Sponsors (3)
The bill secures bigger, predictable public‑health funding and protects patients (especially those on Medicare/Medicaid and people with disabilities) from QALY‑based coverage exclusions, but it does so by restricting cost‑effectiveness tools and demonstrations—trading potential efficiency and budget savings for access protections and transparency.
State and local health departments, community prevention programs, and patients (including low-income individuals and people with chronic conditions) receive predictable, multi-year increases to the Prevention and Public Health Fund, supporting disease prevention, preparedness, and potential long-term reductions in healthcare use and costs.
Medicare beneficiaries, Medicaid and CHIP enrollees, and people with disabilities are protected from coverage denials or limits explicitly tied to QALY-based thresholds, preserving access to treatments that might otherwise be excluded.
Taxpayers and policymakers gain recurring, evidence-based GAO reporting on how QALY-like assessments affect access and discrimination, increasing transparency and providing a factual basis for future legislative or regulatory action.
Taxpayers, insured individuals, and employers may face higher federal and private healthcare costs (higher premiums, taxes, or spending) because prohibiting or restricting standardized cost‑effectiveness tools like QALY removes a widely used mechanism for containing costs.
Medicare, Medicaid, and state programs — and the patients they serve — may lose the ability to prioritize resources efficiently or to test innovative delivery models because QALY-style metrics and certain demonstration waivers are restricted, potentially reducing cost containment and slowing innovation.
Authorization of higher PPHF levels does not guarantee timely obligation or effective use of funds; if funds are delayed, misallocated, or redirected, expected public-health benefits may be limited.
Based on analysis of 4 sections of legislative text.
Bans use of dollars‑per‑QALY measures by federal programs and plans, sets Prevention and Public Health Fund amounts for FY2026–FY2031, and requires annual GAO reports on QALY impacts on people with intellectual/developmental disabilities.
Introduced June 10, 2025 by Kat Cammack · Last progress June 10, 2025
Prohibits federal agencies, Medicare, Medicaid, CHIP, Medicare Advantage, Part D plans, Medicaid managed care organizations, and related entities from using dollars‑per‑quality‑adjusted‑life‑year (dollars‑per‑QALY) or similar cost‑per‑health‑utility measures when making coverage, reimbursement, utilization, or incentive decisions, and blocks waiver authorities from overriding that prohibition; the QALY ban takes effect January 1, 2027. Sets specific annual funding amounts for the Prevention and Public Health Fund for FY2026–FY2031 and requires the Comptroller General to report within one year (and annually thereafter) on how QALY use harms people with intellectual and developmental disabilities and their access to care.