Sponsors (3)
The bill strengthens protections for people on public insurance and increases prevention funding to support public health and equity, but it limits the use of cost‑effectiveness tools (QALYs), likely raising costs and complicating coverage prioritization and budget flexibility.
Medicaid, Medicare, and CHIP enrollees (including people with chronic conditions) will be protected from coverage denials that rely on QALY-based thresholds, preserving access to treatments that might otherwise be deprioritized.
States and federal programs cannot waive the prohibition on QALY-based coverage limits, maintaining a consistent national protection across demonstrations and waivers.
The Prevention and Public Health Fund is increased and given multi-year, predictable funding levels, enabling state and local health departments and health systems to plan and expand prevention, vaccination, and preparedness activities.
Limiting the use of QALY-based cost-effectiveness tools reduces agencies' and plans' ability to control drug and treatment spending and could raise premiums, increase taxpayer costs, and put upward pressure on Medicare and drug-plan spending.
The bill reduces the ability of Medicaid and Medicare (and private plans relying on those tools) to prioritize therapies by expected benefit per dollar, complicating coverage decisions, budgeting, and increasing administrative complexity for payers and providers.
Mandating higher, fixed Prevention Fund levels increases federal spending commitments, which could add to budget pressures and crowd out other priorities.
Based on analysis of 4 sections of legislative text.
Prohibits use of QALY metrics by federal agencies, states, Medicaid/CHIP, Medicare Advantage, and Part D in coverage/reimbursement; sets Prevention Fund levels and requires annual GAO reports.
Introduced June 10, 2025 by Kat Cammack · Last progress June 10, 2025
Prohibits federal agencies, states, Medicaid/CHIP programs, Medicare Advantage, Medicare Part D plans, and certain health plans from using quality‑adjusted life years (QALYs) or similar metrics in coverage, reimbursement, utilization management, incentive programs, and related decisions, with that ban non‑waivable and effective January 1, 2027. It also sets fixed annual funding amounts for the Prevention and Public Health Fund for FY2026–FY2031 and requires the Government Accountability Office to report within one year and annually thereafter on how QALYs affect people with intellectual and developmental disabilities and their access to care. The bill changes how cost‑effectiveness tools may be used across major federal health programs, adjusts public health funding levels for six fiscal years, and creates recurring oversight reporting focused on the disability community.