A Massachusetts Monkey Wrench in Health Care Reform?


By John Coster, RPh., Ph.D.

The upset Republican win in Tuesday’s Senate race in Massachusetts calls into question the future of the health care reform legislation that consumed so much congressional effort in 2009 and into the new year. Along with it, the outlook becomes unclear for several community pharmacy priorities, despite the support of a growing consensus in Congress.

These include the restoration of some of the potentially devastating cuts in Medicaid reimbursement for generic drugs (the average manufacturer price formula or AMP); important transparency requirements on pharmacy benefit managers (PBMs); an exemption from Medicare’s onerous and duplicative accreditation requirements for providing durable medical equipment (DME), like diabetes testing supplies; and provisions expanding the pharmacist’s role in health care through medication therapy management.

In the wake of their loss of a 60-seat, filibuster-proof Senate majority, Democratic leaders face several options going forward. Here are two possible scenarios and what each would mean for community pharmacists:

1) The House passes the Senate bill – Faced with a Republican filibuster that could forestall Senate approval of any compromise bill forged by House and Senate leaders, the Obama Administration and Democratic leaders could press House rank-and-file members to approve the legislation that cleared the Senate on Dec. 24, 2009. This could possibly followed by a more limited bill to modify a few tax and spending related provisions (under the “reconciliation” process which isn’t subject to filibuster).

For community pharmacy, such an outcome would: change Medicaid’s generic reimbursement formula to “no less than” 175% of a weighted AMP (much preferable to the House’s 130% of AMP); impose limited transparency requirements on PBMs operating in Medicare Part D and in the new health exchange set up for the uninsured (the House version didn’t cover Part D, but went farther in other areas); exempt most pharmacies from DME accreditation in a way that’s preferable to the House version; and modestly expand MTM.

In sum, while far from perfect, this would give community pharmacists much of what we asked for in health reform. For more on the differences in pharmacy provisions between the House and Senate bill, read NCPA’s most recent letter to Congressional leaders.

There was speculation that  Democrats would attempt to quickly forge a House-Senate compromise bill and usher it through both chambers before they formally lose the 60-seat majority with the swearing-in of  Senator-elect Scott Brown. But that appears highly unlikely and President Obama rejected that idea today.

2) No health care reform bill – It’s possible that either the failure to hatch a Senate-House compromise in time or any number of other factors could end health care reform efforts, at least for this year. In that case, there would be considerable pressure for Congress to pass a smaller health care measure to address a number of pressing issues that, up until now, have been rolled into the larger package.  NCPA would aggressively advocate the inclusion of an AMP fix and an exemption from DME accreditation requirements as the minimum Congress should do for community pharmacy in such a bill.

Clearly, there’s no shortage of health care reform drama in the wake of Tuesday’s election and it may be some time before the outlook is clearer. What is clear is the strong, bipartisan support in Congress for all of the community pharmacy priorities mentioned above. Lawmakers understand that these provisions help community pharmacists to work with patients to produce better health outcomes at lower cost. NCPA will continue working with lawmakers of both parties to enact these policies into law as soon as possible.

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