Sponsors (2)
Official title: Extend expiring health provisions and improve health care delivery.
Introduced March 6, 2025 by Ronald Lee Wyden · Last progress March 6, 2025
The bill increases transparency, funding, and public‑health preparedness (notably in drug pricing, community care, and emergency response) that could improve access and accountability for many Americans — but it also imposes substantial reporting, compliance, and privacy tradeoffs and raises fiscal and market‑structure risks that may drive higher costs or consolidation unless carefully implemented.
Nearly all insured patients and plan sponsors: PBMs and plan sponsors must report passthroughs, rebates, and per‑claim/net spending in machine‑readable formats and allow audits, increasing transparency into drug pricing and plan spending.
Low‑income, uninsured, and rural patients: substantial new multi‑year funding for community health centers, National Health Service Corps, teaching health centers, and targeted disease programs increases primary care access and workforce in underserved areas.
State, local, Tribal public‑health agencies and the public: increased funding and clearer authorities for overdose response, crisis services, wastewater surveillance, hospital preparedness, regional labs, and AMR strategy strengthen outbreak detection, surge capacity, and emergency response.
Insured individuals and employers: extensive new PBM and plan reporting, audit requirements, and civil penalties will raise compliance costs for PBMs, plans, pharmacies, and vendors that are likely to be passed through as higher premiums, administrative fees, or reduced benefits.
State Medicaid agencies, hospitals, community health centers, and providers: extensive new reporting, retroactive plan amendments, survey requirements, and program conditions create substantial administrative and fiscal burdens for implementation and compliance.
Patients and participants whose data are reported: the collection and sharing of detailed, claims‑level, machine‑readable data (and expanded wastewater surveillance) raise privacy and reidentification risks despite HIPAA and other safeguards.
Based on analysis of 36 sections of legislative text.
Creates streamlined out‑of‑State Medicaid enrollment for providers serving children, mandates broad PBM and plan drug‑level transparency, adjusts Medicare/Medicaid payment/timing, funds public‑health programs, caps certain biosimilar patents, and updates pediatric drug study rules.
Creates a broad package of health‑care and public‑health reforms: it requires streamlined Medicaid enrollment for eligible out‑of‑State providers serving children under 21, tightens reporting for home‑and‑community‑based services waitlists, adds hospital and Medicare payment timing clarifications, and strengthens Medicare Advantage provider‑directory accuracy. It imposes extensive disclosure and reporting obligations on pharmacy benefit managers (PBMs) across Part D and group health plans (including a new IRS reporting provision), limits certain biosimilar patent assertions, extends and funds multiple public‑health programs and preparedness activities (including regional biocontainment labs), updates FDA pediatric study rules for molecularly targeted cancer drugs, extends temporary fentanyl scheduling, and restores a telehealth HDHP safe harbor for specified periods. Effective dates vary by provision (examples: some PBM/Part D and group‑plan reporting rules take effect for plan years beginning Jan 1, 2028; the Medicaid out‑of‑State provider streamlining becomes effective three years after enactment).