Sponsors (4)
Official title: To amend title XI of the Social Security Act to prohibit the use of quality-adjusted life years and similar measures in coverage and payment determinations under Federal health care programs.
Introduced June 10, 2025 by Kat Cammack · Last progress June 10, 2025
The bill strengthens protections for patients—especially those on Medicaid/Medicare and people with disabilities—and boosts prevention funding to improve public health and equity, at the cost of limiting some cost‑effectiveness tools, raising fiscal pressures, and reducing flexibility for program and payer prioritization.
Medicaid, Medicare, and CHIP enrollees (and other patients with chronic conditions) are protected from coverage denials or deprioritization that rely on QALY-based thresholds, and states/federal programs cannot waive that protection, preserving patient access to treatments.
State and local health departments, hospitals, and communities gain larger, multi-year, predictable Prevention and Public Health Fund levels (FY2026–31 increases) to support prevention, vaccination, and preparedness, which can reduce disease outbreaks and downstream healthcare costs.
People with intellectual and developmental disabilities and other vulnerable populations will be better identified as potentially harmed by QALY-based decisionmaking through recurring GAO reporting, giving Congress evidence to pursue policy changes and improving visibility of equity issues in coverage decisions.
Taxpayers, Medicare and Medicaid beneficiaries, and private plan enrollees may face higher overall health spending and upward pressure on premiums, taxpayer costs, or federal spending because agencies and plans are restricted from using some cost‑effectiveness (QALY-based) tools.
State Medicaid programs, Medicare administrators, hospitals, and insurers could have reduced ability to prioritize treatments by expected benefit per dollar, complicating coverage decisions and budgeting and potentially prompting narrower formularies or higher patient cost‑sharing elsewhere.
Mandating higher, fixed Prevention and Public Health Fund levels increases federal spending commitments that could add to budget pressures or crowd out other priorities and reduces HHS flexibility to reallocate funds if public-health needs shift (e.g., emergencies).
Based on analysis of 4 sections of legislative text.
Bans use of QALYs/similar metrics in federal, state, Medicaid/CHIP, Medicare Advantage, and Part D coverage decisions; sets Prevention Fund levels and requires annual GAO reports.
Prohibits federal agencies, states, and specified health plans from using quality-adjusted life years (QALYs) or similar measures in coverage, reimbursement, utilization management, incentive programs, or related decisions, and makes that ban non-waivable by demonstration authorities. Sets specific annual funding levels for the Prevention and Public Health Fund for FY2026–FY2031 and requires the Government Accountability Office (Comptroller General) to report annually on how QALYs negatively affect people with intellectual and developmental disabilities and their access to care.