| TGIF — where today we're having déjà vu with yesterday. 🚨Late last night: House Democrats delayed a vote on a bipartisan infrastructure bill, as fraught negotiations over Biden's social spending bill continue today and Pelosi again pledges a vote (more below). This morning, Merck announced positive results for its experimental pill to treat covid-19. But first: | Biden administration announces new rule against "surprise" medical billing |  HHS Secretary Xavier Becerra oversees the federal health department charged with ensuring patients can't get hit with pricey surprise medical bills. Photographer: Greg Nash/The Hill/Bloomberg | | | While all eyes were on Congress, the Biden administration handed insurers a victory in a much-anticipated rule detailing how to shield patients from pricey, unexpected medical bills. The effort is critical to protecting Americans from bankruptcy after receiving sky-high charges through no fault of their own. And it's served as a perennial reminder that changing the health-care system is exceedingly complex — and contentious. Here's the quick backstory: | - Patients get hit with hefty surprise medical bills when they unknowingly get care from a doctor out of their coverage network or in emergency situations, where they can be sent to out-of-network hospitals.
- The issue was the center of a ferocious lobbying battle on Capitol Hill for nearly two years, pitting powerful insurers and providers against each other.
- In December, lawmakers reached a compromise and passed legislation that protected patients from surprise medical bills.
- Providers successfully pulled the bill further in their direction after spending tens of millions of dollars in ads to promote their preferred fix. But the law charged the federal health department with hashing out some of the thorniest details.
| | How the dispute plays out: Doctors and insurers have 30 days to negotiate the remaining charges of the bill. Afterward, a mediator can step in if they can't agree, and both sides will submit offers. | | Both insurers and providers have been hellbent on avoiding picking up the bulk of the cost they can no longer saddle onto patients. The rule yesterday said the winning payment amount should generally be pegged to the plan's median in-network rate for a similar service. For hospitals or doctors to get paid more — or for insurers to pay less — they must show the treatment was particularly different. That's good news for insurers. Some providers were agitating for the arbiter to heavily consider a wider array of factors, as industries lobbied the administration for months on their preferred approaches. | | Larry Levitt, of the Kaiser Family Foundation: |  | | | | The reaction came swiftly | | Insurers cheered the administration's rule, which is set to take place beginning Jan 1. 2022, while providers sent scathing statements. Here's a sampling: | - Major insurer lobby AHIP called the rule "the right approach" to encourage providers and insurers to "negotiate in good faith."
- A coalition of mainly insurer and employer groups said the rule adhered to Congress' intent on what mediators should take into consideration when settling disputes.
- The Federation of American Hospitals, which represents for-profit chains, slammed the rule as a "total miscue" and "put[ting] a thumb on the scale benefiting insurers against providers."
- The American Hospital Association echoed that sentiment, saying the rule "moved away from Congressional intent."
| | The Biden administration also laid out rules to help uninsured patients contest bills that seem too expensive. Doctors and hospitals will be required to provide an estimate of the price of a procedure beforehand. The federal health department set up a process for patients to dispute their bill if the cost is at least $400 more than the "good faith" estimate they were given. | | |  | On the Hill | | It's another big moment for Biden's social spending bill (and health care policy) |  Rep. Nancy Pelosi (D-Calif.) speaking at her weekly press conference at the U.S. Capitol on Sept. 30. | | | House Democrats delayed a vote on a bipartisan infrastructure bill last night — a dramatic reversal after hours of negotiations, The Post's Tony Romm, Marianna Sotomayor, Mike DeBonis and Seung Min Kim report. We meet again: As Pelosi left the Capitol last night, she said, there will be a vote today, our Early 202 colleagues note. Democrats will try again to repair the schisms between moderate and progressive members of their party, whose distrust of each other led to the stand-off Thursday night. More progressive members of the party are wary of voting for a bipartisan bill before ensuring passage of a massive economic package containing key Democratic priorities, such as expanding Medicare and boosting safety net programs. What's not lost on lawmakers: Democrats campaigned on making health coverage more affordable and accessible — and delivering on that pledge is key to helping the party keep its majorities in both the House and the Senate in the midterms. "We just can't afford to fail. We have the majority in both Houses. We want President Biden to have a successful first year," Sen. Tim Kaine (D-Va.) told The Health 202. | | |  | Coronavirus | | Merck's experimental pill to treat covid-19 is effective, company says |  The pill developed by Merck and Ridgeback Biotherapeutics, would be the first oral medication to treat the covid-19 if authorized by U.S. regulators. | | | This morning: Merck announced that its medication, molnupiravir, reduced the risk of hospitalization and death by nearly half in a clinical trial, The Post's Carolyn Y. Johnson reports. The company and partner Ridgeback Biotherapeutics plan to apply for emergency use authorization from the FDA as soon as possible, which could make it the first antiviral pill for covid-19. | | An independent board of experts monitoring the trial recommended stopping the study early because of the positive results, which is "a significant and telling step in a pharmaceutical study." The data hasn't been published or peer-reviewed. | - "A simple, easy-to-prescribe pill that prevents mild and moderate cases of covid-19, the illness caused by the coronavirus, from turning into dire episodes has been one of the missing pieces of the medical armamentarium to fight the virus," Carolyn reports.
| | |  | Ask a reporter | | | Behind the country's messy coronavirus data The debate over whether federal regulators should allow booster shots relied on conflicting information, an episode that underscored the country's dearth of timely coronavirus data. Our colleagues Joel Achenbach and Yasmeen Abutaleb dug into the United States' incomplete pandemic data — and found systemic problems. After reading their story, we pinged them for more insight: The 30,000-foot view: "The big picture that the pandemic has exposed is that our data are a mess because of the fragmented nature of the U.S. health system, siloed computer systems, underfunded public health departments, and (as some of our sources have told us) a CDC that's by nature academic and scientific and sometimes does not react with the speed that a crisis like this might require." — Joel Sometimes the science conflicts: "Everyone talks about 'follow the science' (or, sometimes, 'follow the data') but that often leads to a fork in the road — because the data don't always tell you what to DO. Booster shots? The same data can be used to argue that round or square. Which is what happened with FDA and CDC advisory panels: They reached different conclusions after they all looked at the same research." — Joel The impact of decentralized data: "You've seen it hurt the response pretty much every time there's a major decision to make. Incomplete data means you don't have a full picture of what the virus is doing. … You set policies and make decisions based on what the data is telling you — and since the U.S. has a huge data problem, that means we're often making decisions without fully understanding what's happening, so sometimes those decisions are premature, too late or just not the best course of action." — Yasmeen | | |  | Reproductive wars | | House members share personal abortion stories during Thursday hearing | | Three lawmakers shared their personal stories of abortion during an emotional hearing on Thursday that comes amid an intensifying battle over Texas' restrictive ban, The Post's Felicia Sonmez reports. Rep. Barbara Lee (D-Calif.) described receiving a "back-alley abortion" in Mexico at age 16 and called herself "one of the lucky ones" because many other women and girls had died from unsafe abortions performed in the mid-1960s. Rep. Cori Bush (D-Mo.) said she had an abortion after she was raped at age 17 by a man she met on a church trip. "Choosing to have an abortion was the hardest decision I had ever made," Bush, 45, told the committee. "But at 18 years old, I knew it was the right decision for me. It was freeing, knowing I had options." And Rep. Pramila Jayapal (D-Wash.) said she had an abortion because she knew that she couldn't go through another high-risk pregnancy after having her first child. | | |  | In other news | | | Here's what else you need to know: | - Four Air Force officers, a Secret Service agent and others have filed an injunction against the Biden administration's coronavirus vaccine mandate, The Post's Paul Duggan and Alex Horton report.
- About a third of parents said they want to get their 5- to 11-year-olds vaccinated "right away" when the coronavirus vaccine is available for that age group, The Post's Paulina Firozi reports.
- The Justice Department filed a formal statement saying Texas's ban on mask mandates prevents disabled children from attending school safely, The New York Times's Amanda Morris writes.
- Americans with disabilities are more likely to want the coronavirus vaccine but less likely to have gotten one, underscoring barriers to accessing the shot, The Post's Caroline Anders reports.
- Covid is killing rural Americans at more than twice the rate of their urban counterparts, Kaiser Health News's Lauren Weber reports.
- Sen. Dianne Feinstein (D-Calif.) introduced a bill requiring vaccination, a negative coronavirus test or recovery from covid-19 for domestic air travel, The Post's Hannah Sampson reports.
- School cafeterias across the country are grappling with food and labor shortages, supply-chain backlogs and delivery delays, pushing the nation's beleaguered public school meal program to its breaking point, The Post's Laura Reiley reports.
| | |  | Quote of the week | | | A CDC official, who spoke on the condition of anonymity | "Come on, government leaders, can you guys work just as hard [as] we're working so the government can keep functioning?" the official told our Post colleagues. "We're trying to get our s--- together, couldn't you get your expletive together, too?" | | | | | | | | |  | Sugar rush | | | Thanks for reading! See y'all tomorrow. | |
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