Federal Health Policy Landscape: What Might Happen during the Lame Duck Congress?

At a Glance

• A small but important group of health extenders lapse at the end of 2026, in addition to other bills that are of high import. High on this list is legislation to prevent looming reductions to Medicare payments to physicians, a priority topic for the physician lobby.
• A large set of bills is awaiting action to get across the goal line, but only a handful are considered "must pass" and the results of the midterm elections will ultimately determine how much or how little gets accomplished during the lame duck session.
• Anticipate a fluid and unpredictable landscape and a need for active and sustained engagement to advance priorities before the 119th Congress comes to a close.

As we inch closer to Election Day, a major question for health policy advocates even before what lies ahead in the next Congress is: How much — or how little — will get done during the postelection or lame duck session of Congress?

As with all such sessions, the outcome of the midterm elections will influence the scope of the session, especially as parties assess who will be sitting where come January and what they should or should not seek to accomplish during the remainder of the current 119th Congress.

While the scope of the lame duck remains to be determined, the landscape can be broken down into a few key categories. The first category is the truly "must pass" legislation that Congress has to act on, followed by the lengthy list of bills that have been making progress throughout this Congress and now need to get over the finish line, especially the legacy items retiring members want to complete before they leave. The final category would be the wildcards whose path forward is unlikely but that still merit attention.

Must-Pass Bills

Atop the "must-pass" list is legislation to fund the federal government after the current temporary spending bill expires on December 11. While the House has advanced several spending bills so far this year, the appropriations process in the Senate has been stunted, given lack of agreement on top-line spending numbers as well as partisan politics with Senate Appropriations Committee Chair Susan Collins (R-ME), engaged in a reelection campaign rated as a toss-up.

A major question will be whether the parties will be incented to come together to enact one or more packages of spending bills (e.g., an omnibus or minibuses) and whether that can be done by the end of the year.

Barring that, the fallback may be a subsequent temporary spending bill, or continuing resolution (CR), punting the deadline into the first quarter and leaving the new 120th Congress — and whoever leads the key spending panels — to resolve fiscal year (FY) 27.

Another scenario could be a fairly straightforward year-long continuing resolution that would essentially fund the government at current FY 26 levels until next September. Importantly, a year-long CR would scuttle funding for the myriad community projects or earmarks that have been submitted for FY 27, forcing would-be recipients to wait for another cycle, an outcome that would not be attractive to members of Congress who have secured funding for a bevy of district projects in these bills.

Beyond funding the government, the list of truly must-pass health measures is modest, thanks in part to Congress acting earlier this year by enacting a year-end like package of bills via the Consolidated Appropriations Act signed into law in February. This law contained a number of traditional "health extenders", such as extending COVID-era telehealth flexibilities within Medicare, as well as other longstanding policy priorities, such as Pharmacy Benefit Manager (PBM) reforms, many of which were teed up for action in late 2024 but scuttled after aggressive opposition by Elon Musk, then an informal advisor to President-Elect Trump.

A small but important group of health extenders do lapse at the end of 2026, in addition to other bills that are of high import. High on this list is legislation to prevent looming reductions to Medicare payments to physicians, a priority topic for the physician lobby. Programs that need their funding extended include Community Health Centers, the National Health Service Corps, and Teaching Health Center Graduate Medical Education (GME) programs as well as the Special Diabetes Program.

Pending Legislation

This category encompasses bills that have made progress throughout the Congress, such as advancing through the committee process or even a chamber, but that need a final nudge to avoid having to be reintroduced in the new Congress. These bills typically enjoy bipartisan support and have cleared the agency (technical assistance) and cost (Congressional Budget Office score) gauntlet.

Bills to reauthorize public health measures as well as to strengthen health care price transparency policies, to ease barriers to generic drug entry to market, to delay the controversial 340B rebate model pilot program, to more fully address looming reductions to Medicare physician payment rates, and other measures are in a long list of pending legislation.

The category also includes bills led by outgoing members of Congress looking for one last legislative victory before they leave Washington. This list, already fairly long, could grow further depending on the outcome of the election, and the set of issues can run from the fairly cut-and-dry to major proposals such as those to limit the out-of-pocket cost of insulin or expand access to hepatitis C medications via a subscription-type model.

Wildcards

The wildcard category would include measures unlikely to pass but that could catch fire, particularly in a very dynamic and expansive lame duck session.

In the health policy space, the list could include legislation to reform the long-struggling Independent Dispute Resolution (IDR) system instituted under the No Surprises Act as well as changes to the 340B drug discount program, or proposals to institute additional site-neutral payment policies or additional requirements for nonprofit hospitals. Each of these faces an uphill climb, but cannot be completely discounted.

For example, Congress and the administration have increased their scrutiny of the 340B safety net program. Three competing proposals emerged this summer: a discussion draft from outgoing Senate HELP Chair Bill Cassidy (R-LA); the bipartisan SECURE 340B Act (H.R. 9599), led by House Energy and Commerce members Representatives Joyce (R-PA) and Peters (D-CA); and the bipartisan SUSTAIN 340B Act, introduced by Senate 340B working group members Senators Capito (R-WV), Baldwin (D-WI), Moran (R-KS), Kaine (D-VA), Boozman (R-AR), and Hickenlooper (D-CO).

The proposals generally agree on the definition of a 340B "patient" but differ on the most contentious issues, including contract pharmacy limits and manufacturer rebate models. Although enactment is unlikely given the limited time remaining in this Congress, the proposals set the stage for debate in the 120th Congress.

Finally, we expect continued discussion of possible additional reconciliation measures, particularly in an environment where Republicans lose control of one or both chambers of Congress and want to enact party line priorities before they lose the opportunity to do so.

But while some will want to pursue use of reconciliation aggressively while they still can, the political realities that have made reconciliation challenging throughout this Congress will most likely be exacerbated further during the lame duck, dimming the likelihood of action. These include the potential for retiring or defeated members to spend limited time in Washington postelection as well as reticence of defeated members to take further action on topics like Medicaid and health care, making an already slim majority smaller or nonexistent.

Conclusion

The lame duck session will bring about opportunities and challenges and will likely maintain the uncertainty and fluidity that has dominated the 119th Congress and Washington more broadly over the past several years. For those looking to advance measures over the goal line, active and sustained engagement over the weeks ahead will be necessary.