国会预算办公室关于医疗保险D部分预测的进展

Honorable Jason SmithChairmanCommittee on Ways and MeansU.S. House of RepresentativesWashington, DC 20515 Honorable Jodey ArringtonChairmanCommittee on the BudgetU.S. House of RepresentativesWashington, DC 20515 Honorable Brett GuthrieChairmanCommittee on Energy andCommerceU.S. House of RepresentativesWashington, DC 20515 Re: Developments in CBO’s Projections for Medicare Part D Dear Chairman Arrington, Chairman Guthrie, and Chairman Smith: You have asked the Congressional Budget Office to describe and explainupdates to spending projections published inThe Budget and EconomicOutlook: 2026 to 2036.1In particular, you requested information concerningCBO’s original estimates and current projections of the budgetary effects ofprovisions of the 2022 reconciliation act (PublicLaw 117‑169) that affectMedicare Part D, the prescription drug program.2 The 2022 reconciliation act contains three major provisions affectingprescription drug prices and coverage: drug price negotiation, which requiresthe Department of Health and Human Services (HHS) to negotiate pricesdirectly with manufacturers for selected high-expenditure drugs; inflation Honorable Jodey ArringtonHonorable Jason SmithHonorable Brett GuthriePage 2 rebates, which manufacturers must pay if increases in their drug pricesoutpace inflation; and a redesign of Part D to cap enrollees’ annual out-of-pocket costs, limit premium increases, and shift more financial liability toplans and manufacturers.3 In September 2022, following the enactment in August, CBO projected thatenacting those provisions would lead to combined deficit reductions of$129 billion over the 2022–2031 period.4At the time, CBO estimated that by2026, the reductions in direct spending stemming from the first two provisionswould more than offset increases associated with enacting the third. Since then, on the basis of new information, CBO has revised its projections.Evidence now indicates that the spending reductions attributable to drug pricenegotiation and inflation rebates have been smaller than CBO originallyestimated. The costs of the Part D redesign have been significantly largerbecause of greater-than-anticipated increases in spending because of greateruse of prescription drugs. As a result, the agency now projects that those provisions will combine toincrease deficits over the 2022–2031 period. This letter provides information about the following topics: •CBO’s original estimate of the 2022 reconciliation act, the evidenceused to inform that estimate, and key sources of uncertainty;•Initial effects of the price negotiation and inflation rebate provisions;•The effects of the Part D redesign; and•Ongoing updates to CBO’s models, including increases in CBO’sprojections for Part D to account for recent experience withimplementing the act’s Part D provisions. Honorable Jodey ArringtonHonorable Jason SmithHonorable Brett GuthriePage 3 Original Estimate of the Budgetary Effects of Drug Provisionsin the 2022 Reconciliation Act CBO originally estimated that a $99 billion reduction attributable to new drugprice negotiation and a $63 billion reduction attributable to the inflation rebateprovision would combine over 10 years to more than offset the estimated$30 billion increase in deficits attributable to the Part D redesign. The estimatealso included $3 billion in costs for implementation. How CBO Estimated the Provisions’ Budgetary Effects.In estimating thebudgetary effects of drug price negotiation, CBO expected that in some cases,HHS would have sufficient leverage to negotiate prices below the maximumamounts established by law. The new upper limits on prices, combined withthat leverage, led CBO to estimate that net prices for drugs selected fornegotiation would decline by roughly 50 percent, on average.5 CBO estimated that the inflation rebate provision would generate budgetarysavings in part through collections of rebates on certain single-source, brand-name drugs whose prices exceeded inflation-adjusted benchmarks and in partthrough lower spending on drugs whose manufacturers reduced net prices toavoid paying those rebates. CBO expected the effects to vary depending onrebate amounts and whether a drug was already on the market at the time ofthe law’s enactment. CBO expected several aspects of the Part D redesign to increase deficits.Some elements, including larger federal subsidies for Part D plans, wereexpected to increase federal spending as those plans assumed a greater portionof drug costs. Other outcomes included increased federal spending associatedwith limits on growth in base premiums (the average amount paid monthly byenrollees based on expected average benefit costs for all Part D enrollees) andenrollees’ increased use of prescription drugs because of reductions in theirout-of-pocket costs. Sources of Uncertainty in the Original Estimates.CBO’s original estimateshad several important sources of uncertainty, including what price reductionswould be achieved through ne