Key Facts

• The Helms Amendment, signed into law almost fifty years ago, as an amendment to the Foreign Assistance Act of 1961, prohibits the use of foreign assistance to pay for the performance of abortion as a method of family planning or to motivate or coerce any person to practice abortion.
• In practice, the Helms Amendment has also been used to prohibit the use of federal funding for all abortions even in the circumstances of rape, incest, or risk to the life of the pregnant person, exceptions that have been allowed in other areas of U.S. international abortion law and policy.
• There has been growing debate about the Helms Amendment, with some advocates and legislators supporting efforts to clarify the application of the Helms Amendment to allow for exceptions and, more recently, to repeal it. To better understand the implications of the Helms Amendment for abortion access globally and to inform ongoing discussions, we examined abortion laws in countries that received U.S. foreign assistance, looking specifically at funding for family planning and reproductive health (FP/RH), maternal and child health (MCH), and PEPFAR.
• We find that of the 56 countries receiving such U.S. global health assistance, most (86%, or 48 countries) allow for abortion in at least one circumstance.
• These 48 countries account for 95% ($4.53 billion) of U.S. global health assistance for FP/RH, MCH, and PEPFAR. Most are in Africa (30 countries). PEPFAR funding reaches the most countries (36), followed by MCH (35) and FP/RH (29).
• Of the 48 countries, 14 (or 25% of those receiving U.S. support) allow abortion in only one or more exceptional circumstances, while the remainder (34 countries) allow for abortion beyond these exceptions.
• Given that the U.S. is often the largest funder of health efforts in low- and middle-income countries, these findings suggest that the outcome of debates about the Helms Amendment stands to significantly affect access to legal abortion in a large number of countries, primarily those in Africa. Repeal of the Helms Amendment would expand the ability of U.S. global health assistance to support legal abortion in many countries, while clarifying Helms to allow such support in exceptional circumstances would also expand the ability of U.S. global health assistance to support legal abortion but in more limited circumstances.

Introduction

The Helms Amendment, signed into law almost fifty years ago, as an amendment to the Foreign Assistance Act of 1961, prohibits the use of foreign assistance to pay for the performance of abortion as a method of family planning or to motivate or coerce any person to practice abortion. In practice, it has also been used to prohibit the use of federal funding for all abortions even in the circumstances of rape, incest, or risk to the life of the pregnant person, exceptions that have been allowed in other areas of U.S. international abortion law and policy, such as the Mexico City Policy when it has been in place. There has been growing debate about the Helms Amendment, with some advocates and legislators supporting efforts to clarify the application of the Helms Amendment to allow for exceptions and, more recently, to repeal it. Last year, the U.S. House of Representatives passed the FY 2022 State and Foreign Operations (SFOPS) appropriations bill without language reiterating the Helms Amendment,¹  and legislation has been introduced that would permanently repeal the Helms Amendment by striking its language from the Foreign Assistance Act of 1961 (see the KFF global health legislation tracker).² 

Still, the prospects of repeal of the Helms Amendment are challenging. While the Biden administration has called for repeal of the Hyde Amendment (the domestic law restricting federal funding for abortion),³  its stance on Helms is unclear. It has not taken a public position on repeal, and its first budget request to Congress included the Helms language. Moreover, both chambers of Congress would have to agree to excluding Helms Amendment language from annual appropriations legislation as well as from the permanent statute, the Foreign Assistance Act of 1961. Even if repealed, it would not necessarily lead to more funding for abortion, especially if U.S. funding for global health remains level.

To better understand the implications of the Helms Amendment for access to abortion services globally and to inform ongoing discussions, we examined abortion laws in countries that received U.S. foreign assistance. We sought to identify the number of countries in which abortion is legal but U.S. funding is not permitted, even in the exceptional circumstances noted above.⁴  While the Helms Amendment applies to all U.S. foreign assistance, we focused our analysis on assistance for family planning and reproductive health (FP/RH), maternal and child health (MCH), and HIV, through PEPFAR, since these are the technical areas of USAID’s health work to which Helms and other FP/RH restrictions “most often apply,” according to USAID.⁵   We placed countries receiving bilateral U.S. global health assistance in FY 2019 (the most recent publicly-available complete data) into three categories according to their abortion laws:

• abortion not legal in any circumstance;
• abortion legal in one or more of the following circumstances: where the pregnancy poses a risk to a pregnant person’s life, is the result of rape or is the result of incest; and
• abortion legal in any circumstance beyond the preceding ones (e.g., to preserve the physical or mental health of a pregnant person or for social or economic reasons).

Findings

In FY 2019, the U.S. provided bilateral global health assistance for FP/RH, MCH, and/or HIV (PEPFAR) to 56 countries. Together, funding across these three areas totaled $4.77 billion. Funding for PEPFAR and MCH was directed to the greatest number of countries (40 and 39, respectively), followed by FP/RH (35). More than half (33) of the 56 countries reached were in Africa, followed by East Asia and the Pacific (8), South and Central Asia (7), Latin American and the Caribbean (4), the Near East (3), and Europe and Eurasia (1).

Abortion is legal in at least one circumstance in almost all – 48 of 56 (or 86%) – of the countries receiving U.S. support. These 48 countries accounted for 95% ($4.53 billion) of U.S. global health assistance for FP/RH, MCH, and PEPFAR. Most were in Africa (30), and PEPFAR reached the largest number (36), followed by MCH (35) and FP/RH (29). See Figure 1 and Tables 1 and 2.

In 14 countries (25% of countries receiving U.S. support) abortion is legal only in at least one exceptional circumstance (where the pregnancy poses a risk to the life of a pregnant person, is the result of rape, or is the result of incest). These countries accounted for 34% ($1.63 billion) of U.S. global health assistance for FP/RH, MCH, and PEPFAR. Half of these countries (7) were in Africa, and the other half were in East Asia and the Pacific (3), South and Central Asia (2), Latin American and the Caribbean (1), and the Near East (1). The MCH program reached the largest number (13), followed by FP/RH (10) and PEPFAR (9).

The remaining 34 countries (61% of countries receiving U.S. support) allow for legal abortion beyond one or more of these exceptions. This includes circumstances where abortion is allowed to preserve the physical or mental health of a pregnant person, for social or economic reasons, or because of fetal impairment. These countries accounted for 61% ($2.9 billion) of U.S. global health assistance for FP/RH, MCH, and PEPFAR. Most of these countries (23) were in Africa, and the remainder were in South and Central Asia (5), East Asia and the Pacific (3), Europe and Eurasia (1), Latin America and the Caribbean (1), and the Near East (1). PEPFAR reached the largest number (27), followed by MCH (22) and FP/RH (19).

There are only 8 countries (14% of countries receiving U.S. support) where abortion is not legal under any circumstance. These accounted for 5% ($238 million) of U.S. global health assistance for FP/RH, MCH, and PEPFAR. Several were in Africa (3), while the remainder were in East Asia and the Pacific (2), Latin America and the Caribbean (2), and the Near East (1). The FP/RH program reached the largest number (6), followed by MCH and PEPFAR (4 each).

Discussion

As members of Congress, advocates, and others continue to debate the future of the Helms Amendment, this analysis finds that the outcome of these discussions stands to significantly affect access to legal abortion in a large number of countries, primarily those in Africa. Indeed, since most countries receiving U.S. global health assistance (86%) allow for abortion in at least one circumstance, including 25% that allow abortion in only one or more exceptional circumstances, repeal of the Helms Amendment would expand the ability of U.S. global health assistance to support legal abortion in many countries; clarifying Helms to allow such support in exceptional circumstances would also expand the ability of U.S. global health assistance to support legal abortion but in more limited circumstances, such as when a pregnancy poses a risk to a pregnant person’s life. Given that the U.S. is the largest global health donor in most countries, whether or not U.S. lawmakers ultimately decide to repeal Helms or modify it to allow for exceptions will likely have an outsized effect on access to legal abortion in low- and middle-income countries.

1. See: U.S. Congress, Department of State, Foreign Operations, and Related Programs Appropriations Act, 2022 (H.R. 4373), 117th Congress. ↩︎
2. The Abortion is Healthcare Everywhere Act would amend the Foreign Assistance Act to remove this language from permanent law. On the other hand, the American Values Act would restate the Helms Amendment as included in the amended Foreign Assistance Act of 1961. See: U.S. Congress, Abortion is Health Care Everywhere Act of 2021 (H.R. 1670), 117th Congress; U.S. Congress, S.239 – American Values Act (S. 239), 117th Congress. ↩︎
3. President Biden supports repeal of the Hyde amendment and did not include it in its budget request to Congress. See: Colby Itkowitz, “Biden budget plan removes decades-old ban on federal funds for abortions,” Washington Post, May 28, 2021, https://www.washingtonpost.com/politics/biden-budget-abortion-hyde-amendment/2021/05/28/7b248838-bfde-11eb-b26e-53663e6be6ff_story.html. ↩︎
4. In all instances, the U.S. continues to provide U.S. funding to support post-abortion care (PAC). See: USAID, “Memo from Duff Gillespie on Post-Abortion Care,” Sept. 10, 2001, https://www.usaid.gov/sites/default/files/documents/1864/duff_memo.pdf. ↩︎
5. USAID, Guidance on the Definition and Use of the Global Health Programs Account: A Mandatory Reference for ADS Chapter 201, partial revision as of Dec. 12, 2014, https://www.usaid.gov/ads/policy/200/201mau. ↩︎

As 2022 kicks off, a number of issues are at play that could affect coverage and financing under Medicaid, the primary program providing comprehensive health and long-term care coverage to low-income Americans.  New COVID variants are surging and the fate of the Build Back Better Act (BBBA), a reconciliation bill that includes significant changes to health coverage and Medicaid, is hanging in the balance.  In addition, Governors are poised to release proposed budgets amid continued uncertainty about the health and economic trajectory of the pandemic while the Biden Administration continues to use its authority to address the pandemic and to further strategic goals to expand coverage and access and to improve equity.  Within this context, this issue brief examines key issues to watch in Medicaid in 2022.

Medicaid Coverage and Enrollment

Enrollment and the pandemic.  Since the start of the coronavirus pandemic, enrollment in Medicaid and the Children’s Health Insurance Program (CHIP) grew to 83.2 million in June 2021, an increase of 12.0 million (16.8%) from February 2020. Enrollment growth reflects downturns in the economy due to the pandemic and provisions in the Families First Coronavirus Response Act (FFCRA) that require states to ensure continuous coverage for current Medicaid enrollees to access a temporary increase in the Medicaid match rate during the Public Health Emergency (PHE) period, recently extended to April .  Continuous enrollment has helped to preserve coverage and halted Medicaid churn, however, when these requirements end, states will begin processing redeterminations and renewals and millions of people could lose coverage if they are no longer eligible or face administrative barriers during the process despite remaining eligible. The Centers for Medicare and Medicaid Services (CMS) has released guidance and strategies for states to help maintain coverage of eligible individuals after the end of continuous enrollment requirements.  The BBBA also includes provisions that would phase-out the continuous enrollment requirement beginning April 1, 2022 with rules about disenrolling people tied to a phased down enhanced match rate.  Within the parameters set by the Administration, or BBBA if enacted, states will largely be responsible for managing the unwinding of the continuous enrollment requirement, which could lead to variation in practices and in how many people are able to maintain coverage.

State decisions around Medicaid coverage.  Beyond the pandemic and continuous enrollment requirements, the American Rescue Plan Act (ARPA) included new coverage options for states.  ARPA provides a two-year fiscal incentive to encourage states to newly adopt the Medicaid expansion.  Over  2 million individuals living in the 12 states that have not adopted the Affordable Care Act’s (ACA) Medicaid expansion fall into the coverage gap because they do not qualify for Medicaid and have incomes below poverty, making them ineligible for premium subsidies in the ACA Marketplace. A KFF analysis shows that all non-expansion states would see a net fiscal benefit from the ARPA incentive for two years if they adopt the expansion.  The ARPA federal incentive reignited discussion around Medicaid expansion in a few non-expansion states during the last state legislative session, but no state newly voted to adopt the expansion. South Dakota will have a Medicaid expansion constitutional amendment on the November 2022 ballot.  Six states have adopted the expansion by ballot initiative (Idaho, Maine, Missouri, Nebraska, Oklahoma, and Utah). ARPA also includes an option to allow states to extend postpartum coverage from 60 days to 12 months.  Under current law, after the 60 days of postpartum coverage, individuals in states that have adopted the Medicaid expansion may continue to be eligible for Medicaid, but in non-expansion states many may become uninsured because Medicaid eligibility levels for parents are much lower than for pregnant people. The new option starts in April 2022 and as of last year, more than half of the states had taken steps to extend postpartum coverage.

BBBA and Medicaid coverage provisions. The version of the BBBA that passed the House would create a temporary pathway to coverage for people in the coverage gap by allowing them to purchase subsidized coverage (with no premiums and minimal cost sharing) in the ACA Marketplace starting in 2022 through 2025. To discourage states that have adopted the ACA Medicaid expansion from dropping that coverage, the BBBA would also increase the federal match rate for the expansion population in these states from 90% to 93% in 2023 through 2025. The CBO estimates that provisions to address the coverage gap would result in 1.7 million fewer uninsured people with a net federal cost of $57 billion over the next decade. In addition, the BBBA would require states to provide 12 months continuous coverage for postpartum people and children, which could help reduce churn among these populations.  The BBBA would also partially lift the inmate exclusion (current policy that prohibits Medicaid from covering services provided during incarceration, except for inpatient services) by allowing federal Medicaid money to be used to pay for Medicaid-covered services 30 days prior to release for people who are incarcerated.

Administrative actions to maintain and expand coverage.  In January 2021, the Biden Administration issued an Executive Order that called for efforts to “protect and strengthen Medicaid” and directed a review of waivers that may reduce coverage or undermine Medicaid.  As part of that effort, the Administration issued final withdrawals of waivers, promoted under the Trump Administration, that conditioned Medicaid eligibility on work requirements. More recently, the Biden Administration took steps to withdraw or phase out waivers that included premiums in Medicaid. The Administration also approved some waivers to expand postpartum coverage and, in November 2021, issued a strategic vision for Medicaid and CHIP that includes expanding coverage and access as a key priority.

The Administration has also issued an Executive Order focused on streamlining eligibility and enrollment processes and increased efforts to reach uninsured individuals who are eligible for Medicaid or Marketplace coverage. In 2020, seven million uninsured people were eligible for Medicaid but not enrolled. Most of these individuals were adults and nearly two-thirds were people of color. For the 2022 Marketplace open enrollment period, the Biden Administration launched an expansive advertising and outreach campaign to educate consumers on the availability of both Marketplace and Medicaid coverage. It also increased funding for Navigators in the federal Marketplace seven-fold from $10 million in 2020 to $80 million in 2021. The enhanced Navigator funding will mean more staff to assist both Marketplace and Medicaid applicants.

What to Watch:

• What will happen to Medicaid enrollment when the continuous enrollment requirement ends? Will many people lose Medicaid coverage due to administrative barriers despite remaining eligible? Will people no longer eligible for Medicaid successfully transition to subsidized Marketplace coverage?
• If the BBBA passes, how will that affect Medicaid coverage and coverage options for those who are uninsured?
• If the BBBA is not enacted, will states use existing options and authority to expand Medicaid coverage?

Institutional and Home and Community Based Long-Term Care

Staff and residents at long-term care facilities have been disproportionately affected by the pandemic.  In the first year of the pandemic, long-term care facilities accounted for 31% of all COVID-19 deaths in the US as of June 30, 2021. KFF analysis found that, following vaccine rollout in winter 2020-2021, weekly cases and deaths in long-term care facilities (including nursing homes, assisted living facilities, ICF/IIDs, and some congregate community-based settings) dropped, reaching an all-time low in June 2021, prior to new surges due to the Delta and most recently omicron variants. The pandemic has also affected the long-term care workforce.  Unlike past recessions, the health sector saw a big drop in employment in early 2020, similar to other sectors as the COVID-19 pandemic shut down much of the nation’s economy and remains below expected employment levels through November 2021.  Data show that the number of workers in nursing care and elder care facilities has continued to decline even after other health settings experienced a rebound. As of November, nursing care facilities and elder care facilities employed 15% and 11.1% fewer workers than they did in February 2020.  The health and long-term care workforce could continue to be strained as some workers are vaccine hesitant and the new vaccine mandate for health care workers has been challenged in the federal courts. The Supreme Court recently allowed the rule to take effect  while lawsuits proceed in 24 Republican-led states challenging it.

The COVID-19 pandemic brought new focus to the long-standing unmet need for home and community-based services (HCBS) among seniors and people with disabilities and direct care workforce shortages. The Medicaid HCBS provider infrastructure declined during the pandemic, with two-thirds of states responding to a KFF survey reporting a permanent closure of at least one provider. Additionally, important data gaps remain with just under half of responding states tracking COVID-19 vaccination rates among Medicaid HCBS enrollees. Recognizing Medicaid as the primary payer for HCBS, recent legislation has increased federal funding to support Medicaid HCBS. The American Rescue Plan Act (ARPA) temporarily increases federal matching funds for Medicaid HCBS by an estimated $11.4 billion, and the BBBA passed by the House in November 2021 would provide $150 billion in new federal funds for Medicaid HCBS, including a permanent increase in the federal matching rate. The BBBA also includes new nursing facility staffing requirements, including a requirement to have a at least one registered nurse on duty 24 hours a day, seven days per week.

What to Watch:

• How will institutional and community based long-term care congregate settings continue to be impacted by the pandemic in terms of cases, deaths and staffing? How will providers and staff respond now that the Supreme Court has allowed CMS’s health care staff vaccine mandate to take effect, and how will litigation challenging the rule ultimately be resolved?
• Will states retain policies adopted under emergency authorities that expanded access to HCBS after the PHE ends?
• How will existing investments help states address the need to continue to expand access to HCBS?
• If BBBA passes, how will states use additional Medicaid HCBS funding to further expand eligibility and services and bolster the direct care workforce?

Access, Social Determinants of Health, and Health Equity

In response to the pandemic, states took action to increase the use of telehealth to expand access to care and also to increase the scope of coverage (and availability of telehealth) for behavioral health services. In response to the COVID-19 pandemic, many states expanded Medicaid telehealth coverage for a number of services and using multiple modalities (audio-visual and audio-only).  Post-pandemic telehealth coverage and reimbursement policies are being evaluated in most states, with states weighing expanded access against quality concerns, especially for audio-only telehealth.  In addition to telehealth, states continue to expand behavioral health services.  Behavioral health conditions—including mental illnesses and substance use disorder (SUD)—are  especially common among Medicaid enrollees and have worsened during the COVID-19 pandemic. The proposed Build Back Better Act (BBBA) passed by the House of Representatives on November 19, 2021 would expand funding for HCBS and community mental health services. Also, CMS under the Biden Administration has identified behavioral health policy and investments as a key federal Medicaid priority.

In KFF’s 50-state budget survey, most states reported that the COVID-19 pandemic prompted them to expand Medicaid programs to address social determinants of health, especially related to housing supports. States also reported existing initiatives in this area in managed care organization (MCO) contracts (e.g., requirements for MCOs to screen and refer enrollees for social needs). Social determinants of health (SDOH) are the conditions in which people are born, grow, live, work, and age that shape health.  In response to the pandemic, federal legislation has been enacted to provide significant new funding to address the health and economic effects of the pandemic including direct support to address food and housing insecurity as well as stimulus payments to individuals, federal unemployment insurance payments, and expanded child tax credit payments. While measures like these have a direct impact in helping to address SDOH, health programs like Medicaid can also play a supporting role. Although federal Medicaid rules prohibit expenditures for most social needs, such as rent, state Medicaid programs have been developing strategies to identify and address enrollee social needs both within and outside of managed care.

The Administration and the majority of state Medicaid programs are implementing initiatives to address disparities in health care by race/ethnicity in Medicaid.  Key state initiatives are focused on specific health outcomes including maternal and infant health, behavioral health, and COVID-19 outcomes and vaccination rates. In addition, the Administration issued a Request for Information to federal agencies to assess barriers and opportunities to advance equity for historically underserved individuals and communities.  The COVID-19 pandemic exacerbated already existing health disparities for a broad range of populations, but specifically for people of color. Early analyses of available federal, state, and local data show that people of color were experiencing a disproportionate burden of COVID-19 cases and deaths, but more recent data show racial disparities in cases and death rates have narrowed for Black and Hispanic people compared to earlier in the pandemic, while American Indian/Alaska Native people continue to experience higher rates of infection and death.  In addition to worse health outcomes, data from the Census Bureau’s Household Pulse Survey show that during the pandemic, Black and Hispanic adults have fared worse than White adults across nearly all measures of economic and food security.

State Medicaid agencies and Medicaid MCOS are implementing a variety of activities aimed at promoting the take-up of COVID-19 vaccinations. Given the large number of people covered by Medicaid, including groups disproportionately at risk of contracting COVID-19 as well as many individuals facing access challenges, state Medicaid programs and Medicaid MCOs (which enroll over two-thirds of all Medicaid beneficiaries) can help in COVID-19 vaccination efforts. MCOs are using member and provider incentives, member outreach and education, provider engagement, assistance with vaccination scheduling and transportation coordination, and partnerships with state and local organizations. Medicaid agencies are taking actions such as partnering with public health agencies, providing technical assistance to providers, and conducting outreach to facilitate vaccine take-up.  States were also implementing policies to help facilitate access to vaccines for HCBS enrollees by partnering with public health agencies, using non-emergency transportation services and enlisting HCBS providers in outreach.  More broadly, the BBBA would require state Medicaid programs to cover all approved vaccines recommended by Advisory Committee on Immunization Practices (ACIP) and vaccine administration, without cost sharing, for adults (and receive a 1 percentage point FMAP increase for 8 quarters).

What to watch? 

• How will states continue to leverage Medicaid to help address SDOH and racial equity and how will the Administration support these efforts through investments, guidance and demonstration waivers?
• How will Medicaid agencies continue to work with public health agencies, providers, managed care plans and enrollees to facilitate access to vaccines and boosters?

In this commentary for Barron’s, Cynthia Cox and Lindsey Dawson examine the cost and availability of at-home COVID-19 tests and how the new Biden administration policy requiring private insurances to cover their costs may work.

In a new Policy Watch, KFF experts explain why Medicare’s preliminary decision to cover a new Alzheimer’s drug only for a limited group of beneficiaries is likely to intensify pressure on officials to reconsider the increase in the Medicare Part B premium for 2022.

Earlier this week, CMS issued a preliminary National Coverage Determination that would limit coverage of the new drug, Aduhelm, to beneficiaries with mild cognitive impairment who participate in approved clinical trials – a decision that is expected to result in a relatively small number of Medicare beneficiaries receiving Aduhelm over the next several years.

Medicare officials cited the high price of the drug as a key reason for a 14.5 percent increase in the Part B premium, from $148.50 in 2021 to $170.10 in 2022. But that was before Biogen, the drug’s manufacturer, announced a 50 percent reduction in the drug’s price at the end of 2021, and before the proposed coverage decision was made. Together, these factors suggest that Medicare Part B spending on this drug is not expected to be as large as previously forecast.

Medicare beneficiaries who use Aduhelm, however, will still face thousands of dollars in coinsurance costs if they do not have supplemental coverage to help defray the cost.

The Policy Watch and other analyses related to Aduhelm and Medicare spending are available at kff.org.

After much anticipation, the Centers for Medicare & Medicaid Services (CMS) has announced that Medicare will cover the new Alzheimer’s drug, Aduhelm, subject to evidence development. This preliminary National Coverage Determination (NCD) comes after months of handwringing over the potential impact of this new high-priced drug on Medicare spending and a substantial Medicare Part B premium increase that took effect in January 2022. CMS proposes to cover Aduhelm and similar FDA-approved antiamyloid monoclonal antibody treatments under Coverage with Evidence Development (CED) for patients participating in CMS-approved or NIH-supported randomized clinical trials, which will help to generate the evidence that CMS suggests is currently lacking regarding whether Aduhelm is reasonable and necessary for the treatment of Alzheimer’s disease.

While this decision, which will be finalized in April 2022, proposes the terms of Medicare coverage of these treatments for Alzheimer’s disease, the Aduhelm story is not likely to end here. Only one day before the preliminary NCD was issued, HHS Secretary Becerra directed CMS to reassess the monthly Medicare Part B premium for 2022 in light of the announcement from Biogen, the drug’s manufacturer, that it was slashing the price of Aduhelm by 50% from $56,000 to $28,200 in response to anemic demand for the new drug.

Back in November 2021, prior to the release of the preliminary national coverage determination and the drop in the price of Aduhelm, CMS announced a 14.5% hike in the Medicare Part B premium for 2022. The increase in the premium – from $148.50 in 2021 to $170.10 in 2022 – was based on a “high-cost” scenario that took into account the potential increase in Medicare Part B spending for Aduhelm, among other factors (Figure 1). CMS attributed about half of the premium increase to the need to boost revenues to cover higher projected Part B spending for this one drug alone.

While only a small fraction of Medicare beneficiaries are likely to use the drug, all but the very lowest income Medicare beneficiaries will pay the higher Medicare Part B premium this year. For many beneficiaries, the Part B premium is not a trivial share of income. For example, a senior living on an income at 175% of the federal poverty level (~$23,000 for an individual) will spend nearly 9% of her income this year on the Part B premium alone, before factoring in other expenses, like Part D drug plan premiums or cost sharing for Medicare covered services. And for low-income Medicare beneficiaries who have coverage from both Medicare and Medicaid, the Part B premium increase will have implications for Medicaid spending because Medicaid pays their Medicare premiums.

CMS is now considering a possible adjustment in the 2022 Medicare Part B premium, a change which would be unprecedented – with the Part B premium already determined for the year and being deducted from Social Security payments – but perhaps not unwarranted in this case. Yet even if CMS rolls back a portion of the Part B premium for 2022, Medicare beneficiaries who use Aduhelm could still be on the hook for the Part B coinsurance, which is 20% of the drug’s total cost, or more than $5,000. While most beneficiaries have supplemental coverage to help them pay their Medicare cost-sharing requirements, many do not. This group includes nearly 6 million beneficiaries with no supplemental coverage and most of the 26 million enrollees in Medicare Advantage plans, which typically charge the same 20% coinsurance rate that beneficiaries in traditional Medicare face for Part B drugs (though out-of-pocket costs for Medicare Advantage enrollees would be limited to their plan’s out-of-pocket maximum, which averaged $5,091 for in-network services and $9,208 for both in-network and out-of-network services (in PPOs) in 2021).

In terms of Medicare spending, it appears that Medicare will not experience as large an increase in Part B spending associated with Aduhelm as was originally forecast and that CMS projected when setting the Part B premium for 2022, based on the drug’s initial high price and relatively high expected utilization. For example, in the summer of 2021, just after the FDA approved aducanumab, we estimated that the drug’s initial price tag of $56,000 could boost annual Medicare spending by roughly $30 billion if used by 500,000 Medicare beneficiaries. Considering the reduction in the price of Aduhelm and the likelihood of lower utilization based on the preliminary NCD, it is likely that Medicare spending on this drug will be substantially lower, at least in the near term.

In addition to Medicare, the Aduhelm coverage decision could have implications for Medicaid. While Medicaid must cover FDA-approved drugs under the Medicaid Rebate program, states may be able to impose medical necessity criteria as well as strict prior authorization requirements based on the Medicare coverage determination limiting utilization. The magnitude of the financial implications for Medicaid could hinge on further coverage guidance from CMS.

It is not hard to imagine a future scenario where a combination of a high-priced drug and high utilization actually do generate billions of dollars in additional Medicare spending annually and contribute to sizable increases in Medicare premiums. Given that Medicare has no authority under current law to lower drug prices or limit drug price growth, this raises the stakes for ongoing policy discussions around prescription drug price proposals in the Build Back Better Act. These proposals include allowing the federal government to negotiate the price of certain high-cost drugs, requiring drug companies to pay rebates if drug prices rise faster than the rate of inflation, and capping out-of-pocket costs under Medicare Part D. While these proposals could result in a very modest reduction in the number of new drugs coming to market in the U.S. over the next few decades, according to CBO, and would not affect spending associated with Aduhelm, they could provide meaningful savings on other high-cost drugs down the road.

This week, the Biden Administration announced that individuals in the United States with private insurance would be able to get the cost of at-home COVID-19 tests covered by their plans. While this could significantly improve affordability, and therefore accessibility, for many people, the success of the policy rests in part on test availability. In the U.S. test availability has been constrained due to a number of factors, as we outlined here. We also examined at-home test availability in September and November and while we found some improvement by November, tests were generally still hard to come by.

Now, in the week leading up to the private insurance coverage announcement, we again examined test availability. We searched for 10 tests¹  across 6 retailer websites for home delivery over an 8-day period (January 3, 2022 through January 10, 2022). In total, this provided 480 opportunities to buy a test (6 x 10 x 8). We found that tests were available less than 10% of the time. In addition, certain tests were never available and some retailers never had any tests available for online purchase. Prices for tests ranged from $17.98 for two tests ($8.99 per test) to $49.99 for a single test. In most cases, among the limited tests that were available, shipping dates for tests were over a week out. Additional details in Table 1. Full search data available here.

Overall, we find that despite efforts to increase test production by manufacturers and the administration, test availability remains limited. This has posed a challenge for consumers looking to purchase home tests to date, especially when looking for a test without a lengthy delivery timeline. Continued challenges with home test availability could limit the reach of the new reimbursement policy and if the policy drives additional demand for these tests, could exacerbate the problem. As more tests are authorized and production hopefully ramps up, shortages may ease.

1. We searched for the 10 tests that appeared on the websites of the retailers surveyed. ↩︎

In November 2021, CMS announced the monthly Medicare Part B premium would rise from $148.50 in 2021 to $170.10 in 2022, a 14.5% ($21.60) increase. This is the largest increase in dollar terms since the start of the program, even though premiums have risen faster in percentage terms on three other occasions in the last 20 years – 2016 (16.1%), 2010 (14.6%), and 2005 (17.4%).

CMS explained that the increase for 2022 was due in part to the potential costs associated with the new Alzheimer’s drug, Aduhelm (aducanumab), manufactured by Biogen, which had an initial annual price tag of $56,000. The increase in the Part B premium was to allow for a “high-cost scenario” of Aduhelm coverage based on assumptions about utilization months before the scheduled announcement of a National Coverage Determination (NCD).

A proposed NCD was announced on Tuesday, January 11, that will be followed by a 30-day comment period and a final decision to be announced by April 11, 2022. The NCD proposes to cover Aduhelm and other similar FDA-approved antiamyloid monoclonal antibodies under Coverage with Evidence Development (CED) in approved randomized controlled trials that satisfy particular coverage criteria. In effect, these drugs will not be covered for people on Medicare unless they are part of a qualifying clinical trial.

On January 10, HHS Secretary Xavier Becerra instructed CMS to reassess the amount of the 2022 Medicare B premium to account for a 50% price reduction in Aduhelm announced by Biogen in late December 2021. Becerra’s order to reassess the Part B premium after it had been announced was highly unusual.

New federal protections that took effect Jan. 1 will bar insured patients from receiving surprise medical bills when they unexpectedly receive care from an out-of-network provider.

These bills have been a major concern for Americans for years. About 1 in 5 emergency visits and about 1 in 6 inpatient admissions at in-network facilities result in an out of network charge, putting patients at risk of a surprise bill, and the prevalence of surprise bills varies by condition, we have found.

More than any other type of hospitalizations, surgery admissions are more likely to result in an out-of-network charge (21%), followed by admissions for mental health and/or substance abuse (20%). Nearly a quarter (23%) of inpatient admissions for heart attacks resulted in an out-of-network bill, and 21% of women undergoing mastectomiess had an out-of-network charge.

Even if there’s widespread compliance with the new protections under the No Surprises Act, problems with surprise bills could still arise each year. Consumers should be aware of the new protections and know how to seek out help if they have improperly received a surprise bill.

Source

Following years of bipartisan outcry over surprise medical bills, a new federal law that took effect Jan. 1 shields patients from receiving potentially large bills when they unexpectedly receive care out of network. In this new video, KFF Senior Fellow Karen Pollitz explains why surprise bills have been such a major problem for patients, how the new law works, potential gaps in the protections, and what patients can do if they believe they have received a surprise bill.

“This is a really important new protection,” Pollitz says in the video. “People are more worried about unexpected medical bills than just about any other affordability concern.”

Patients with a complaint about a surprise bill can contact a new federal hotline, the “No Surprises Help Desk,” at 1-800-985-3059.