you tell us a little bit more about how AI is being
utilized in the diagnostic lab industry?
Ms. Van Meter. Thank you, Congressman. Really, in two key
facets. One is to improve and create efficiencies within the
operation of the laboratory, and that could also move into the
business side with the administration--right--as we have to
deal with huge volumes of claims and the like.
But when it comes to clinical care, particularly in the
space of genomics, leveraging AI tools to look at enormous data
sets that can't be consumed by a human on its own allows us to
open up discoveries both in terms of improving personalized
diagnostics but then driving therapies on an individualized
basis for patients. So, really, there is tremendous promise
that exists today with AI tools and diagnostics.
Mr. Obernolte. Sure. Well, it is interesting that that
mirrors the use of AI in other spaces in the healthcare
industry, where initially we are seeing the biggest returns in
terms of improving administration. I mean,for example,
physicians' automated note taking is the number-one way that
they are using AI right now, which is not what you would think
of when you first think of the application of AI to healthcare.
But all of those other concomitant uses for AI are coming, and
we hope they come to the diagnostic lab space as well.
Mr. Ryan, I was really interested in the part of your
testimony when you said that the reimbursement rates for liquid
oxygen are far below supplier costs. Could you talk a little
bit more about that gap between the CMS reimbursement rates and
the actual supplier expenses? Because I am very interested in
that.
Mr. Ryan. You know, like I said earlier--thank you,
Congressman, for the question--that Medicare's reimbursement
for oxygen is based on, you know, all product categories, and
different product categories have different cost points to
them. Liquid oxygen is one of the most expensive product
categories due to the nature of the FDA oversight and the
infrastructure that the company must build to provide liquid
oxygen.
Back before competitive bidding, Medicare would pay per
pound for liquid oxygen. My company probably had--when I was in
business before competitive bidding, 30 to 40 percent of the
patients would be on liquid oxygen. It was extremely convenient
for the patient. They could ambulate and get out and about. You
could fill it from your liquid canister--portable canister and
go out and about. You know, you didn't have to be limited by
the number of hours and limited hours of a gaseous oxygen tank.
But the reimbursement changed drastically, and then,
because of that, everybody--like my company, some--I didn't
survive the competitive bidding--but they got out of the
business. And now technology has evolved. So you do have things
like portable oxygen concentrators where you can get, you know,
lower-flow oxygen from a portable concentrator device that, you
know, provides a battery, and the battery is your lifeblood. Do
I have enough batteries to make sure I can go out and about and
get my chores done?
But there is a subset of patients who require a higher-
liter flow, and that higher-liter flow in today's technology is
not able to be accomplished with a POC, and it can be
accomplished with a gaseous tank, but the amount of oxygen that
you would need to use--that gaseous tank would empty out in 30
minutes.
I said earlier that, you know, 1 cubic foot of liquid
oxygen expands to 860 cubic feet of gaseous oxygen. So old
technology but very, very useful for a subset of patients that
has been completely taken off the market due to the
reimbursement structure.
Mr. Obernolte. Right. Well, I think sometimes we forget as
we negotiate these reimbursement rates that the end goal is not
just greater efficiencies for the taxpayer. We are trying to
strike this balance between providing world-class healthcare
with positive healthcare outcomes, you know, at the lowest cost
to taxpayers. And achieving that balance can be tricky, but
that is why all of you being here today is so important. So
thanks very much for your testimony.
I yield back.
Mr. Griffith. The gentleman yields back.
I now recognize the gentlelady from Florida, Mrs. Cammack,
for her 5 minutes of questioning.
Mrs. Cammack. Thank you, Mr. Chairman, and thank you to our
witnesses and everyone for being here today.
I know that we are looking at several proposals that all
point to the same reality: Medicare is struggling to keep pace
with how care is delivered for people who live with chronic
conditions and disabilities. For many seniors and individuals
with complex needs, the goal is not a cure, it is a maintaining
of their independence, whether it is staying at home and
avoiding unnecessary trips to the hospital or ending up in a
nursing facility. Home-based services play a critical role in
making that possible.
But we continue to hear from providers and patients that
outdated payment structures and rigid policies are limiting
access to care that is often safer and more cost effective when
delivered in the home. So, whether it is lab testing, home
infusion, or durable medical equipment, these services are
essential for people who depend on them every single day.
When Medicare does not reflect the real cost and realities
of care delivery, providers are forced to make difficult
decisions. In rural areas like my district, there are fewer
options, longer delays, and tougher challenges for patients who
already face an extraordinary amount of difficulty in accessing
care.
So I am going to start with you, Mr. Ryan. Your testimony
highlights that home-based care can both reduce costs and
improve quality of life, particularly for seniors and people
living with disabilities and chronic conditions. I have
introduced H.R. 3864, the Protecting Healthcare For All
Patients Act of 2025, to address concerns that some Federal
healthcare decision-making tools may not fully capture the
value of care for these populations.
From your perspective, do policy metrics such as the
Quality-Adjusted Life Years that influence coverage and payment
decisions across Federal health programs risk undervaluing the
needs of patients receiving home-based services?
Mr. Ryan. Yes. As I said earlier--Congresswoman, thank you
for the question--we have seen actually a decrease in the
amount of dollars put in, you know, home--for my particular
industry--from 2.2 percent to 1.3 percent. We are continuing to
see a downward decrease in reimbursement for programs like
competitive bidding. And then the managed care organizations
certainly pay a percentage of that, so we see--even see a lower
point-of-care dollars.
And one of the things that we have seen over this period of
time is--again, I keep talking about the thwarting of
technology, but it is very, very significant. When no dollars
have been put into the DMEPOS sector, we see the 95 percent
decrease in patents. We have seen many of our products now go
offshore. I mean, when I--back in the day, you know, most of my
products I bought from an American manufacturer right here in
the United States.
Mrs. Cammack. Just because I want to be sensitive to time,
I just want to just really put a button on it. So things like
QALYs, a formula that would effectively define the value of
someone's care or life--that is a policy that we need to move
away from in all of our Federal programs, correct?
Mr. Ryan. That certainly is happening in my industry which
I can speak to.
Mrs. Cammack. OK. Perfect. And I do have a followup. Now,
many of my rural counties cover a large geographic area, and
suppliers often have to drive long distances to deliver oxygen
or make equipment repairs.
When reimbursement does not reflect those real-world costs,
what happens to service reliability? I think we all know. So
touch on just some real-world examples there. But then, also,
what types of access issues do you expect to see if suppliers
further consolidate or just leave the program?
Mr. Ryan. The access issues--as I talked in the survey we
have done--is that people that are living in service areas--we
are losing suppliers. Thirty seven percent of the industry has
gone out of business. We are reimbursing in the nonbid,
nonrural area, which is--the chairman mentioned his district
potentially is really, really rural. At the same rate, we are
reimbursing for products in a competitive bid program, and that
is unfair.
The bill that we have out here, H.R. 2005, will put
reimbursement back for a short period of time. I hope we can
convince the agency like they did in the rural portion of
America--that they determined was a rural portion--make it in
regulation a 50/50 blended rate. Again, our bills, both H.R.
2005 and the SOAR Act--which would take oxygen out of the
competitive bidding and take that 50/50 blended rate and make
it permanent but also take that 75/25 rate and make it
permanent--would certainly be help when it comes to making sure
we are getting the proper care and technology and outcomes that
these patients deserve.
Mrs. Cammack. And I just want--because when people watch
this video clip back, I want folks at home to really
understand. Hit that 37 percent number once again.
Mr. Ryan. Thirty seven percent of the DMEPOS providers have
gone out of business since 2013.
Mrs. Cammack. That is a staggering number. Staggering. And
so, for folks at home and people in underserved communities and
rural communities, you need to understand that consolidation
and services are going away. I think they are living it every
day, but people in America need to understand that this is at a
tipping point. Would you agree?
Mr. Ryan. I think the unthought-out remote item delivery
program that came out in this final rule that is looking to
take categories like ostomy and CGMs and limit it to eight to
10 players is going to be devastating. It is not thought out.
It is very problematic. We have to make a change before that
goes into effect.
Mrs. Cammack. I appreciate your testimony and your time
here today, and my time has expired.
With that, Mr. Chairman, I yield back.
Mr. Griffith. The gentlelady yields back.
I now, at long last, recognize the gentleman from Colorado,
Mr. Evans, for his 5 minutes of questioning.
Mr. Evans. Thank you, Mr. Chairman. Thanks for letting me
waive on to this committee.
Of course, thanks to my fellow Coloradoan, the ranking
member, and to our witnesses for coming today so we can talk
about something that is deeply personal to me and to many of my
constituents, and that is supplemental oxygen.
I have a bipartisan bill that I helped introduce. It is
included in today's discussion: The Supplemental Oxygen Access
Reform Act, or the SOAR Act. I have had family members rely on
supplemental oxygen, and representing a State like Colorado
where we have high altitude, we know that many of our
constituents also rely on supplemental oxygen. House
Republicans have been laser-focused on affordability this
Congress, but affordability goes hand-in-hand with
accessibility, which is the centerpiece of the SOAR Act.
So, Mr. Ryan, I wanted to thank you and your organization
for supporting this legislation. We know how important
supplemental oxygen is--liquid supplemental oxygen at times--
for people battling a variety of conditions. And I actually
wrote down the number you just threw out: 860 times more oxygen
in the liquid form in the same volume as you get in gaseous
form.
Can you describe the dilemma and the real human impacts
that patients face when the existing system that we have with
the Medicaid--excuse me--Medicare DME program significantly
limits access to liquid oxygen?
Mr. Ryan. Yeah. The reality is, looking at Medicare claims
data, the decrease in both liquid portable oxygen and
stationary portable oxygen has been significant. It is down 80
percent. So there, again, is a subset of patients that require
high-flow liquid oxygen, and essentially, because of a poor
reimbursement program, a failed competitive bid program, those
patients no longer get that service.
When I provided oxygen, we had a--I am a respiratory
therapist. The SOAR Act provides a payment structure to get
paid for respiratory therapy. I think that is important. We
competed on service and service alone, and our standard of care
was excellent. But compressing prices, completely compressing
them down, again, has taken the service model and changed it
severely. It has taken the opportunity to have a respiratory
therapist that could go into their home and do the proper
services it would need, it has taken it away. The SOAR Act
could bring that back. It is concerned about our patients. It
has got a patient's bill of rights in there.
It is also leveraging technology. It is using something
called e-prescribing where we could not go to the subjective
medical record and we could simply have a template that is
agreed upon by the pulmonary community, and it will be the
basic components of what is a medical necessity for oxygen.
This bill is supported by well over 30 pulmonary groups:
American Thoracic Society, CHEST, American Association of
Respiratory Care. We have a letter for the record that shows
the 30 groups in the pulmonary community working hand-in-hand
with the DMEPOS community to get this legislation passed into
law.
Mr. Evans. Thank you for that. I think one of the key
phrases you used there was just the quality of care. And so we
know that that quality of care happens when we balance
affordability and accessibility. And a big part of that is
making sure that these programs work, making sure that the
money goes where it is supposed to while also rooting out the
fraud, waste, and abuse.
And so can you speak to the SOAR Act and specifically how
it has some of those guardrails in place but also takes a light
touch via the creation of a national standardized electronic
template to appropriately balance the needs of patients,
providers, CMS, and make sure that we are being good stewards
of the money?
Mr. Ryan. Yeah. Well, again, I think the current problem is
that the Medicare program relies on medical records which are
written to support patient followup care, not to provide the
legal support for a Medicare claim.
The SOAR Act would make it easier for CMS to prevent
fraudulent and abusive claims by requiring Medicare contractors
to adopt electronic--electronic data elements, i.e., a
template. To date, contractors have refused to adopt this
commonsense approach. Adopting an electronic process in lieu of
using physician short notes would provide much more needed
clarity and accuracy in the review process. And I think it
would help in the fraud and abuse.
Mr. Evans. Thank you so much for that. And again, I--
obviously I am supporting the bill. I knew it was a good bill.
But I am just struck by that 860 number that you threw out
there, people that need this high-flow oxygen. Sometimes there
is really only one answer to that, and that is that liquid
oxygen.
And so I just want to thank you. Thank the chairman and the
ranking member for, again, for letting me waive onto this and
be able to talk to this issue that is so critically important
to me, to many of my constituents, and I look forward to
working with everybody on both sides of the aisle and the
coalition that you mentioned to continue to advance this bill.
And I yield back. Thank you.
Mr. Griffith. The gentleman yields back.
I ask unanimous consent to insert in the record the
documents included on the staff hearing document list. Without
objection, so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Griffith. I would like to thank all of our witnesses
again for being here today. You saw a lot of Members showed up,
and that tells you how important this hearing was to the
Members, and glad to have all that input.
Members may have additional written questions for you. I
will remind Members that they have 10 business days to submit
those questions for the record. And I ask the witnesses to
respond to the questions promptly. Members should submit their
questions by the close of business on Friday, January 23rd.
Without objection, the subcommittee is adjourned.
[Whereupon, at 1:25 p.m., the subcommittee was adjourned.]
[Material submitted for inclusion in the record follows:]
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