What This Bill Does
This bill stops federal health care programs from using quality-adjusted life years (a way of measuring how much a treatment extends someone's life based on its quality) when deciding what treatments to cover or how much to pay for them. The bill also prevents these programs from treating treatments that extend the lives of elderly, disabled, or terminally ill people as less valuable than treatments for younger or healthier people.
Who It Affects
Federal agencies running health care programs; States running Medicaid (health insurance for low-income people) and CHIP (Children's Health Insurance Program); Medicare Advantage plans (an alternative to traditional Medicare); prescription drug plans under Medicare; managed care organizations (companies that deliver health insurance services); and people enrolled in these health care programs.
Key Provisions
• Federal agencies and States cannot use quality-adjusted life years or similar measures in decisions about what treatments to cover or how much to pay for treatments (Sec. 2(a)).
• Federal agencies and States cannot treat extending the life of an elderly, disabled, or terminally ill person as less valuable than extending the life of a younger or healthier person (Sec. 2(a)).
• States must make sure their Medicaid programs follow the rules about not using quality-adjusted life years (Sec. 2(b)(1)).
• Medicare Advantage plans must follow the same rules as the federal government about not using quality-adjusted life years (Sec. 2(b)(3)).
• Prescription drug plans under Medicare must follow the same rules about not using quality-adjusted life years (Sec. 2(b)(4)).
What Changes
Federal health care programs and States lose the ability to use quality-adjusted life years as a tool for making coverage and payment decisions. Agencies also cannot get around these rules by requesting special waivers or demonstrations (test programs) to use these measures.
Important Definitions
Quality-adjusted life year: A way of measuring a treatment's value based on how long it extends someone's life and the quality of that extra life. Not specified in bill text for other key terms.
Effective Date
Not specified in bill text
IIB
118TH CONGRESS
2D SESSION
H. R. 485
IN THE SENATE OF THE UNITED STATES
FEBRUARY 8 (legislative day, FEBRUARY 7), 2024
Received; read twice and referred to the Committee on Finance
AN ACT
To amend title XI of the Social Security Act to prohibit
the use of quality-adjusted life years and similar meas-
ures in coverage and payment determinations under Fed-
eral health care programs.
Be it enacted by the Senate and House of Representa-
1
tives of the United States of America in Congress assembled,
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SECTION 1. SHORT TITLE.
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This Act may be cited as the ‘‘Protecting Health Care
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for All Patients Act of 2023’’.
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SEC. 2. PROHIBITING THE USE OF QUALITY-ADJUSTED
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LIFE YEARS AND SIMILAR MEASURES IN COV-
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ERAGE
AND
PAYMENT
DETERMINATIONS
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UNDER FEDERAL HEALTH CARE PROGRAMS.
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(a) IN GENERAL.—Section 1182(e) of the Social Se-
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curity Act (42 U.S.C. 1320e–1(e)) is amended—
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(1) by inserting ‘‘or treats extending the life of
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an elderly, disabled, or terminally ill individual as of
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lower value than extending the life of an individual
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who is younger, non-disabled, or not terminally ill’’
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after ‘‘because of an individual’s disability’’;
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(2) by inserting ‘‘described in the preceding
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sentence’’ after ‘‘such a similar measure’’;
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(3) by striking ‘‘The Secretary shall not’’ and
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inserting ‘‘A Federal agency (including the CMI (as
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described in section 1115A)) or State may not’’;
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(4) by striking ‘‘under title XVIII.’’ and insert-
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ing the following: ‘‘under any Federal health care
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program (as defined in section 1128B, except that
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such term shall include the health program estab-
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lished under chapter 89 of title 5, United States
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Code).’’; and
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HR 485 RFS
(5) by adding at the end the following new sen-
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tence: ‘‘Notwithstanding any other provision of law,
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a Federal agency (including the CMI) or State may
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not waive the application of the provisions of this
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subsection (or the provisions of section 1852(o), sec-
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tion 1860D–12(h), section 1902(a)(88), section
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1932(b)(9), or section 2102(e)) under section 1115,
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section 1115A, or any other demonstration or waiver
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authority.’’.
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(b) CONFORMING AMENDMENTS.—
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(1) MEDICAID.—
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(A) IN GENERAL.—Section 1902(a) of the
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Social Security Act (42 U.S.C. 1396a(a)) is
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amended—
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(i) in paragraph (86), by striking
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‘‘and’’ at the end;
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(ii) in paragraph (87)(D), by striking
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the period and inserting ‘‘; and’’; and
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(iii) by inserting after paragraph (87)
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the following new paragraph:
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‘‘(88) provide for compliance with the require-
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ments of section 1182(e) (relating to prohibiting the
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use of certain measures in coverage determinations,
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reimbursement, and incentive programs).’’.
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(B) MANAGED
CARE
ORGANIZATIONS.—
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Section 1932(b) of the Social Security Act (42
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U.S.C. 1396u–2(b)) is amended by adding at
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the end the following new paragraph:
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‘‘(9) PROHIBITION
ON
USE
OF
QUALITY-AD-
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JUSTED
LIFE
YEARS.—The provisions of section
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1182(e) shall apply to the utilization of a dollars-
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per-quality adjusted life year or similar measure (as
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described in such section) by a medicaid managed
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care organization under this title (or a prepaid inpa-
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tient health plan or prepaid ambulatory health plan,
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as defined in section 438.2 of title 42, Code of Fed-
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eral Regulations (or any successor regulation), under
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a contract with the State) in the same manner as
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such provisions apply to the utilization of such a
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year or measure by a State under this title.’’.
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(2) CHIP.—Section 2102 of the Social Security
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Act (42 U.S.C. 1397bb) is amended by adding at
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the end the following new subsection:
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‘‘(e) PROHIBITION ON THE USE OF QUALITY-AD-
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JUSTED LIFE YEARS AND SIMILAR MEASURES.—A State
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child health plan shall provide for compliance with the re-
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quirements of section 1182(e) (relating to prohibiting the
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use of certain measures in coverage determinations, reim-
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bursement, and incentive programs).’’.
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(3) MEDICARE ADVANTAGE.—Section 1852 of
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the Social Security Act (42 U.S.C. 1395w–22) is
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amended by adding at the end the following new
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subsection:
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‘‘(o) PROHIBITION ON USE OF QUALITY-ADJUSTED
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LIFE YEARS.—The provisions of section 1182(e) shall
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apply to the utilization of a dollars-per-quality adjusted
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life year or similar measure (as described in such section)
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by an MA plan in the same manner as such provisions
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apply to the utilization of such a year or measure by the
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Secretary under this title.’’.
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(4) MEDICARE PART D.—Section 1860D–12 of
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the Social Security Act (42 U.S.C. 1395w–112) is
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amended by adding at the end the following new
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subsection:
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‘‘(h) PROHIBITION ON USE OF QUALITY-ADJUSTED
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LIFE YEARS.—The provisions of section 1182(e) shall
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apply to the utilization of a dollars-per-quality adjusted
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life year or similar measure (as described in such section)
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by a prescription drug plan in the same manner as such
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provisions apply to the utilization of such a year or meas-
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ure by the Secretary under this title.’’.
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(c) IMPLEMENTATION.—The amendments made by
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this section shall apply beginning on January 1, 2025.
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SEC. 3. PREVENTION AND PUBLIC HEALTH FUND.
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Section 4002(b) of the Patient Protection and Af-
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fordable Care Act (42 U.S.C. 300u–11) is amended by
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striking paragraphs (7), (8), and (9) and inserting the fol-
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lowing:
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‘‘(7) for each of fiscal years 2024 and 2025,
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$1,102,000,000;
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‘‘(8) for each of fiscal years 2026 and 2027,
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$1,327,000,000;
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‘‘(9) for each of fiscal years 2028 and 2029,
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$1,526,000,000; and’’.
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SEC. 4. REPORT.
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Not later than 1 year after the date of the enactment
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of this Act, and annually thereafter, the Comptroller Gen-
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eral of the United States shall submit to Congress a report
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on how quality-adjusted life years negatively impacts indi-
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viduals with intellectual and developmental disabilities and
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their access to care.
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Passed the House of Representatives February 7,
2024.
Attest:
KEVIN F. MCCUMBER,
Clerk.
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