H.R. 3864: Protecting Health Care for All Patients Act of 2025

This bill, known as the Protecting Health Care for All Patients Act of 2025, aims to amend the Social Security Act specifically to prohibit the use of "quality-adjusted life years" (QALYs) and similar measures when determining coverage and payment in federal health care programs. Here’s a summary of its key provisions:

Prohibition on Quality-Adjusted Life Years (QALYs)

The bill seeks to make it illegal for federal health agencies or state programs to use QALYs in their decision-making for health care coverage. QALYs are a method used to evaluate the value of medical interventions by measuring the quality and quantity of life they provide. The bill specifies that extending life for elderly, disabled, or terminally ill individuals cannot be seen as having less value compared to extending life for younger, non-disabled individuals.

Changes to Federal Health Programs

• The bill prohibits federal agencies, including the Center for Medicare and Medicaid Innovation, from using QALYs in coverage determinations for all federal health care programs.
• It makes specific amendments to the Social Security Act that apply to Medicare and Medicaid, ensuring that these programs cannot use QALYs when making decisions about covered services or payment rates.

Provisions Affecting Medicaid and CHIP

In particular, it details that Medicaid managed care organizations and Child Health Insurance Program (CHIP) plans must also comply with this prohibition against using QALYs. This means that state Medicaid plans cannot base decisions about services and reimbursements on QALYs or related metrics.

Implementation Timeline

The changes proposed by the bill are set to take effect on January 1, 2027, allowing time for the necessary adjustments within federal and state health programs.

Funding Adjustments

The bill also modifies the allocations for the Prevention and Public Health Fund established by the Affordable Care Act. It sets specific funding amounts for fiscal years 2026 through 2031, ensuring increased funding over the years.

Reporting Requirement

Finally, the bill mandates an annual report by the Comptroller General of the United States to Congress about how the use of QALYs adversely affects people with intellectual and developmental disabilities and their access to health care services. This is intended to ensure ongoing evaluation and attention to the potential negative impacts of such metrics.

Relevant Companies

None found