Healthcare in the Lame Duck
Lawmakers have returned to Washington for what many observers predict will be a subdued lame duck session. With former President Donald Trump set to return to the White House in January 2025 and Republicans poised to control both chambers of Congress in the new session, the current Democratic-led Congress faces tough decisions about which healthcare priorities can realistically advance before the year ends. Given these shifting dynamics and a continuing resolution set to expire on December 20th, many healthcare stakeholders are closely watching to see if a handful of critical policies—ranging from Medicare telehealth extensions to community health center funding—will receive even short-term relief.
Multiple programs tied to patient access and affordability are slated to expire on December 31, 2024. These include expanded Medicare telehealth flexibilities, community health center (CHC) funding, and measures preventing Medicaid Disproportionate Share Hospital (DSH) payment reductions. Efforts to stabilize Medicare physician payments, address pharmacy benefit manager (PBM) practices, and implement site-neutral payment reforms are also on the table. However, the political uncertainty, combined with constrained legislative days and an incoming administration that may set different healthcare priorities, create a complex landscape for deciding which items are addressed before the new year.
The Broader Political Context
The upcoming change in leadership is already influencing legislative calculations. Republicans, who will soon have unified control in 2025, may choose to defer major reforms or costly extensions until they can shape policy more extensively under the incoming Trump Administration. Analysts suggest that lawmakers will likely focus on minimal, must-pass measures to keep essential programs afloat while leaving more sweeping changes to the next Congress.
Several sources point to a “lamer-than-usual” lame duck session, with meaningful healthcare legislation potentially limited to urgent deadlines. The December 20th government funding cutoff provides a possible vehicle for limited healthcare fixes. Short-term extensions—buying mere months, rather than years—are a likely reality. During this time, people living with chronic conditions, those receiving services at safety-net providers, and people living in rural areas risk seeing uncertainty in care continuity if Congress cannot secure even interim solutions.
The incoming administration’s planned appointments to health agencies and global health leadership changes could realign federal priorities. While the previous administration’s approach emphasized a strong response to public health emergencies, the incoming leadership has signaled greater skepticism toward traditional vaccine policies and may focus less on infectious disease prevention, shifting attention toward other areas of healthcare. As a result, the current Congress may feel pressure to secure patient protections now, anticipating policy moves in 2025 that could reduce certain resources or alter public health strategies.
Must-Pass Healthcare Extensions: Preserving Patient Access Before 2025
Medicare Telehealth Flexibilities
One of the most urgent healthcare priorities involves extending Medicare telehealth flexibilities set to expire on December 31st. Initially expanded during the COVID-19 public health emergency, these provisions have allowed Medicare beneficiaries—including those in rural and underserved communities—to receive certain types of care without the geographic and site restrictions that once applied. The expansion has played a significant role in maintaining continuity of care, especially for behavioral health and chronic disease management services. A House Energy & Commerce Committee proposal would extend these provisions for two years, enabling policymakers to gather more data on telehealth’s cost and quality impact.
A permanent expansion faces a cost barrier. While telehealth enjoys bipartisan support, the price tag remains a challenge to achieving a long-term fix. Thus, a short-term extension appears the most likely outcome. If Congress allows the telehealth provisions to lapse, people who have integrated virtual visits into their healthcare routines—particularly for managing conditions such as HIV—might lose access to services they have come to rely on. This would create new hurdles for maintaining adherence to treatment regimens and managing ongoing care.
Medicare Physician Payment Stabilization
Another pressing issue involves Medicare physician payment rates. Under the current trajectory, doctors face a 2.83% pay cut in 2025—a continuation of multiple consecutive years of reimbursement reductions. Physician groups and bipartisan coalitions in Congress support a Medicare payment stabilization bill that would offset these reductions. Yet cost considerations and the search for budgetary offsets loom large.
Some policymakers view site-neutral payment reforms—discussed later—as a potential “pay-for” to fund these physician payment patches. The prospect of linking physician payment relief with spending cuts elsewhere may shape what Congress accomplishes now. Without a temporary fix, physicians in rural and lower-resource areas might limit the number of Medicare beneficiaries they see, potentially shrinking access to care just as winter months and other public health challenges approach.
Community Health Centers and Safety-Net Providers
CHCs, serving roughly 31 million people, face potential disruptions if their funding authorization expires at year’s end. According to George Washington University research, CHCs often operate on thin margins and rely heavily on federal support. Any gap in funding could mean reduced primary care services, delayed hiring or retention of medical staff, and less capacity to serve people who rely on these centers as their primary healthcare access point.
Medicaid DSH payments, which help hospitals serving people with lower incomes and those living in poverty, also face cuts. Without legislative action, an $8 billion reduction in DSH payments could take effect. Advocacy groups and hospital associations warn that this could erode crucial parts of the healthcare safety net, limiting services at facilities that care for populations disproportionately affected by chronic conditions and economic instability.
The lame duck session provides a narrow window to secure short-term extensions, preserving CHC and Medicaid DSH programs into early 2025. Lawmakers must balance competing priorities, including the need for cost offsets, making it uncertain whether robust, multi-year reauthorizations are possible. With Republicans waiting to implement their policy vision next year, the likely outcome may be modest stopgaps rather than a long-term solution.
Uncertainty for Other Key Programs: Ryan White and PEPFAR
Beyond the well-known year-end deadlines, advocates are also paying attention to larger federal programs that were previously reauthorized but now continue largely through appropriations. The Ryan White HIV/AIDS Program and the President’s Emergency Plan for AIDS Relief (PEPFAR) have historically enjoyed bipartisan support, delivering life-saving care, treatment, and prevention services for people living with HIV in the U.S. and abroad. However, as the next Congress and Administration look to reduce spending, longstanding programs that rely on continued federal investment but lack recent formal reauthorization could come under scrutiny.
Advocates fear that with a new majority eager to trim budgets and revisit healthcare spending priorities, both Ryan White and PEPFAR could face more critical examination. While no immediate action on these programs is expected in the lame duck session, their future stability may depend on how the incoming leadership chooses to address them in the months ahead. This uncertainty raises concerns in public health communities that rely on these programs to maintain progress in HIV prevention, treatment retention, and global health collaborations.
PBM Reform and Drug Pricing: A Fleeting Opportunity?
Pharmacy Benefit Managers have drawn increasing scrutiny from Congress for pricing practices that, according to some analyses, drive up medication costs and limit access to necessary prescriptions. There has been a rare display of bipartisan interest in addressing PBM transparency. The House-passed Lower Costs, More Transparency Act—referenced by Mercer—offers a framework for imposing new reporting requirements on PBMs and prohibiting certain practices like spread pricing in Medicaid.
Recent Federal Trade Commission (FTC) actions against the largest PBMs underscore these concerns. The FTC’s administrative complaint alleges that PBM rebating structures inflate medication costs, impairing access to more affordable alternatives. Policymakers, patient advocates, and public health officials have pointed out that PBM practices may particularly affect people living with HIV and other chronic conditions, who depend on stable access to medications. Restrictions like mandatory mail-order pharmacy rules can disrupt continuity of care, especially for those who require regular medication management.
Still, significant PBM reforms may not pass during the lame duck session. Republicans may prefer to tackle drug pricing and PBM oversight under their upcoming majority, potentially shaping legislation more to their liking. If any PBM-related measures pass now, they will likely serve as incremental changes or as offsets for other healthcare priorities rather than representing the comprehensive reform that some lawmakers and patient advocates seek.
Site-Neutral Payment Reforms: A Budgetary Lever
One of the most closely watched and potentially transformative policy changes up for discussion involves site-neutral payment reforms. Current Medicare regulations often allow higher reimbursements for services delivered at off-campus hospital outpatient departments compared to physician offices or ambulatory surgical centers. Hospitals justify these higher rates based on overhead and regulatory requirements, but policymakers, backed by advisors like the Medicare Payment Advisory Commission (MedPAC), have increasingly called for aligning payments across settings to reduce unnecessary spending.
According to Modern Healthcare reporting, robust site-neutral legislation could save over $100 billion over ten years. This makes the policy attractive as a funding mechanism—lawmakers can use those savings to pay for other priorities like extending telehealth, stabilizing Medicare physician payments, or preserving safety-net funding.
In previous Congresses, only modest site-neutral measures advanced. However, the political environment has changed. Analysts note that with a unified Republican government in 2025, policymakers may be more inclined to pass significant site-neutral reforms to secure long-term savings. During the lame duck session, a narrow measure included in the bipartisan Lower Costs, More Transparency Act—requiring site-neutral payments for certain drug administration services—could move forward as a pay-for. This smaller step might pave the way for broader reforms next year.
Hospitals, supported by the American Hospital Association, strongly oppose site-neutral policies, arguing these cuts would limit their ability to provide comprehensive services. Some advocates worry that reducing hospital outpatient department payments could disproportionately affect rural and underserved areas, threatening access to care if hospitals respond by consolidating or reducing less profitable services. Congress must weigh these concerns against the promise of substantial cost savings. Whether any notable site-neutral measures pass now or wait until next year remains uncertain.
The Upcoming Administration: Implications for Public Health Priorities
By early 2025, incoming administration appointees will shape federal healthcare priorities. As PBS NewsHour reports, the Administration’s picks signal possible skepticism toward established vaccine policies and a shift in public health approach, potentially reducing the emphasis on infectious disease prevention that guided previous eras. Meanwhile, experts warn that changes could weaken U.S. influence on global health initiatives.
This shifting focus could impact ongoing campaigns to address HIV and other chronic or communicable conditions. Without consistent federal direction and robust support, gains made under established programs may not be sustained. Advocates hope that at least some lame duck extensions can preserve the foundation of existing programs—like telehealth and CHCs—helping insulate vulnerable communities from policy swings that may come with new leadership.
Programs like Ryan White and PEPFAR, which have maintained strong bipartisan support in the past, could face new scrutiny in an environment where budget discipline and re-examining unreauthorized programs take center stage, potentially embroiling these critical pillars of HIV care and prevention in broader spending debates.
Navigating Short-Term Extensions and Long-Term Implications
Analysts predict a restrained legislative approach during the lame duck, with lawmakers likely settling for short-term solutions to avert immediate disruptions rather than enacting comprehensive reforms. This approach may feel unsatisfying to those seeking lasting certainty, but it can prevent sudden gaps in coverage and services while buying time to reassess priorities in 2025.
For example, a brief funding extension for CHCs or a short-term continuation of telehealth flexibilities could prevent abrupt care disruptions. Telehealth has already proven critical for expanding access to behavioral health services, and federal agencies have now taken further steps to preserve this access. The U.S. Drug Enforcement Administration (DEA) and U.S. Department of Health and Human Services (HHS) recently extended telemedicine flexibilities for prescribing Schedule II-V controlled substances through the end of 2025. This marks the third extension of pandemic-era policies that allow practitioners to prescribe controlled medications—such as suboxone (used in opioid use disorder treatment)—via telemedicine without an in-person evaluation. Retaining these flexibilities, even if temporary, helps sustain harm reduction efforts and essential treatment access for those managing substance use disorders.
A modest Medicare physician payment patch could also preserve provider participation while deeper structural reforms are debated. On the revenue side, modest site-neutral tweaks may generate savings to fund these stopgaps without forcing lawmakers to finalize wide-ranging changes immediately.
Meanwhile, Democrats have floated extending Affordable Care Act subsidies in a potential year-end health deal that also includes telehealth extensions and incremental improvements in physician reimbursements. Such proposals face uncertainty as Republicans prepare to take full control in 2025, but even short-term deals could maintain coverage gains and service expansions that benefit people managing chronic conditions and those relying on affordable insurance options.
Given the incoming administration’s focus on spending and efficiency, it may be prudent for stakeholders to identify areas where reducing waste, redundancy, or abuse is possible—particularly within large, long-standing programs. Offering proactive solutions aligned with fiscal priorities, while demonstrating that essential services remain intact, could help preserve support for programs like Ryan White. This approach allows advocates to show policymakers that sustained funding can go hand-in-hand with accountability and cost-effectiveness, paving the way for more secure, long-term access to critical healthcare services.
Actions for Advocates and Public Health Officials
Engage Legislators Before December 20th:
With deadlines looming, advocates can communicate the importance of even short-term extensions for telehealth, CHC funding, and Medicare physician payment stabilization. Stressing the immediate impact of allowing these programs to expire can help secure stopgap measures.
Highlight Evidence and Outcomes:
Data-driven arguments can persuade legislators that certain policies merit continued investment. For example, demonstrating that telehealth has improved access in rural areas or that CHCs reduce costly emergency department visits can make a compelling case for sustained support.
Prepare for 2025 Debates:
The new Congress will likely reassess programs ranging from telehealth expansions to broader HIV initiatives like Ryan White and PEPFAR. Advocates should cultivate coalitions and gather patient stories now, ensuring they can respond effectively to future proposals that may challenge established healthcare priorities. By proactively preparing data and first-person accounts, stakeholders can better influence upcoming debates.
Monitor Agency Leadership and Policy Shifts:
Staying informed about new federal health agency leaders and their public statements helps anticipate changes in priorities. Understanding where the Administration might diverge from past practice can help advocates and providers design strategies to maintain access and care quality—even if federal emphasis shifts away from certain public health initiatives.
Conclusion
December 2024 places the U.S. healthcare landscape at a turning point. The lame duck session unfolds under a cloud of political transition, with an incoming administration and unified Republican control set to reshape policy debates. Lawmakers face a stacked agenda of expiring programs and urgent healthcare needs but may opt only for minimal extensions that maintain the status quo for now.
Decisions made in these final weeks of 2024—from temporary telehealth fixes to short-term CHC funding—will determine how seamlessly care continues into the new year. As Congress weighs sites of service, physician reimbursements, PBM practices, and the future of critical programs like Ryan White and PEPFAR, advocates must remain engaged. The approaching shift in power and priorities adds urgency to even the smallest policy wins now, as they may offer a critical foundation to protect patient access and maintain progress on significant public health initiatives in a potentially more challenging political climate.
Upholding Our Ethical, Moral, and Bipartisan Commitment to HIV/AIDS
"Where your treasure is, there your heart will be also."
These words from Jesus found in Matthew 6:21 resonate profoundly as we examine the current legislative actions on HIV/AIDS funding in the U.S. Congress. It is hard to imagine forty years into the epidemic that we’d be witnessing a systemic attack on numerous HIV-related programs, especially ones with proven track records of success. The House L-HHS Appropriations Bill (H.R. 5894), proposing a staggering $767 million in cuts to domestic HIV programs, starkly contradicts the values of compassion and faith professed by certain lawmakers. These cuts, detailed by the AIDS Budget and Appropriations Coalition (ABAC), threaten to dismantle decades of public health progress, disproportionately impacting marginalized communities, minorities, and the LGBTQIA+ community. The appropriations bill is only the tip of the iceberg.
The irony of these legislative actions is both profound and deeply troubling. Lawmakers, often vocal about their 'pro-life' stance, are endorsing policies that will cause significant harm to millions of Americans dependent on HIV services. This bill represents more than just fiscal adjustments; it's a direct attack on the services and supports afforded to people living with HIV (PLWH), reflecting a worldview that stigmatizes and punishes rather than supports and heals. This approach starkly betrays the bipartisan legacy of the HIV/AIDS fight, which brought together the ideological opposites of the late Senators Orrin Hatch (R-UT) and Edward Kennedy (D-MA).
The bill's proposed eliminations include funding for the bipartisan Trump-era Ending the HIV Epidemic Initiative, the Ryan White HIV/AIDS Program, and the Community Health Centers Program. Alarmingly, it suggests completely eliminating Part F of the Ryan White HIV/AIDS Program (RWHAP), which supports critical components like Dental Programs and AIDS Education and Training Centers. Additionally, the bill proposes a 53% cut in the Minority HIV/AIDS Fund and the total elimination of Minority AIDS Initiative funding within the Substance Abuse and Mental Health Services Administration.
But the attack isn’t exclusive to domestic programs combating HIV/AIDS.
The stalemate over the reauthorization of the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), as highlighted in a recent POLITICO article, further exemplifies the moral failure of the Freedom Caucus – which is driving most of the vitroil behind these proposed cuts. Disputes over abortion and a blatantly bigoted reluctance to aid Africa have jeopardized the most successful global health initiatives of our time.
“I’m disappointed,” Rep. Michael McCaul (R-Texas) told POLITICO. “Honestly, I was looking forward to marking up a five-year reauthorization, and now I’m in this abortion debate.” Additionally, he said, “a lot of the Freedom Caucus guys would not want to give aid to Africa.”
Jen Laws (he/him/his), President & CEO of the Community Access National Network (CANN), poignantly captures this duplicity in a tweet: “HIV is a bipartisan issue and always has been. May those who wish to insert their culture war politics onto this historical space enjoy their moral rot for as long as the spotlight lasts because the sense of power certainly won't.”
We stand at a critical crossroads, not merely facing a policy challenge but a profound moral crisis. The battle against HIV/AIDS reflects our societal values of empathy, compassion, and collective responsibility. The proposed cuts and the deadlock over PEPFAR reauthorization challenge the very foundations of equity and justice, calling for a decisive response to maintain the fragile progress made in HIV/AIDS care and prevention. These cuts are not distant policy changes; they are immediate threats to lives and well-being, demanding our urgent attention and action.
Critical Juncture
RWHAP and PEPFAR stand at a critical juncture, pivotal to the global and domestic response to HIV/AIDS. The Ryan White Program, a testament to America's commitment to combating HIV/AIDS, is under threat from the proposed House L-HHS Appropriations Bill (H.R. 5894), which includes significant funding cuts. Concurrently, PEPFAR, a global beacon in the fight against HIV/AIDS and the largest commitment by any nation to address a single disease, faces legislative hurdles that could impede its future effectiveness.
The Ryan White Program has been a cornerstone in achieving a 90% viral suppression rate among its clients, as reported by the Health Resources and Services Administration (HRSA). PEPFAR, on the other hand, has been instrumental in saving 25 million lives and supporting over 5 million infants born HIV-free, providing antiretroviral treatment to over 20 million people across 55 countries. This program has played a crucial role in significantly reducing new HIV infections worldwide.
The potential funding cuts under H.R. 5894 pose a severe risk to the Ryan White Program's continued success in the United States, especially in light of the 12% decline in new HIV infections from 2017 to 2021. The reauthorization stalemate of PEPFAR underscores the moral failure of certain lawmakers, who, despite their 'pro-life' claims, are obstructing a program that has been a lifeline for millions globally.
Comprehensive Strategy is Key
The achievements made over the last four decades in the fight against HIV/AIDS underline the necessity of a comprehensive strategy. The increase in PrEP prescriptions in the United States and the high rate of viral suppression achieved through treatment as prevention exemplify the effectiveness of a holistic approach, encompassing treatment, prevention, care, and support services. It is crucial that policymakers and the public recognize the importance of these programs and advocate for their continued support, ensuring the progress in combating HIV/AIDS is not only maintained but also advanced. Time is of the essence to embrace and implement a comprehensive HIV/AIDS strategy that goes beyond mere treatment to encompass prevention, care, and support.
Challenging Extremism and Fostering Advocacy
The battle against H.R. 5894 transcends mere policy disagreements. It represents a stand against a form of political extremism that poses a grave threat to marginalized populations, including people living with HIV/AIDS. These proposed cuts, in stark contrast to the proclaimed pro-life stance of the very lawmakers pushing them, unveil a troubling hypocrisy reminiscent of the words of Jesus in Matthew 23:27-28: "Woe to you, teachers of the law and Pharisees, you hypocrites! You are like whitewashed tombs, which look beautiful on the outside but on the inside are full of the bones of the dead and everything unclean."
Just as Jesus admonished the outwardly righteous but inwardly corrupt, these policies, under the guise of fiscal prudence, risk causing significant harm to the most vulnerable, particularly PLWH, minorities, and the LGBTQIA+ community. The stark contrast between the proclaimed values and the actual legislative actions of these lawmakers echoes the biblical warning against such duplicity. The time to stand against this political extremism is now. We cannot afford to be bystanders as these policies threaten to unravel decades of progress.
A Resounding Call to Action:
This critical juncture calls for a united, nonpartisan response from all who value public health, health equity, and human dignity. Health and human dignity are not political weapons to be wielded in service of talking points when lives hang in the balance. We urge individuals and organizations across the political spectrum to join the Southern AIDS Coalition in their efforts to push back against these cuts by signing their letter. Your voice and actions are crucial in shaping the future of HIV/AIDS policy and ensuring our continued progress towards Ending The Epidemic.
There are easy to use tools to contact your congressional representation in Congress. Not sure of your congressional district or who your member of the U.S. House of Representatives is? This service will assist you by matching your ZIP code to your congressional district, with links to your member's website and contact page. Or complete this online form to find your two U.S. Senators.
Now is the time to reaffirm our bipartisan commitment to fighting HIV/AIDS. This battle is not just about preserving past achievements; it is about resolutely advancing our collective efforts against HIV/AIDS. Your involvement is not just beneficial; it is essential. By standing together, regardless of political affiliation, we can overcome these challenges and continue our journey towards a world free from HIV/AIDS. Act now, for this fight is about life, justice, and human dignity. Your voice and action are indispensable in this crucial hour.