By Megan R. Wilson

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• Up next, PBMs: Sens. Mike Crapo (R-Idaho) and Ron Wyden (D-Oregon) are dusting off their bipartisan package to reform pharmacy benefit managers, the so-called “middlemen” between drugmakers and insurance companies.
• ACA premium debate: The Senate Finance Committee huddled about health costs ahead of a Dec. 15 ACA enrollment deadline. As Republicans push varying proposals to provide consumers with health savings accounts, Democrats pan the idea as a handout to insurers.
• Another line to the resume: Former FDA commissioner Scott Gottlieb joins the board of UnitedHealth Group.

Good afternoon and happy Wednesday. This is the Health Brief newsletter. Make sure to send me your health policy tips and scoops. You can find me at megan.wilson@washpost.com, or you can message me securely on Signal at megan.434.

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Sens. Mike Crapo (R-Idaho), right, and Ron Wyden (D-Oregon) are reviving their PBM reform package. (Craig Hudson/For the Washington Post)

	The Lead Brief

The PBM fight is coming back to Congress: Senate Finance Chairman Mike Crapo (R-Idaho) said on Wednesday that he and Sen. Ron Wyden (Oregon), the top Democrat on the panel, will “soon” be reintroducing their bipartisan package of reforms to the pharmacy benefit manager industry.

PBMs — which negotiate discounts on medications with drugmakers and decide which treatments insurance plans will cover — have become the target of bipartisan ire over the last several years, and drawn big money lobbying campaigns from pharmaceutical manufacturers and independent pharmacies that have pushed for reforms.

The three largest PBMs control about 80 percent of the prescription market and are owned by insurance companies — and often have their own pharmacies. Policymakers, regulators and industry rivals argue that consolidation among the largest PBMs drives up the cost of medicines, harms patient access, and steers people away from smaller pharmacies.

The pharmacy benefits industry counters that the rebates they obtain from drug companies help keep costs down, arguing that they play a key role in the system.

The reforms would “realign incentives in the drug supply chain to lower patient costs at the pharmacy counter,” Crapo said on Wednesday.

In 2023, the panel advanced Wyden and Crapo’s PBM package 26-1. A few of the key provisions include:

• Delinking: In order to “delink” a PBM’s compensation from the cost of medicines, the legislation would require any payments from Medicare Part D plan sponsors to be for a flat “bona fide service fee” unrelated to the price of a drug or where it appears on the insurance formulary.
• Spread pricing ban: A prohibition on a practice in which PBMs charge an insurance company more for a drug than it reimburses a pharmacy to dispense it, called spread pricing, in Medicaid.
• Increased transparency: The legislation would increase the transparency and reporting requirements related to drug coverage, pricing and access.

→ Crapo and Wyden aren’t elaborating on when they’re seeking to act on the policies, which had originally been proposed in the last Congress. There could be a health care package that rides along with government funding legislation that Congress will need to pass by Jan. 30.

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It comes as the Pharmaceutical Care Management Association, the industry group for PBMs, is searching for its new leader following the departure this month of current CEO JC Scott.

	Health on the Hill

Lawmakers appear no closer to a health care cost solution, and there are 13 legislative days until Dec. 15 — the deadline for people to sign up for health insurance through the Affordable Care Act marketplaces if they want coverage to kick in Jan. 1.

A Senate Finance Committee hearing Wednesday appeared poised to discuss the proposals to help people buy insurance — perhaps setting the stage for legislative efforts for parties to rally behind — but proved to be a grab bag of various ideas that have been circulating around the Hill, some for more than a decade.

Ultimately, the issue of rising premiums for more than 20 million ACA enrollees appears no closer to being resolved.

“I’m a little bit disappointed about the discussion today, because none of this has to do with anything that’s the least bit a coherent strategy on how to really drive down health costs,” said Sen. Thom Tillis (R-North Carolina) toward the end of the hearing. “None of it.”

A critic of the ACA, Tillis has been advocating for a temporary extension of the enhanced tax credits while policymakers mull larger reforms of the health system, and he echoed that call again on Wednesday.

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“You could argue whether or not the subsidy should have ever been passed, but they are what they are. People are relying on them,” said Tillis, who is leaving Congress at the end of next year. “It makes more sense to extend it and bend the curve in the out years.”

The math: A bipartisan group of senators is working on a compromise that would temporarily extend the enhanced tax credits, but those details aren’t yet settled. Democrats would need at least 13 Republicans to agree on the eventual deal to meet the 60-vote threshold in the Senate.

COMPETING HSA PROPOSAL

Meanwhile, some Republicans in the Senate have rallied around the idea of using health savings accounts to help people pay for their care, but there are still divisions among them about the details. The unifying theme, however, is allowing patients to control how they spend money on health care, rather than sending cash to insurance giants.

→ Democrats have largely panned the proposals outright. Wyden on Wednesday released a report on behalf of Democrats on the Senate Finance Committee, arguing that the HSAs would also “fatten the profit margins of the nation’s largest financial institutions and health insurers.”

“The same corporate institutions and special interests that Republicans claim to dislike receive significant profits for administering HSAs, some or all of which they often pass on to insurers that either own or partner with them — the same big insurers that Republicans claim to oppose giving federal funding to,” according to the report. “OptumBank, for example, one of the largest providers of HSAs in the country, is owned by the largest health insurer in America, UnitedHealth Group.”

Proponents of the HSA proposal, including Sen. Bill Cassidy (R-Louisiana), say that the investment vehicles would bring overall costs down and allow people to have more flexibility over their own health care decisions.

	Jobs Report

UnitedHealth Group added Scott Gottlieb, the former head of the Food and Drug Administration, to its board, the company announced.

In a statement, Gottlieb said he wants to help UnitedHealth Group — which has a health insurance arm and a separate division that includes a PBM and its own physician groups — “help shape how medical breakthroughs are developed and made accessible to patients who may benefit from them.”

Gottlieb, a practicing physician who was FDA commissioner during the first Trump administration, also serves on the boards of drug giant Pfizer, genomics company Illumina, health analytics company Aetion, biopharmaceutical companies Xaira Therapeutics and Comanche Biopharma, contract development and manufacturing organization Resilience, and medical AI company Tempus AI. He’s a partner at the venture capital firm New Enterprise Associates and a senior fellow at the American Enterprise Institute.

	What We’re Reading

“A small Texas Think Tank Cultivated COVID Dissidents. Now They’re Running US Health Policy,” reports Rachana Pradhan for KFF Health News.

“Patient showed signs of life during organ harvest in N.J., House members allege,” writes Peter Whoriskey at The Washington Post.

“PBMs, FTC clash in court over agency’s in-house insulin challenge,” Nicole DeFeudis reports at Endpoints News.

“‘Ticking Time Bomb’: A Pregnant Mother Kept Getting Sicker. She Died After She Couldn’t Get an Abortion in Texas,” Kavitha Surana and Lizzie Presser write for ProPublica.