Will Congress get another shot at PBM reform?

Health Care

The Big Story

Congress missed a chance at PBM reforms. Will they get another?

Lawmakers ended 2024 on the cusp of passing a significant health package, including changes to the pharmacy benefit manager (PBM) industry payments to community health centers, a rollback of physician payment cuts and more.

The policies put forward in December never passed amid an 11th-hour revolt by conservatives. And it’s not clear whether it could happen in the new GOP-majority Congress this year.

Ready to roll: Most of the work on PBM reforms was done ahead of the government spending bills passed in March of last year. When last-minute disagreements derailed their inclusion, lawmakers and staff hammered out the final details ahead of the December funding deadline. The language is now already written and could be inserted ready-made into a new bill.

Favorable conditions: Analysts expect congressional pressure on PBMs to continue. The spending bill that ultimately passed just before Christmas only funds the government through mid-March, so the next version could be a vehicle for those same policies that were jettisoned in December.

Additionally, the telehealth flexibilities and health center funding that passed in December were only extended until March, giving lawmakers another incentive.

A spokesman for incoming Senate Finance Committee Chairman Mike Crapo (R-Idaho) wouldn't speculate on what a path forward may look like for the health items not included in the most recent funding package. But he noted the senator is committed to passing his health priorities, which include those in the original bill that didn’t make the cut.

Partisan priorities: With full GOP control of government, lawmakers may burn a lot of precious time on partisan issues. Major Medicaid changes are likely on the horizon, as is a potential rollback of the Inflation Reduction Act’s drug pricing changes.

That may not engender much bipartisan cooperation to pass any of the provisions as a standalone, though there is bipartisan support for PBM changes.

Republicans also want to raise the debt limit and pass an extension of President-elect Trump’s 2017 tax cuts using the party-line reconciliation process, which would potentially rule out including health care changes in those bills.

Welcome to The Hill’s Health Care newsletter, we’re Nathaniel Weixel and Joseph Choi — every week we follow the latest moves on how Washington impacts your health.

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