The January chat is traditionally a look at what to expect for the new year and what issues will be most prominent. This chat was no different and took a look at what to expect in 2025.

The Community Oncology Alliance’s (COA’s) Executive Director Ted Okon, Managing Director Nick Ferreyros, and Director of Patient Advocacy and Education Rose Gerber prepared advocates for a year of advocacy with insight on key cancer policy issues for 2025. Over the last few years, COA and its advocates have made great headway on significant policy issues, including cancer drug delivery, pharmacy benefit manager (PBM) abuses, and regulations. Ted, Nick, and Rose delivered an update on where these issues stand, who our allies are in the incoming administration and Congress, and what challenges community oncology can expect to face.

What Does the Crystal Ball Say for 2025?

The bottom line is that the crystal ball for 2025 tells us we have no idea what will happen. As a result of the election, the Republicans have control of the White House, a very slim majority in the Senate, and a razor-thin majority in the House.

The big issue and the murkiness of the crystal ball is that the Senate must confirm the nomination for Health and Human Services (HHS) Secretary Robert F. Kennedy, Jr. His nomination has cleared the Senate Finance Committee and has been sent to the full Senate for an imminent vote. Concurrently, Dr. Mehmet Oz, nominated to head the Centers for Medicare and Medicaid (CMS), has yet to have his committee hearings and full Senate vote. Long a proponent of Medicare Advantage, Dr. Oz has also promised to offer programs enabling patients to be more engaged in their health care. The outcome of these nominations has vast implications.

In addition, Elon Musk will head the Department of Government Efficiency (DOGE), which is likely to suggest dividing up some of the huge agencies that are moving people out. That could have profound implications for staffing at HHS and CMS.

These confirmation hearings will start in the Senate Finance Committee, which controls those agencies.

It is important to remember that the proposed initial bipartisan agreed-upon continuing resolution (CR) for funding the government had several provisions that had significant implications for cancer care related to PBMs and PBM transparency. Those were not in the final CR, but what did survive were provisions on telehealth.

Topics on the 2025 Radar

It was a tumultuous end of the year, but two years ago, we were nowhere near as close to PBM reform or dialogue on the 340B program, and there was no discussion on a meaningful “doc fix” for reimbursement payments. Today, we see the result of decades of advocacy, education, and energy investment. COA hopes to make good progress on some of its issues.

It is going to be a busy first 100 days for President Trump. The budget issue will recur in March, and the new administration has promised to make other changes. Amidst all that, part of COA’s job is to ensure its issues stay at the top of the mind.

The First 100 Days

Speaker of the House Johnson has told COA that they will not make the same mistake previous Republican administrations have made of dilly-dallying. He expects to launch into activity very quickly. The big issues will be taxes and immigration. The Republicans can use reconciliation, which allows a simple 50-vote majority rather than a 60-vote majority to overcome a filibuster. It now appears that there will be one big reconciliation bill to address these issues, but it is unclear if there will be health care provisions in that bill.

The scuttle is that the health care bill will be kept separate because these issues have more bipartisan agreement than other issues. Around March 20, a reconciliation bill must be passed to keep the government open. We will know by then if there will be one bill or separate bills.

Power Dynamics at Play

While the Republicans control the executive and legislative branches, the margins are razor slim. This means there will be a negotiated consensus. We talk about our two-party system, but factions on the right, left, and center make things more contentious than a two-party system might imply.

A second-term president, like Trump, is often considered a lame duck from day one because he cannot be elected again. That can mean legislators are less susceptible to presidential pressure to compromise on a reconciliation bill.

PBM Legislation & the “Doc Fix”

After a great deal of work by COA, there has been much bipartisan support for PBM legislation. The new chair of the Senate Finance Committee, Senator Michael Crapo (R-ID), has promised to start moving that legislation. There will be big movement on PBMs.

Congress will have to deal with the “doc fix.” The last time the “doc fix” was introduced, it was retroactive and will probably be retroactive again. As a reminder, in response to CMS’ finalized 2.83 percent physician reimbursement reduction, a bipartisan group of lawmakers introduced the “doc fix” legislation on October 29, 2024.

New Focus on Hospitals, Site Neutrality & 340B

Conversations on rising health care costs are now focusing on hospitals. This goes beyond the issue of 340B to the differing payment rates for hospitals versus physician offices. CMS just published a study in Health Affairs that shows the acceleration in inflation in the hospital sector. We are beginning to see more emphasis on hospital charges and, for the first time, a bipartisan Senate working group on 340B. They will look at site neutrality, meaning the same charge for the same care no matter where it is delivered.

Senator William Cassidy (R-LA), the chairman of the Senate Health, Education, Labor, and Pensions (HELP) Committee, is a physician who has long been a proponent of 340B revisions. One of the driving forces behind 340B legislation was Senator John Thune (R-SD), now the Senate majority leader. Change is likely to occur with the majority leader behind 340B legislation.

Inflation Reduction Act  & Drug Negotiations

It will be very interesting to see how a Republican-led HHS and CMS deal with the Inflation Reduction Act (IRA) and drug price negotiations. There are no Republicans in favor of this, but there is a law governing what action must be taken and when. However, much can be done to slow things down, reevaluate, and even scuttle the process. Senator Crapo said the Senate would take up the IRA.

While campaigning, President Trump said he wanted to see drug prices come down. He has also already said that he doesn’t know who the middlemen are, but he will get rid of them to lower drug prices. That is huge! Instead of talking about the pharmaceutical industry charging too much, the conversation has shifted to the middlemen—PBMs. That is a major shift.

Some aspects of the IRA are very good, such as the $2000 annual drug cap. One of COA’s issues with the IRA is the nature of drug approvals. Drugs, especially cancer drugs, are approved for use for one type of cancer. As time passes, treatment for other types of cancers may be approved. Typically, the last approval is for pediatric use. The IRA did nothing to change that and improve access to treatment for pediatric cancers.

The Stark Mail Order Issue

COA spent much time getting the House to stop CMS from classifying the delivery or pick-up by a caregiver or family member of cancer treatment drugs as a Stark violation. Few thought COA could accomplish this. This was included in the first CR, which blew up and did not pass. COA will ask the two original sponsors of the bill, which had already passed the House, to work with the Senate to reintroduce it or attach it to one of the health care bills that will be considered.

In addition, with a new HHS and CMS, COA has worked with its lawyers to put together a document that says CMS can legally address the Stark issues. COA does not believe that the new administration would want to limit or even stop access to drugs for patients with cancer. Whether through a legislative or regulatory fix, COA is confident this issue can be resolved.

While the lame-duck period was disappointing, there was much discussion about various aspects of cancer care. The result was an “upping” of the discourse about cancer care. While COA would like to see a cancer cure, the belief is that by focusing on the care, a cure will evolve. This reinforces the axiom that showing up to advocate, educate, and dispel inaccuracies and untruths is never-ending. Despite all the conversations from the past, the need continues.

Prescription for Health Care Reform & Future Recommendations

After over a year of work, COA announced the release of the COA Prescription for Health Care Reform, an extensive five-point, 50-page opus that is a blueprint for the 119^th, 120^th, and beyond Congresses. The Prescription for Health Care Reform is a comprehensive blueprint that diagnoses the fundamental challenges facing our health care system, outlines the consequences for patients across America, and presents actionable solutions that Congress must act on now to address these urgent issues. Within this, COA identifies key legislative priorities and recommends “treatments” that ensure patients have access to the highest quality, most affordable, local cancer care.

The plan points to five specific legislative fixes:

• Hospitals and Health System Consolidation
• Insurance and PBMs Consolidation and Market Dominance
• Fixing Physician Reimbursement and Workforce Shortages
• Ensuring Access to Oncology Therapies (Drugs)
• Modernizing Structural CMS Medicare Policies

Each issue underwent an extensive and specific diagnosis, with policy and legislative recommendations that are likely to apply to other areas of health care. There are so many interrelated issues that COA determined that an organized framework was necessary.