Federal and State Policy
As the largest US healthcare payer, the federal government plays a dominant role in shaping the healthcare marketplace, while states take center stage when it comes to developing novel policy approaches. Our experts track, interpret, and model policies that affect insurance coverage, access, and consumer choice so you can see around the bend.
Part D Senior Savings Model Participation and Premiums Vary
New Avalere analysis finds higher premiums for the enhanced standalone drug plans participating in the model.
Step Therapy Can Lead to Higher OOP Costs for Crohn’s Disease Patients
Avalere analysis finds that patients with Crohn’s disease who experience a negative outcome when required to step through a plan’s preferred product may face higher upfront out-of-pocket (OOP) costs and could increase costs to payers.
Election Outcome Will Play Pivotal Role in State Healthcare Priorities
The outcomes of the 2020 elections will hold implications for state policymaking on key healthcare issues that could impact patients’ health insurance coverage status and how they access care.
Interview: 2020 Election with Avalere: SCOTUS ACA Outlook
Tune into our fifth episode of the Avalere Health Essential Voice: 2020 Election series. In this segment, our experts discuss the evolving makeup of the Supreme Court and the outlook on California vs. Texas — the upcoming Supreme Court case regarding the constitutionality of the Affordable Care Act and, in particular, the individual mandate.
Video: 2020 Election with Avalere: SCOTUS ACA Outlook
Tune into the fifth video of the Avalere Health Essential Voice: 2020 Election series. In this segment, our experts discuss the evolving makeup of the Supreme Court and the outlook on California vs. Texas — the upcoming Supreme Court case regarding the constitutionality of the Affordable Care Act and, in particular, the individual mandate.
Video: 2020 Election with Avalere: First Presidential Debate Healthcare Recap
Watch the fourth video in the Avalere Health Essential Voice: 2020 Election series. In this segment, our experts discuss top healthcare issues and platforms from the first Presidential debate, including the Affordable Care Act (ACA), COVID-19, public health, health disparities, and drug-pricing reform.
Interview: 2020 Election with Avalere: First Presidential Debate Healthcare Recap
Tune into our fourth episode of the Avalere Health Essential Voice: 2020 Election series. In this segment, our experts discuss top healthcare issues and platforms from the first Presidential debate, including the Affordable Care Act (ACA), COVID-19, public health, health disparities, and drug-pricing reform.
ESRD Patient Spending Differences Between Puerto Rico and the 50 States
Avalere analysis finds End Stage Renal Disease (ESRD) spending in Puerto Rico varies substantially, and most spending is related to outpatient dialysis and inpatient services.
COVID-19 Provider Relief Funding and Future Allocation Considerations
The Coronavirus Aid, Relief, and Economic Security (CARES) Act appropriated $100 billion for the Public Health and Social Services Emergency Fund—known as the Provider Relief Fund (PRF)—and subsequent legislation appropriated an additional $75 billion through the Paycheck Protection Program and Health Care Enhancement Act.
Anticipated Impact of COVID-19 Treatments on State Medicaid Budgets
Compared to other drivers of state budget pressures during the COVID-19 pandemic—including higher Medicaid program enrollment due to increased unemployment and lower state tax revenues as a result of economic shutdowns—the relative financial impact of COVID-19 therapeutics on state Medicaid budgets will likely be minimal.
Avalere Statement on “Most Favored Nation” Executive Order
Yesterday, the Administration released the awaited “Most Favored Nation” Executive Order (EO), which calls for a model that would cap the price Medicare pays for select Part B and D drugs.
Fall Medicaid Outlook: Key Events to Watch
Medicaid will continue to experience considerable changes at the state and federal levels, both in terms of beneficiary demographics and the payer landscape. Stakeholders should consider how upcoming elections, policy proposals, and COVID-19 will impact benefits and payer dynamics.
CMMI Model Would Increase Gap Discounts for Non-Insulin Products
Avalere analysis finds that 51% of all drug spending for non-LIS beneficiaries using insulins and enrolled in enhanced plans in 2018 was for products not participating in the model.
Interview: 2020 Election with Avalere: What Are the Differences in Healthcare Platforms?
Tune into our second episode of the Avalere Health Essential Voice: 2020 Election series. In this segment, experts from the policy and vaccines teams discuss the healthcare themes heard at the recent political conventions, and differences we can expect to see in the candidates’ healthcare platforms.
Video: 2020 Election with Avalere: What are the Differences in Healthcare Platforms?
Tune into our second episode of the Avalere Health Essential Voice: 2020 Election series. In this segment, experts from the policy and vaccines teams discuss the healthcare themes heard at the recent political conventions, and differences we can expect to see in the candidates’ healthcare platforms.
COVID-19 Guide for Patients and Providers
As our healthcare industry rapidly evolves to address the COVID-19 pandemic, keep track of new resources and policies affecting patients and providers with the COVID-19 guide below.
MedPAC Proposes Replacement for MA Star Ratings Program
Under the Medicare Advantage (MA) Star Ratings Program, plans with 4-stars or more receive the greatest benefit from the Quality Bonus Program (QBP) in the form of higher benchmarks and bonus payments.
Charitable Assistance Covers a Small Share of Part D Non-LIS OOP Costs
As policymakers discuss ways to curb program expenditures and improve patient affordability in Medicare Part D, the role of charitable assistance in helping beneficiaries with out-of-pocket (OOP) costs has garnered interest. To understand the relationship between charitable assistance and various Part D metrics, Avalere examined Part D prescription drug claims for beneficiaries without the Low Income Subsidy (LIS) for 2014 and 2018.
Overview: Balance Billing or Surprise Medical Bill Reform
Surprise and balance billing reform efforts have been a subject of ongoing debate at the federal level.
EO on Rebate Reform Raises Key Considerations for Pharmacies
As currently written, a proposed rule on rebate reform from January 2019 may impose financial and operational challenges for pharmacies related to cash flow and new technology requirements.