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I reproduce the exhaustive list from The National Center for Transgender Equality (The Discrimination Administration)TLDR: About 77 other things listed below like permitting discrimination by homeless shelters (July 23, 2020) - Please Vote!Anti-Transgender and Anti-LGBTQ ActionsJuly 23, 2020: The Department of Housing and Urban Development formally announced the rollback of a previous rule that protected transgender people from discrimination by homeless shelters and other housing services receiving federal funds.June 19, 2020: The Department of Health and Human Services announced that it finalized the extensive rollback of health care discrimination rules, to eliminate the protections for transgender people experiencing discrimination in health care settings and/or by insurance companies denying transition-related care, as well as to weaken nondiscriminatory access to health care for those with Limited English Proficiency.May 15, 2020: The Department of Education issued a letter declaring that the federal Title IX rule requires school to ban transgender students from participating in school sports, and threatening to withhold funding from Connecticut schools if they do not comply.May 8, 2020: The Department of Health and Human Services published a final rule eliminating collection of sexual orientation data on foster youth and foster and adoptive parents and guardians and rejecting proposals to collect gender identity data.May 6, 2020: The Department of Education published a final rule encouraging schools to dramatically weaken protections for student survivors of sexual violence and harassment, and eliminating a provision that encouraged religiously-affiliated schools to notify the Department and the public of their intent to discriminate on the basis of sex under a Title IX waiver.March 26, 2020: The Department of Justice filed a court brief in the District of Connecticut in opposition to a Connecticut Interscholastic Athletic Conference policy that allows transgender athletes to play sports with their peers.February 27, 2020: The Department of Justice filed another court brief, this time in the Western District of Kentucky, expressing the view of the United States that anti-LGBTQ discrimination is not "a sufficient government interest" to overcome the objections of private businesses who want to deny "expressive" services such as photography services to LGBTQ people, and that these businesses must be permitted to opt out of complying with local nondiscrimination laws.January 16, 2020: Nine federal agencies - Departments of Agriculture, Education, Health and Human Services, Homeland Security, Housing and Urban Development, Justice, Labor, and Veterans Affairs, and the U.S. Agency on International Development - all proposed rule changes that would eliminate the rights of people receiving help from federal programs to request a referral if they have a concern or problem with a faith-based provider and to receive written notice of their rights; and that would encourage agencies to claim religious exemptions to deny help to certain people while receiving federal funds.November 5, 2019: The Department of Labor proposed to exempt the TRICARE health care program for military dependents and retirees from requirements not to discriminate on the basis of sexual orientation or gender identity. It is not immediately apparent whether TRICARE intends to make any changes in its benefits policies. Currently, TRICARE covers hormone therapy and counseling for transgender retirees and dependents, but DOD interprets the TRICARE statute to exclude transition-related surgery regardless of medical necessity.=November 1, 2019: The Department of Health and Human Services announced it would not enforce, and planned to repeal, regulations prohibiting discrimination based on gender identity, sexual orientation, and religion in all HHS grant programs. These include programs to address the HIV, opioid, and youth homelessness epidemics, as well as hundreds of billions of dollars in other health and human service programs.November 1, 2019: The Department of Education published final regulations permitting religious schools to ignore nondiscrimination standards set by accrediting agencies.September 19, 2019: The Department of Health and Human Services cancelled a plan to explicitly prohibit hospitals from discriminating against LGBTQ patients as a requirement of Medicare and Medicaid funds.August 16, 2019: The Department of Justice filed a brief in the U.S. Supreme Court arguing that federal law “does not prohibit discrimination against transgender persons based on their transgender status.”August 14, 2019: The Department of Labor announced a proposed rule that would radically expand the ability of federal contractors to exempt themselves from equal employment opportunity requirements, allowing for-profit and non-profit employers to impose “religious criteria” on employees that could include barring LGBTQ employees.July 15, 2019: The Departments of Justice and Homeland Security announced an interim final rule that would block the vast majority of asylum-seekers from entering the United States, with deadly consequences for those fleeing anti-LGBTQ violence.July 8, 2019: The Department of State established a “Commission on Unalienable Rights” aimed at narrowing our country’s human rights advocacy to fit with the “natural law” and “natural rights” views of social conservatives, stating it would seek to “be vigilant that human rights discourse not be corrupted or hijacked or used for dubious or malignant purposes.” (Shortly thereafter, the State Department official tasked with coordinating the new commission was fired for “abusive” management including homophobic remarks.)July 3, 2019: The Department of Housing and Urban Development removed requirements that applicants for homelessness funding maintain anti-discrimination policies and demonstrate efforts to serve LGBT people and their families, who are more likely to be homeless.May 24, 2019: The Department of Health and Human Services published a proposed rule that would remove all recognition that federal law prohibits transgender patients from discrimination in health care. Courts across the nation have ruled otherwise.May 22, 2019: The Department of Housing and Urban Development (HUD) announced a plan to gut regulations prohibiting discrimination against transgender people in HUD-funded homeless shelters.May 14, 2019: President Trump announced his opposition to the Equality Act (H.R. 5), the federal legislation that would confirm and strengthen civil rights protections for LGBTQ Americans and others.May 2, 2019: The Department of Health and Human Services published a final rule encouraging hospital officials, staff, and insurance companies to deny care to patients, including transgender patients, based on religious or moral beliefs. This vague and broad rule was immediately challenged in court.April 19, 2019: The Department of Health and Human Service announced a proposed rule to abandon data collection on sexual orientation of foster youth and foster and adoptive parents and guardians.April 12, 2019: The Department of Defense put President Trump’s ban on transgender service members into effect, putting service members at risk of discharge if they come out or are found out to be transgender.March 13, 2019: The Department of Defense laid out its plans for implementing its ban on transgender troops, giving an official implementation date of April 12.January 23, 2019: The Department of Health & Human Services' Office of Civil Rights granted an exemption to adoption and foster care agencies in South Carolina, allowing religiously-affiliated services to discriminate against current and aspiring LGBTQ caregivers.November 23, 2018: The U.S. Office of Personnel Management (OPM) erased critical guidance that helped federal agency managers understand how to support transgender federal workers and respect their rights, replacing clear and specific guidance reflecting applicable law and regulations with vaguely worded guidance hostile to transgender workers. While this guidance change did not change the rights of transgender federal workers under applicable law, regulations, Executive Orders, and case law, it is likely to cause confusion and promote discrimination within the nation's largest employer.November 19, 2018: The Department of State appealed a court order directing it to issue a passport with a gender-neutral designation to a non-binary, intersex applicant.October 25, 2018: U.S. representatives at the United Nations worked to remove references to transgender people in UN human rights documents.October 24, 2018: The Department of Justice submitted a brief to the Supreme Court aruging that it is legal to discriminate against transgender employee, contradicting court rulings that say protections under Title VII in the workplace don’t extend to transgender workers.October 21, 2018: The New York Times reported that the Department of Health and Human Services proposed in a memo to change the legal definition of sex under Title IX, which would would leave transgender people vulnerable to discrimination.August 10, 2018: The Department of Labor released a new directive for Office of Federal Contract Compliance Programs (OFCCP) staff encouraging them to grant broad religious exemptions to federal contractors with religious-based objections to complying with nondiscrimination laws. It also deleted material from an OFCCP FAQ on LGBT nondiscrimination protections that previously clarified the limited scope of allowable religious exemptions.June 11, 2018: Attorney General Jeff Sessions ruled that the federal government would no longer recognized gang violence or domestic violence as grounds for asylum, adopting a legal interpretation that could lead to rejecting most LGBT asylum-seekers.May 11, 2018: The Bureau of Prisons in the Department of Justice adopted an illegal policy of almost entirely housing transgender people in federal prison facilities that match their sex assigned at birth, rolling back existing protections.April 11, 2018: The Department of Justice proposed to strip data collection on sexual orientation and gender identity of teens from the National Crime Victimization Survey.March 23, 2018: The Trump Administration announced an implementation plan for its discriminatory ban on transgender military service members.March 20, 2018: The Department of Education reiterated that the Trump administration would refuse to allow transgender students to use bathrooms and locker rooms based on their gender identity, countering multiple court rulings reaffirming that transgender students are protected under Title IX.March 5, 2018: The Department Housing and Urban Development Secretary announced a change to its official mission statement by removing its commitment of inclusive and discrimination-free communities from the statement.February 18, 2018: The Department of Education announced it will summarily dismiss complaints from transgender students involving exclusion from school facilities and other claims based solely on gender identity discrimination.January 26, 2018: The Department of Health and Human Services proposed a rule that encourages medical providers to use religious grounds to deny treatment to transgender people, people who need reproductive care, and others.January 18, 2018: The Department of Health and Human Services' Office of Civil Rights opened a "Conscience and Religious Freedom Division" that will promote discrimination by health care providers who can cite religious or moral reasons for denying care.December 29, 2017: President Trump fired the White House Presidential Advisory Council on HIV/AIDS. The transgender community is disproportionately affected by HIV.December 20, 2017: President Trump nominated Gordon P. Giampietro to serve as a United States District Judge of the United States District Court for the Eastern District of Wisconsin. Giampietro called marriage equality “an assault on nature.” Giampietro's nomination was eventually withdrawn.December 14, 2017: Staff at the Centers for Disease Control and Prevention were instructed not to use the words “transgender,” “vulnerable,” “entitlement,” “diversity,” “fetus,” “evidence-based,” and “science-based” in official documents.October 6, 2017: The Justice Department released a sweeping "license to discriminate" allowing federal agencies, government contractors, government grantees, and even private businesses to engage in illegal discrimination, as long as they can cite religious reasons for doing so.October 5, 2017: The Justice Department released a memo instructing Department of Justice attorneys to take the legal position that federal law does not protect transgender workers from discrimination.October 2, 2017: President Trump nominated Kyle Duncan to serve as a United States Circuit Judge of the United States Court of Appeals for the Fifth Circuit. Duncan has dedicated his career to limiting the rights of transgender people, and even defended the anti-trans parties in the North Carolina’s infamous HB2 debacle and the school district that discriminated against Gavin Grimm.September 7, 2017: The Justice Department filed a legal brief on behalf of the United States in the U.S. Supreme Court, arguing for a constitutional right for businesses to discriminate on the basis of sexual orientation and, implicitly, gender identity.September 7, 2017: President Trump nominated Gregory G. Katsas to serve as a United States Circuit Judge of the United States Court of Appeals for the District of Columbia Circuit. Katsas played a central role in helping Trump ban qualified transgender people serving in the miiltary.September 7, 2017: President Trump nominated Matthew J. Kacsmaryk to serve as a United States District Judge of the United States District Court for the Northern District of Texas. Kacsmaryk opposes LGBTQ protections in housing, employment, & and health care, and called transgender people a “delusion.”September 7, 2017: President Trump nominated Jeff Mateer to become a United States District Judge of the United States District Court for the Eastern District of Texas. Mateer called transgender children part of “Satan’s plan” and openly supported debunked and dangerous “conversion therapy.” Mateer’s nomination was eventually withdrawn.August 25, 2017: President Trump released a memo directing Defense Department to move forward with developing a plan to discharge transgender military service members and to maintain a ban on recruitment.July 26, 2017: President Trump announced, via Twitter, that "the United States Government will not accept or allow Transgender individuals to serve in any capacity in the U.S. Military."July 26, 2017: The Justice Department filed a legal brief on behalf of the United States in the U.S. Court of Appeals for the Second Circuit, arguing that the 1964 Civil Rights Act does not prohibit discrimination based on sexual orientation or, implicitly, gender identity.July 13, 2017: President Trump nominated Mark Norris to the United States District Court for the Western District of Tennessee. Norris has worked to make it easier to discriminate against LGBTQ people, and even worked to discriminate specifically against transgender kids.June 14, 2017: The Department of Education withdrew its finding that an Ohio school district discriminated against a transgender girl. The Department gave no explanation for withdrawing the finding, which a federal judge upheld.May 2, 2017: The Department of Health and Human Services (HHS) announced a plan to roll back regulations interpreting the Affordable Care Act’s nondiscrimination provisions to protect transgender people.April 14, 2017: The Justice Department abandoned its historic lawsuit challenging North Carolina’s anti-transgender law. It did so after North Carolina replaced HB2 with a different anti-transgender law known as “HB 2.0.”April 4, 2017: The Departments of Justice and Labor cancelled quarterly conference calls with LGBT organizations; on these calls, which had happened for years, government attorneys shared information on employment laws and cases.March 31, 2017: The Justice Department announced it would review (and likely seek to scale back) numerous civil rights settlement agreements with police departments. These settlements were put in places where police departments were determined to be engaging in discriminatory and abusive policing, including racial and other profiling. Many of these agreements include critical protections for LGBT people.March 2017: The Department of Housing and Urban Development (HUD) removed links to four key resource documents from its website, which informed emergency shelters on best practices for serving transgender people facing homelessness and complying with HUD regulations.March 28, 2017: The Census Bureau retracted a proposal to collect demographic information on LGBT people in the 2020 Census.March 24, 2017: The Justice Department cancelled a long-planned National Institute of Corrections broadcast on “Transgender Persons in Custody: The Legal Landscape.”March 13, 2017: The Department of Health and Human Services (HHS) announced that its national survey of older adults, and the services they need, would no longer collect information on LGBT participants. HHS initially falsely claimed in its Federal Register announcement that it was making “no changes” to the survey.March 13, 2017: The State Department announced the official U.S. delegation to the UN’s 61st annual Commission on the Status of Women conference would include two outspoken anti-LGBT organizations, including a representative of the Center for Family and Human Rights (C-FAM): an organization designated as a hate group by the Southern Poverty Law Center.March 10, 2017: The Department of Housing and Urban Development (HUD) announced it would withdraw two important agency-proposed policies designed to protect LGBT people experiencing homelessness. One proposed policy would have required HUD-funded emergency shelters to put up a poster or "notice" to residents of their right to be free from anti-LGBT discrimination under HUD regulations.The other announced a survey to evaluate the impact of the LGBTQ Youth Homelessness Prevention Initiative, implemented by HUD and other agencies over the last three years. This multi-year project should be evaluated, and with this withdrawal, we may never learn what worked best in the project to help homeless LGBTQ youth.March 8, 2017: Department of Health and Human Services (HHS) removed demographic questions about LGBT people that Centers for Independent Living must fill out each year in their Annual Program Performance Report. This report helps HHS evaluate programs that serve people with disabilities.March 2, 2017: The Department of Justice abandoned its request for a preliminary injunction against North Carolina’s anti-transgender House Bill 2, which prevented North Carolina from enforcing HB 2. This was an early sign that the Administration was giving up defending trans people (later, on April 14, it withdrew the lawsuit completely).March 1, 2017: The Department of Justice took the highly unusual step of declining to appeal a nationwide preliminary court order temporarily halting enforcement of the Affordable Care Act’s nondiscrimination protections for transgender people. The injunction prevents HHS from taking any action to enforce transgender people's rights from health care discrimination.February 22, 2017: The Departments of Justice and Education withdrew landmark 2016 guidance explaining how schools must protect transgender students under the federal Title IX law.January 31, 2017: President Trump nominated Neil Gorsuch to the Supreme Court. Gorsuch has a history of anti-transgender rulings.January 20, 2017: On President Trump’s inauguration day, the adminstration scrubbed all mentions of LGBTQ people from the websites of the White House, Department of State, and Department of Labor.Other Harmful Trump Administration ActionsThe Trump administration has taken many other actions to roll back civil rights and health care protections and target vulnerable communities. While not specifically directed at transgender people or gender identity protections, we list them here because it is critically important that we view our quest for transgender equality as intertwined with other social justice movements. These include attacks on reproductive rights, the Affordable Care Act, refugees and other immigrants and the enforcement of civil rights laws. Many of these actions will also disproportionately harm transgender people. These are just a few examples:Kicking Americans off Medicaid and Food Stamps: The Trump Administration has taken numerous actions to kick Americans in need off of Medicaid and SNAP coverage. On April 10, Trump signed an executive order directing federal agencies to push for work requirements for low-income people in America who receive federal assistance, including Medicaid and SNAP.Targeting Reproductive Rights: On October 6, 2017, the Department of Health and Human Services issued a regulation allowing employers and insurers to deny coverage for birth control, as long as they can cite religious reasons for doing so. In April, President Trump and Congress overturned a regulation that protected Planned Parenthood, one of the nation’s largest providers of care for transgender people, and other family planning clinics from funding discrimination by states.Harming Sexual Assault Survivors. On September 7, 2017, Education Secretary Betsy DeVos announced she would withdraw historic guidance on schools' and universities' responsibilities to address sexual assault and sexual harassment. On September 27, 2017, the Department replaced this guidance with flawed and dangerous “interim guidance” tipping the scales against student survivors seeking protection on campus. This is especially dangerous for transgender students, because 47% of transgender adults in the US Transgender Survey were sexual assault survivors.Cruel and Relentless Attacks on Immigrant Communities. On September 5, 2017, President Trump acted to strip hundreds of thousands of Americans and their families of security, stability, and safety by ending the Deferred Action for Childhood Arrivals (DACA) program. On April 6, 2018, Attorney General Jeff Sessions announced a “zero tolerance” policy that separated hundreds of immigrant children from their families. On April 10, a federal official announced that the Department of Justice was halting the Legal Orientation Program, which offers legal assistance to immigrants. On June 11, Attorney General Sessions ruled that domestic or gang violence are not grounds for asylum in the United States. These are just a few of many anti-immigrant actions that are especially dangerous for many LGBT immigrants who could face life-threatening violence if deported.Putting Health Care Out of Reach: On April 13, 2017, the Department of Health and Human Services rolled back numerous Affordable Care Act rules to reduce protections for people seeking and using health insurance. These actions make it harder to enroll in health care plans, allow plans to sharply raise deductibles, and weaken requirements for insurance plans to have in-network providers that serve low-income communities. These changes disproportionately affect people of color and any one with lower incomes, including transgender people. These changes make getting health care coverage harder for people who lose coverage or who depend on community clinics.Expanding Immigration Detention: The Department of Homeland Security is vastly expanding the number of immigrants held in immigration detention centers nationwide, while also eliminating protections for health and safety in detention centers. Reducing these protections for immigrants who are being detained is wrong, and it's especially dangerous for vulnerable transgender immigrants, many of whom are asylum-seekers who risk extreme abuse.Banning Muslims and Refugees: On January 27, 2017 and again on March 6, President Trump signed executive orders seeking to ban entry by refugees and travelers from certain Muslim-majority countries and drastically reduce the number of refugees allowed to seek safety in the United States. We cannot stand for a world where people in danger are denied entry because of who they are, including where they come from or whether they are Muslim or any other religion. LGBT refugees are among the many who are fleeing life-threatening persecution because of who they are or what they believe. While the bans were allowed to take effect by the Supreme Court, court cases challenging them continue.

The American health care industry wastes $1T by some estimates, and possibly as much as 30% of health care spending by others. US health care expenditures are twice the OECD average – for instance, we spend twice what the UK does on health care (as a percentage of GDP) – and American health care costs are growing at 5% a year.Healthcare presents one of the greatest policy challenges for our country because profit incentives and care for the patient are often misaligned. It’s clear that the government is going to play some role in making sure the least well-off Americans have access to medicine, but we need healthcare policies that incentivize providers and payors to educate patients to make informed, data-driven choices. Only intelligent consumer choice will stimulate functioning, competitive markets in insurance, patient care, the pharmaceutical industry, and elsewhere. Today, pharmaceutical companies, health providers, electronic health record (EHR) systems, and other actors often have misaligned incentives and fail to enable more efficient solutions that do more for the patient per dollar - indeed, often the winners in these areas are those that unnecessarily charge more. Aligning incentives will spur top technology startups to develop innovative healthcare solutions, bring down costs, and deliver superior outcomes to American patients. Here are a few necessary reforms:Medical SchoolsExperts project a total physician shortfall of between 42,600 and 121,300 by 2030.* We need more medical schools fast, but the Liaison Committee on Medical Education accreditation process takes 8 years on average and most states require new medical schools to obtain a “certificate of need” before beginning construction. In addition, medical schools are required to sustain the high overhead of medical research rather than focusing exclusively on training doctors, and inflexible requirements prevent medical schools from experimenting with new curricula. Organic chemistry and other undergraduate prerequisites are completely irrelevant to becoming a good practicing doctor, and should be optional.High medical school costs force students to become high-earning specialists, e.g. plastic and orthopedic surgeons, when our country really needs more primary care physicians (PCPs). Primary care physicians, nurse practitioners, and physician’s assistants are far cheaper than specialists, but limited medical school and residency supply as well as occupational licensing concerns keep them out of the market. In addition, foreign doctors are almost always required to complete a full residency before being allowed to practice in the United States. Given a current skills gap of 30,000 doctors, adding 30,000 new PCPs, nurse practitioners, or physicians assistants could save $2.3B, $5.1B, or $6B in salary costs alone relative to the current mix of specialists and primary care doctors.In addition, primary care doctors achieve better health outcomes for patients than specialists by engaging in long-term counselling, tracking, and preventive care. Scholars estimate that replacing specialists with primary care physicians at a density of 1 per 10,000 population could save $931 per beneficiary a year. Adding a supply of 30,000 primary care physicians would save our country about $150-200B a year.*If implemented correctly, data-driven telemedicine can ameliorate demand for physicians somewhat. Doctors should be able to digitally prescribe most drugs, and data from increasingly sophisticated wearables will enable physicians to swiftly and efficiently diagnose patients.Reform PBMsIn 2017 the Centers for Medicare and Medicaid Services (CMS) spent $175B on prescription drugs alone, and there are currently shortages of vital drugs across the country. An oligopoly of Pharmacy Benefit Managers (PBMs) generates $200B a year in revenue by forcing drug manufacturers to pay rebates and other kickbacks in order for the PBM to place their drug on the “formulary”, or list of insurable drugs. Securing a place on the formulary is a matter of life and death for manufacturers, and by one estimate the current value of rebates and other price concessions from manufacturers to PBMs increased from $59B in 2012 to $127B in 2016.After speaking extensively with politicians on both sides, we were thrilled to see the Senate recently outlaw PBM “gag-orders” on pharmacies by a 98-2 vote. We are encouraged to see that Alex Azar’s Department of Health and Human Services (HHS) is planning to subject PBM rebates to anti-kickback law, but we would go further and require full price transparency on PBM contracts in the style of Colorado HB 1260. Although some rebate money flows to insurers, we estimate that reforming the space could save America on the order of $50B.End of Life Palliative CareAlthough discredited by hyperbolic language about “death panels”, counselling patients at end-of-life is both cost-effective and humane. 30% of Medicare expenditures are attributable to 5% of beneficiaries who die each year, and acute care in the final 30 days of life accounts for 78% of the costs incurred in the final year of life. While acute-care for the dying should obviously be available to those who want it, our country must shift to a model of counselling and palliative care at the end of life.Just having an end of life discussion with the cancer patient reduces medical costs by 35.7% on average, and given that there are roughly 600,000 cancer deaths in the United States a year, would have saved $687M a year for cancer patients in the last week of life alone! In addition accountable care organizations (ACOs) have saved $12,000 per patient during the final three months of life by implementing home-based palliative care. If extended to all cancer, end stage renal disease, and congestive heart failure patients this program could save the country $11.7B a year.We all agree that we must treat families of the dying with delicacy and compassion. But introducing a program by which families will share in Medicare/Medicaid savings from palliative care would help families and patients factor the overall social cost of end-of-life care into their decision calculus. We estimate that extending proven programs and testing different incentives structures could save our country $30-50B a year.FDA ReformClinical trials are an arduous multi-year process and have become drastically more costly in the last 30 years. Phase II and III efficacy trials cost roughly $400M per new drug, which severely limits the number of drugs that make it to the final stage of Food and Drug Administration (FDA) approval. A “progressive approval” approach would allow drugs to be repurposed for other uses and possibly sold after passing Phase I safety trials, which establish that a drug has a favorable risk balance and qualifies as value-based care. Drug companies could gradually establish efficacy by logging the effects the drug has on each person who opts to use it over the next several years.The extreme costs of clinical trials and FDA approval not only stymie drug development and the application of treatments to new indications, they effectively privilege Big Pharma over other innovators, inhibiting innovation and medical progress. A data-driven approach in which doctors and hospitals verify drug efficacy over time would allow the FDA to concentrate its resources on ensuring safety, particularly as the market for new drugs becomes sophisticated at assimilating information from the progressive approval process. While ramping up the number of drugs approved may not save our healthcare system money on net, a framework which encourages innovation will positively impact millions of lives by improving quality of care.Give Medicare Negotiating PowerTo pass the Affordable Care Act (ACA), the Obama Administration made a critical concession: Medicare would not be able to negotiate the price of drugs by controlling which drugs make it onto Medicare’s formulary. As a consequence, our federal government is a “price taker” that must blindly accept whatever prices drug companies demand, and the American government winds up subsidizing drug development costs for the rest of the world. Drug prices at home are extremely high, representing 10% of total healthcare expenditures, and about $144B of federal healthcare spending.In many other developed countries, governments use their monopsony or near-monopsony buying power to force pharmaceutical companies to sell drugs at much cheaper rates. For instance, Canada spends 70% of what the US spends on brand name drugs, the UK 40% of what we spend, and Denmark only 35%. If the US federal government used its considerably larger “countervailing power” to negotiate reduced drug prices – whether on a case by case basis or by pegging the value of a Quality Adjusted Life Year at a generous but fixed rate - savings could be in the range of $30-40B, possibly even as high as $90B a year.Pharmaceutical industry lobbyists (PhRMA) argue that high drug prices are necessary to stimulate R&D which generates many new life saving drugs every year. But in fact, median R&D spending on new cancer drugs – the most difficult to develop – is only around 40% of total revenue. In addition, most R&D is funded by American universities, and manufacturers of silver-bullet specialty drugs could continue to charge high prices to a federal payor. Giving government negotiating power isn’t a novel solution, but it’s one of the correct solutions to driving down drug costs for Americans.Tort LawThe threat of malpractice lawsuits forces doctors to engage in costly defensive medicine. Although the current administration has made some progress on tort reform (making arbitration legal for federal contractors and nursing homes), Congress must insist on Texas-style reforms including capped punitive and noneconomic damages from healthcare providers, eliminating contingency fees for speculative tort lawyers, reinforced federal preemption doctrine for food and drug products, and more. Unfortunately the trial lawyers lobby – one of the biggest political donors in the country – will fight reform at every step of the way.Some studies estimate that reducing physician malpractice fears to “somewhat concerned” about malpractice would decrease costs by 14%, saving the country $100B a year. Others argue that medical liability reform could save our country up to $210B a year. Congress must protect our doctors from being attacked by unscrupulous prosecutors in order to reduce the cost of healthcare for American citizens. We all agree that we must insist on protecting patients, but unchecked tort lawsuits just punish American patients and taxpayers with an unaffordable system.Data InteroperabilityThe ACA’s “meaningful use” requirements did little to make healthcare data accessible. As of 2015, only 6% of health care providers could share patient data with other clinicians who use an EHR system different from their own. Although 21st Century Cures Act made “information blocking” illegal, big EHR vendors routinely prevent their competitors from importing patient data by disclosing health records in garbled, incoherent formats. As a result, physicians are unable to make fully informed decisions about their patients.Judy Faulkner, CEO of EPIC, famously condescended then Vice-President Biden, “Why do you want your medical records? They’re a thousand pages of which you understand 10.” The answer is that only real, semantic interoperability which makes health data available to third parties via and open application programming interface (API) will allow an innovation ecosystem of apps, medical devices, and novel insurance plans to flourish. Granular, transparent healthcare data will allow entrepreneurs – whether college students or IBM executives – to invent new solutions from the bottom up and swiftly incorporate best practices into their businesses. In addition, direct service-to-service comparisons will allow consumers to make informed decisions about how to stay healthy, stimulating market competition for their dollars.We have been excited to see CMS’s Blue Button 2.0 API program formalize the Fast Healthcare Interoperability Resources (FHIR) standard for health records, which includes programmer resources, a complete API, and gives beneficiaries full control over their data – but EHR providers are refusing to use it. While any EHR system should ensure compliance with the Health Insurance Portability and Accountability Act (HIPAA) by storing protected health information on secure servers, we need to make interoperability truly mandatory.If patients could easily share their medical records with new providers and selectively reveal their data to health apps, fitness devices, diagnostic companies, insurers, and academic researchers, our entire healthcare industry would become hugely more affordable and effective. Reliable, real-time information about which treatments work, which failed, and what they cost will enable hospitals to identify and minimize cost centers as they strive to produce care more cheaply than federal benchmarks and share in the savings.Financing ReformOvertreatment and poor physician incentives may be the main driver of health care costs. Most hospital networks are local monopolies with limited incentives to innovate or save money. Replacing this broken system with value-based care models will immediately save over $100B in total, and should grow steadily over time to $200-300B as doctors harness digital technology interventions and other new techniques to make care cheaper and more effective. We break down a few potential sources of savings below:Bundled PaymentsThe Bundled Payment Care Initiative (“BPCI”) introduced in 2013 shows serious promise in making acute care clinical workflows more efficient, particularly in orthopedic care and oncology. Results continue to improve as providers adapt to the program.After adopting a bundled payment model, the NYU Medical center reduced costs to Medicare by 10% and reduced patient stays by 25% for total hip arthroplasty procedures, and a private practice joint arthroplasty generated 20% savings for CMS per episode while decreasing readmissions. The Congressional Budget Office estimates that a voluntary bundled payments system could save Medicare $6.6B a year. If CMS makes bundled payments mandatory for both Medicare and Medicaid, achieves health record interoperability, and allows the ecosystem to iterate on data-driven incentives, we expect savings to surpass $100B.Accountable Care OrganizationsACOs are widely seen as the Affordable Care Act’s main instrument to rein in health care spending, and ultimately we expect that bundled payments will be folded into a broader ACO model. To date ACOs have generated modest savings on average, but some, such as the Memorial-Hermann ACO, have generated 11% savings for Medicare. ACO contracts are more efficient if they involve two-sided risk (rewards for savings, penalties for overages), but studies have shown that even early versions of upside-risk only ACOs are associated with a 3% reduction in Medicare reimbursement. In addition, Medicare ACOs have improved quality measures across the board, despite their old, sickly populations.Provider networks are still adjusting to the ACO model, and returns will increase in the future. Projecting savings at 5-10% and assume that all Medicare beneficiaries are enrolled in ACO providers, ACOs would save Medicare $30-60B a year. If extended to Medicare and Medicaid, full ACO enrollment could generate between $56-112B a year.Preventive MedicineThe ACA now mandates coverage for all evidence-based prevention in non-grandfathered plans, so preventative screening and vaccinations have increased since the advent of Obamacare. However we need to drastically increase the scope of preventive medicine under the aegis of value-based care. Preventable chronic diseases are 7 of 10 top causes of death in the country, and account for 75% of health care costs. Half of American adults have chronic disease, and surprisingly, chronic illness among those younger than 65 years accounts for 67% of total medical spending. 70% of American adults are overweight, and 1 in 3 American kids and teens is overweight or obese. Prevalence of obesity has tripled since 1971.Some of the most cost-effective, successful preventive health interventions include childhood immunization, youth and adult tobacco counselling, alcoholism interventions, aspirin use for people with heart disease, and screenings for common cancers, STDs, and chronic conditions like hypertension. Evidence suggests that many other preventive health interventions are cost-neutral or increase long-term medical costs (because they extend lifespans). However critics often miss the fact that preventive health measures will extend the working careers of Americans, and pay for themselves in the long-run.In kidney care, for example, the federal government subsidizes extremely costly dialysis treatments for end stage renal disease patients but has not crafted incentives to perform preventative treatments before a patient advances to this critical, debilitating condition. Rather than fill the coffers of the corrupt duopoly that runs the dialysis industry, we should give providers incentives to halt the progression of kidney disease in its tracks. As a country we spend $42B on hemodialysis. Just getting prevention right here could save our system north of $10B a year.ConclusionFixing our sprawling, tangled healthcare system is one of our nation’s greatest policy challenges. In the coming years, America should move swiftly to embrace value-based care models which align market incentives to produce a wealth of patient data and an ecosystem of new information technologies geared at preventive treatment. At the same time, we must address specific areas where poor incentives have throttled the production and delivery of medical services. Replacing bureaucratic mandates with proven Western values of entrepreneurial innovation and educated individual decision-making will yield better patient experiences and results for Americans from every walk of life while saving our country $600-$900B annually – a transformative amount of money for the well-being of our nation.

There is not much of a health plan that can become a replacement for the Patient Protection and Affordable Care Act of 2010, AKA Obamacare. It is likely to leave with no health care plan, just a patchwork of some Executive Orders that may still be applicable without the supporting PPACA in place, and lot of directives that have little force of law.The PPACA has provision for adults up to 26 years to be included on a parent’s healthcare plan, there is protection from being refused claims based on pre-existing conditions, there is a lifetime and annual maximum on out-of-pocket expenses, there are some states that have availed themselves to expand access to Medicare, there are tax rebate subsidies to support low-paid workers access to commercial and comprehensive health insurance plans if an employer does not offer anything, and some standards for Health Insurers and Providers. Nothing negative in the package, except that it is complex. There are 906 pages of detailed provisions across a range of Health Care issues. https://www.congress.gov/111/plaws/publ148/PLAW-111publ148.pdfTrump’s healthcare is a an ‘ask’ for Pharmaceutical Companies to lower drug prices, make available cheap and cut-down Insurance Plans, provide some guarantees for Medicaid recipients with a lowest -price drug option, and removed the individual mandate tax penalty, weakening the participation in health care insurance. What is called a ‘Plan’ is just a list of initiatives that do not all have the weight and validity as a provision in a law, and will have no obligation to be followed - in this 8-page summary: https://www.govinfo.gov/content/pkg/FR-2020-10-01/pdf/2020-21914.pdfAs a plan, it is bankrupt, like its author. It merely summarizes positions, and does not wrap up an approach to Healthcare for all Americans, except for the assumption that if you are poor, you can die, and if you are rich, and might need to have coverage, their are a range of options now for you. If you are old, there is some Federal Support from what you have already paid for in Medicaid contributions, but do not hold out that it would last if you are not already on it now. Better that you read and understand that the emperor has no clothes, hence he stormed out of the 60 minutes meeting with Leslie Stahl as he does not understand what a Political. Government, or Legislative plan should entail.An America-First Healthcare PlanSection 1. Purpose. Since January 20, 2017, my Administration has beencommitted to the goal of bringing great healthcare to the American peopleand putting patients first. To that end, my Administration has taken monumental steps to improve the efficiency and quality of healthcare in theUnited States.(a) My Administration has been committed to restoring choice and controlto the American patient.On December 22, 2017, I signed into law the repeal of the burdensomeindividual-mandate penalty, liberating millions of low-income Americansfrom a tax that penalized them for not purchasing health-insurance coveragethey did not want or could not afford. Through Executive Order 13813of October 12, 2017 (Promoting Healthcare Choice and Competition Acrossthe United States), my Administration has expanded coverage options formillions of Americans in several ways. My Administration increased theavailability of renewable short-term, limited-duration healthcare plans, providing options that are up to 60 percent cheaper than the least expensivealternatives under the Patient Protection and Affordable Care Act (ACA)and are projected to cover 500,000 individuals who would otherwise beuninsured. My Administration expanded health reimbursement arrangements,which have been projected by the Department of the Treasury to reach800,000 businesses and over 11 million employees and to expand coverageto more than 800,000 individuals who would otherwise be uninsured. MyAdministration also issued a rule to increase the availability of associationhealth plans for small businesses, which, upon implementation of the rule,are projected to cover up to 400,000 previously uninsured individuals foron average 30 percent less cost.As set forth in the Economic Report of the President (February 2020), myAdministration’s expansion of health savings accounts will further helpmillions of Americans pay for health expenditures by allowing them tosave more of their own money free from Federal taxation, and will especiallyhelp Americans with chronic conditions who now have more flexibilityto enroll in plans that fit their complicated care needs and can be pairedwith a tax-advantaged account.At the beginning of the current COVID–19 pandemic, my Administrationacted to dramatically increase the accessibility and availability of telehealthservices for Medicare beneficiaries, enabling millions of individuals to usethese services. Pursuant to Executive Order 13941 of August 3, 2020 (Improving Rural Health and Telehealth Access), the Secretary of Health and HumanServices will make permanent many of the new policies that improve theaccessibility and availability of telehealth services. In addition, pursuantto that order, the Secretary of Health and Human Services and the Secretaryof Agriculture will develop and implement a strategy to improve the physicaland communications healthcare infrastructure available to rural Americans.Through our State Relief and Empowerment Waivers, my Administrationhas given States additional health-insurance flexibility, which has expandedhealth-insurance coverage options for consumers and lowered costs for patients. These waivers allow States to move away from the ACA’s rigidVerDate Sep<11>2014 21:36 Sep 30, 2020 Jkt 253001 PO 00000 Frm 00003 Fmt 4705 Sfmt 4790 E:\FR\FM\01OCE0.SGM 01OCE0jbell on DSKJLSW7X2PROD with EXECORD62180 Federal Register / Vol. 85, No. 191 / Thursday, October 1, 2020 / Presidential Documentsstructure and are estimated to have lowered premiums by approximately11 percent in Wisconsin, 20 percent in Minnesota, and 43 percent in Maryland. Due to actions my Administration took, like the State Relief andEmpowerment Waivers, after years of dwindling choices and escalatingprices, plan options for consumers increased and for 2019, for the firsttime ever, benchmark premiums actually decreased on Get 2020 health coverage. Health Insurance Marketplace. For2020, the average benchmark premium dropped by nearly 4 percent.After the prior Administration spent tens of billions of dollars creatingelectronic health records systems unable to accurately or effectively recordand communicate patient data, my Administration has paved the way fora new wave of innovation to allow patients to safely send their own medicalrecords to care providers of their choosing. My Patients over Paperworkinitiative has cut red tape for doctors and nurses so they can spend moretime with their patients, which the Centers for Medicare and MedicaidServices (CMS) within the Department of Health and Human Services (HHS)has estimated to save over 40 million hours of wasted time for providersand suppliers between 2017 and 2021.(b) My Administration has been ceaseless in its efforts to lower coststo make healthcare more affordable for American patients.Under my tenure, prescription drugs saw their largest annual price decreasein nearly half a century. For three consecutive years, we have approveda record number of generic drugs. The Council of Economic Advisers hasestimated that these approvals saved patients $26 billion in the first 18months of my Administration alone. As part of the Further ConsolidatedAppropriations Act, 2020, I signed into law the Creating and RestoringEqual Access to Equivalent Samples Act, which will pave the way foreven more generic drugs and is projected to save taxpayers $3.3 billionfrom 2019 to 2029.CMS has acted to offer Medicare beneficiaries prescription drug plans withthe option of insulin capped at $35 in out-of-pocket expenses for a 30-day supply. We are also reducing Government payments to overcharginghospitals participating in the 340B Drug Pricing Program by instead payingrates that more accurately reflect the hospitals’ acquisition costs, whichCMS estimated would save Medicare beneficiaries $320 million on copayments for drugs alone.As a result of Executive Order 13937 of July 24, 2020 (Access to AffordableLife-Saving Medications), low-income Americans who receive care from afederally qualified health center will have access to insulin and injectableepinephrine at prices lower than ever before. Under Executive Order 13938of July 24, 2020 (Increasing Drug Importation to Lower Prices for AmericanPatients), my Administration will be the first to complete a rulemakingto authorize the safe importation of certain lower-cost prescription drugsfrom Canada. Pursuant to Executive Order 13939 of July 24, 2020 (LoweringPrices for Patients by Eliminating Kickbacks to Middlemen), my Administration is taking action to eliminate wasteful payments to middlemen by passingdrug discounts through to patients at the pharmacy counter without increasing premiums for beneficiaries or cost to Federal taxpayers. And my Administration is taking action to ensure that Medicare patients receive the lowestprice that drug companies offer comparable foreign nations through ExecutiveOrder 13948 of September 13, 2020 (Lowering Drug Prices by Putting AmericaFirst).As part of the Further Consolidated Appropriations Act, 2020, I also signedinto law the repeal of the medical device tax, the annual fee on healthinsurance providers, and the ‘‘Cadillac’’ tax on certain employer-sponsoredhealth insurance, which threatened to dramatically increase the cost ofhealthcare for working families.My Administration is transforming the black-box hospital and insurancepricing systems to be transparent about price and quality. Regardless ofhealth-insurance coverage, two-thirds of adults in America still worry aboutthe threat of unexpected medical bills. This fear is the result of a systemVerDate Sep<11>2014 21:36 Sep 30, 2020 Jkt 253001 PO 00000 Frm 00004 Fmt 4705 Sfmt 4790 E:\FR\FM\01OCE0.SGM 01OCE0jbell on DSKJLSW7X2PROD with EXECORDFederal Register / Vol. 85, No. 191 / Thursday, October 1, 2020 / Presidential Documents 62181under which individuals and employers are unable to see how insurancecompanies, pharmacy benefit managers, insurance brokers, and providersare or will be paid. One major culprit is the practice of ‘‘surprise billing,’’in which a patient receives unexpected bills at highly inflated prices fromproviders who are not part of the patient’s insurance network, even ifthe patient was treated at a hospital that was part of the patient’s network.Patients can receive these bills despite having no opportunity to selectaround an out-of-network provider in advance.On May 9, 2019, I announced four principles to guide congressional effortsto prohibit exorbitant bills resulting from patients’ accidentally or unknowingly receiving services from out-of-network physicians. Unfortunately, theCongress has failed to act, and patients remain vulnerable to surprise billing.In the absence of congressional action, my Administration has already takenstrong and decisive action to make healthcare prices more transparent. OnJune 24, 2019, I signed Executive Order 13877 (Improving Price and QualityTransparency in American Healthcare to Put Patients First), directing certainagencies—for the first time ever—to make sure patients have access to meaningful price and quality information prior to the delivery of care. BeginningJanuary 1, 2021, hospitals will be required to publish their real price forevery service, and publicly display in a consumer-friendly, easy-to-understand format the prices of at least 300 different common services that areable to be shopped for in advance.We have also taken some concrete steps to eliminate surprise out-of-networkbills. For example, on April 10, 2020, my Administration required providersto certify, as a condition of receiving supplemental COVID–19 funding,that they would not seek to collect out-of-pocket expenses from a patientfor treatment related to COVID–19 in an amount greater than what thepatient would have otherwise been required to pay for care by an innetwork provider. These initiatives have made important progress, althoughadditional efforts are necessary.Not all hospitals allow for surprise bills. But many do. Unfortunately, surprisebilling has become sufficiently pervasive that the fear of receiving a surprisebill may dissuade patients from seeking appropriate care. And researchsuggests a correlation between hospitals that frequently allow surprise billingand increases in hospital admissions and imaging procedures, putting patients at risk of receiving unnecessary services, which can lead to physicalharm and threatens the long-term financial sustainability of Medicare.Efforts to limit surprise billing and increase the number of providers participating in the same insurance network as the hospital in which they workwould correspondingly streamline the ability of patients to receive careand reduce time spent on billing disputes.On May 15, 2020, HHS released the Health Quality Roadmap to empowerpatients to make fully informed decisions about their healthcare by facilitating the availability of appropriate and meaningful price and quality information. These transformative actions will arm patients with the tools tobe active and effective shoppers for healthcare services, enabling them toidentify high-value providers and services, and ultimately place downwardpressure on prices.My Administration has cracked down on waste, fraud, and abuse that directvaluable taxpayer resources away from those who need them most. MyAdministration implemented a ‘‘site neutral’’ payment system between hospital outpatient departments and physicians’ offices, to ensure Medicarebeneficiaries are charged the same price for the same service regardlessof where it takes place, which CMS estimates will save them approximately$160 million in co-payments for 2020. We also changed the rules to enableGovernment watchdogs to proactively identify and stop perpetrators of fraudbefore money goes out the door.(c) My Administration has been dedicated to providing better care forall Americans.VerDate Sep<11>2014 21:36 Sep 30, 2020 Jkt 253001 PO 00000 Frm 00005 Fmt 4705 Sfmt 4790 E:\FR\FM\01OCE0.SGM 01OCE0jbell on DSKJLSW7X2PROD with EXECORD62182 Federal Register / Vol. 85, No. 191 / Thursday, October 1, 2020 / Presidential DocumentsThis includes a steadfast commitment to always protecting individuals withpre-existing conditions and ensuring they have access to the high-qualityhealthcare they deserve. No American should have to risk going withouthealth insurance based on a health history that he or she cannot change.In an attempt to justify the ACA, the previous Administration claimedthat, absent action by the Congress, up to 129 million (later updated to133 million) non-elderly people with what it described as pre-existing conditions were in danger of being denied health-insurance coverage. Accordingto the previous Administration, however, only 2.7 percent of such individualsactually gained access to health insurance through the ACA, given existinglaws and programs already in place to cover them. For example, the HealthInsurance Portability and Accountability Act of 1996 has long protectedindividuals with pre-existing conditions, including individuals covered bygroup health plans and individuals who had such coverage but lost it.The ACA produced multiple other failures. The average insurance premiumin the individual market more than doubled from 2013 to 2017, and thosewho have not received generous Federal subsidies have struggled to maintaincoverage. For those who have managed to maintain coverage, many haveexperienced a substantial rise in deductibles, limited choice of insurers,and limited provider networks that exclude their doctors and the facilitiesbest suited to care for them.Additionally, approximately 30 million Americans remain uninsured, notwithstanding the previous Administration’s promises that the ACA wouldaddress this intractable problem. On top of these disappointing results,Federal taxpayers and, unfortunately, future generations of American workers,have been left with an enormous bill. The ACA’s Medicaid expansion andsubsidies for the individual market are projected by the Congressional BudgetOffice to cost more than $1.8 trillion over the next decade.The ACA is neither the best nor the only way to ensure that Americanswho suffer from pre-existing conditions have access to health-insurancecoverage. I have agreed with the States challenging the ACA, who havewon in the Federal district court and court of appeals, that the ACA, asamended, exceeds the power of the Congress. The ACA was flawed fromits inception and should be struck down. However, access to health insurancedespite underlying health conditions should be maintained, even if theSupreme Court invalidates the unconstitutional, and largely harmful, ACA.My Administration has always been committed to ensuring that patientswith pre-existing conditions can obtain affordable healthcare, to loweringhealthcare costs, to improving quality of care, and to enabling individualsto choose the healthcare that meets their needs. For example, when theCOVID–19 pandemic hit, my Administration implemented a program toprovide any individual without health-insurance coverage access to necessaryCOVID–19-related testing and treatment.My commitment to improving care across our country expands vastly beyondthe rules governing health insurance. On July 10, 2019, I signed ExecutiveOrder 13879 (Advancing American Kidney Health) to improve care for thehundreds of thousands of Americans suffering from end-stage renal disease.Pursuant to that order, my Administration launched a program to encouragehome dialysis and promote transplants for patients, and expects to enrollapproximately 120,000 Medicare beneficiaries with end-stage renal diseasein the program. We also have removed financial barriers to living organdonation by adding additional financial support for living donors, suchas by reimbursing expenses for lost wages, child care, and elder care. HHS,together with the American Society of Nephrology, issued two phases ofawards through KidneyX’s Redesign Dialysis Price Competition to worktoward the creation of an artificial kidney.My Administration has taken unprecedented action to improve the qualityof and access to care for individuals with HIV, as part of our goal ofending the epidemic of HIV in the United States by 2030. HHS has awardedVerDate Sep<11>2014 21:36 Sep 30, 2020 Jkt 253001 PO 00000 Frm 00006 Fmt 4705 Sfmt 4790 E:\FR\FM\01OCE0.SGM 01OCE0jbell on DSKJLSW7X2PROD with EXECORDFederal Register / Vol. 85, No. 191 / Thursday, October 1, 2020 / Presidential Documents 62183at least $226 million to expand access to HIV care, treatment, medication,and prevention services, focused on 48 counties, Washington, DC, and SanJuan, Puerto Rico, where more than 50 percent of new HIV diagnoses occurredin 2016 and 2017, as well as seven States with a substantial rural HIVrate. We secured a historic donation of a groundbreaking HIV preventivemedication that is available at no cost to eligible patients.My Administration has started a transformation in healthcare in rural America. This includes a new effort, pursuant to my directive in Executive Order13941, to support small hospitals and health clinics in rural communitiesin transitioning from volume-based Medicare and Medicaid reimbursement,which has failed rural communities that struggle with a lack of patientvolume, and toward value-based payment mechanisms that are tailored tomeet the needs of their communities. We updated Medicare payment policiesto address a problem in the program’s payment calculation that has historically disadvantaged rural hospitals, and released a Rural Action Plan toincorporate recommendations from experts and leaders across the FederalGovernment. We have also dedicated a special focus on improving careoffered through the Indian Health Service (IHS) within HHS, including bycreating the Office of Quality, implementing an increase in annual fundingfor IHS by $243 million from 2019 to 2020, and expanding nationwideIHS’s successful Alaska Community Health Aide Program.My Administration has additionally demonstrated an incredible dedicationto protecting and improving care for those most in need, including seniorcitizens, those with substance use disorders, and those to whom our Nationowes the greatest debt: our veterans.I have protected the viability of the Medicare program. For example, onFebruary 9, 2018, I signed into law the repeal of the Independent PaymentAdvisory Board, which would have been a group of unelected bureaucratscreated by the ACA, designed to be insulated from the will of America’selected leaders for the purpose of cutting the spending of this importantprogram. On October 3, 2019, I signed Executive Order 13890 (Protectingand Improving Medicare for Our Nation’s Seniors), to modernize the Medicareprogram and continue its viability. According to CMS estimates, seniorshave saved $2.65 billion in lower Medicare premiums under my Administration while benefiting from more choices. For example, the average monthlyMedicare Advantage premium has declined an estimated 28 percent since2017, and Medicare Advantage has included about 1,200 more plan optionssince 2018. New Medicare Advantage supplemental benefits have helpedseniors stay safe in their homes, improved respite care for caregivers, andprovided transportation, more in-home support services and assistance, andnon-opioid pain management alternatives like therapeutic massages. MedicarePart D premiums are at their lowest level in their history, with the averagebasic premium declining 13.5 percent since 2016.My Administration has directed unprecedented attention on the substanceuse disorder epidemic, with a focus on reducing overdose deaths fromprescription opioids and the deadly synthetic opioid fentanyl. On October24, 2018, I signed the Substance Use-Disorder Prevention that PromotesOpioid Recovery and Treatment for Patients and Communities Act, enablingthe expenditure of billions of dollars of funding for important programsto support prevention and recovery. My Administration has provided approximately $22.5 billion from 2017 to 2020 to address the opioid crisisand improve access to prevention, treatment, and recovery services. Wesaw a 34 percent decrease in total opioids dispensed monthly by pharmaciesbetween 2017 and 2019, an approximate increase of 64 percent in thenumber of Americans who receive medication-assisted treatment for opioiduse disorder since 2016, and a 484 percent increase in naloxone prescriptionssince 2017. Data show that drug overdose deaths fell nationwide for thefirst time in decades between 2017 and 2018, with many of the hardesthit States leading the way.VerDate Sep<11>2014 21:36 Sep 30, 2020 Jkt 253001 PO 00000 Frm 00007 Fmt 4705 Sfmt 4790 E:\FR\FM\01OCE0.SGM 01OCE0jbell on DSKJLSW7X2PROD with EXECORD62184 Federal Register / Vol. 85, No. 191 / Thursday, October 1, 2020 / Presidential DocumentsImproving care for our Nation’s veterans has been a priority since the beginning of my Administration. On June 6, 2018, I signed the VA MaintainingInternal Systems and Strengthening Integrated Outside Networks (MISSION)Act of 2018, which authorized billions of dollars to improve options forveterans to receive care outside of Department of Veterans Affairs (VA)healthcare providers. Since taking effect, the VA estimates that more than2.4 million veterans have benefited from more than 6.5 million referralsto the 725,000 private healthcare providers with which the VA is nowworking. On June 23, 2017, I signed the Department of Veterans AffairsAccountability and Whistleblower Protection Act of 2017 to hold our civilservants accountable for maintaining the best quality of care possible forour Nation’s veterans by giving the Secretary of Veterans Affairs more powerto discipline employees and shorten an appeals process that can last years.On March 5, 2019, I signed Executive Order 13861 (National Roadmapto Empower Veterans and End Suicide) to ensure that the Federal Governmentleads a collective effort to prevent suicide among our veterans.I have used scientific research to focus on areas most pressing for thehealth of Americans. On September 19, 2019, I signed Executive Order13887 (Modernizing Influenza Vaccines in the United States to PromoteNational Security and Public Health), recognizing the threat that pandemicinfluenza continues to represent and putting forward a plan to preparefor future influenza pandemics. To modernize influenza vaccines and promote national security and public health, HHS issued a 6-year, $226 millioncontract to retain and increase capacity to produce recombinant influenzavaccine domestically, and the National Institute of Allergy and InfectiousDiseases, part of the National Institutes of Health within HHS, initiatedthe Collaborative Influenza Vaccine Innovation Centers program.Investments my Administration has made in scientific research will helptackle some of our most pressing medical challenges and pay dividendsfor generations to come. This includes working to increase funding forAlzheimer’s disease research by billions of dollars since 2017 and a planto invest more than $500 million over the next decade to improve pediatriccancer research. On December 18, 2018, I signed the Sickle Cell Diseaseand Other Heritable Blood Disorders Research, Surveillance, Prevention,and Treatment Act of 2018 to provide support for research into sicklecell disease, which disproportionately impacts African Americans and Hispanics, and to authorize programs relating to sickle cell disease surveillance,prevention, and treatment.On May 30, 2018, I signed the Trickett Wendler, Frank Mongiello, JordanMcLinn, and Matthew Bellina Right to Try Act of 2017, which gives terminally ill patients the right to access certain treatments without being blockedby onerous Federal regulations.In response to the COVID–19 pandemic, my Administration launched Operation Warp Speed, a groundbreaking effort of the Federal Government toengage with the private sector to quickly develop and deliver safe andeffective vaccines, therapeutics, and diagnostics for COVID–19. On August6, 2020, I signed Executive Order 13944 (Combating Public Health Emergencies and Strengthening National Security by Ensuring Essential Medicines,Medical Countermeasures, and Critical Inputs Are Made in the United States),to protect Americans through reduced dependence on foreign manufacturersfor essential medicines and other items and to strengthen the Nation’s PublicHealth Industrial Base.Taken together, these extraordinary reforms constitute an ongoing effort toimprove American healthcare by putting patients first and delivering continuous innovation. And this effort will continue to succeed because of myAdministration’s commitment to delivering great healthcare with morechoices, better care, and lower costs for all Americans.Sec. 2. Policy. It has been and will continue to be the policy of the UnitedStates to give Americans seeking healthcare more choice, lower costs, andVerDate Sep<11>2014 21:36 Sep 30, 2020 Jkt 253001 PO 00000 Frm 00008 Fmt 4705 Sfmt 4790 E:\FR\FM\01OCE0.SGM 01OCE0jbell on DSKJLSW7X2PROD with EXECORDFederal Register / Vol. 85, No. 191 / Thursday, October 1, 2020 / Presidential Documents 62185better care and to ensure that Americans with pre-existing conditions canobtain the insurance of their choice at affordable rates.Sec. 3. Giving Americans More Choice in Healthcare. The Secretary of theTreasury, the Secretary of Labor, and the Secretary of Health and HumanServices shall maintain and build upon existing actions to expand accessto and options for affordable healthcare.Sec. 4. Lowering Healthcare Costs for Americans. (a) The Secretary of Healthand Human Services, in coordination with the Commissioner of Food andDrugs, shall maintain and build upon existing actions to expand accessto affordable medicines, including accelerating the approvals of new genericand biosimilar drugs and facilitating the safe importation of affordable prescription drugs from abroad.(b) The Secretary of the Treasury, the Secretary of Labor, and the Secretaryof Health and Human Services shall maintain and build upon existing actionsto ensure consumers have access to meaningful price and quality informationprior to the delivery of care.(i) Recognizing that both chambers of the Congress have made substantialprogress towards a solution to end surprise billing, the Secretary of Healthand Human Services shall work with the Congress to reach a legislativesolution by December 31, 2020.(ii) In the event a legislative solution is not reached by December 31,2020, the Secretary of Health and Human Services shall take administrativeaction to prevent a patient from receiving a bill for out-of-pocket expensesthat the patient could not have reasonably foreseen.(iii) Within 180 days of the date of this order, the Secretary of Healthand Human Services shall update the Medicare.gov: the official U.S. government site for Medicare Hospital Comparewebsite to inform beneficiaries of hospital billing quality, including:(A) whether the hospital is in compliance with the Hospital Price Transparency Final Rule, as amended (84 Fed. Reg. 65524), effective January1, 2021;(B) whether, upon discharge, the hospital provides patients with a receiptthat includes a list of itemized services received during a hospital stay;and(C) how often the hospital pursues legal action against patients, includingto garnish wages, to place a lien on a patient’s home, or to withdrawmoney from a patient’s income tax refund.(c) The Secretary of Health and Human Services, in coordination withthe Administrator of CMS, shall maintain and build upon existing actionsto reduce waste, fraud, and abuse in the healthcare system.Sec. 5. Providing Better Care to Americans. (a) The Secretary of Healthand Human Services and the Secretary of Veterans Affairs shall maintainand build upon existing actions to improve quality in the delivery of carefor veterans.(b) The Secretary of Health and Human Services shall continue to promotemedical innovations to find novel and improved treatments for COVID–19, Alzheimer’s disease, sickle cell disease, pediatric cancer, and other conditions threatening the well-being of Americans.Sec. 6. General Provisions. (a) Nothing in this order shall be construedto impair or otherwise affect:(i) the authority granted by law to an executive department or agency,or the head thereof; or(ii) the functions of the Director of the Office of Management and Budgetrelating to budgetary, administrative, or legislative proposals.(b) This order shall be implemented consistent with applicable law andsubject to the availability of appropriations.VerDate Sep<11>2014 21:36 Sep 30, 2020 Jkt 253001 PO 00000 Frm 00009 Fmt 4705 Sfmt 4790 E:\FR\FM\01OCE0.SGM 01OCE0jbell on DSKJLSW7X2PROD with EXECORD62186 Federal Register / Vol. 85, No. 191 / Thursday, October 1, 2020 / Presidential Documents(c) This order is not intended to, and does not, create any right or benefit,substantive or procedural, enforceable at law or in equity by any partyagainst the United States, its departments, agencies, or entities, its officers,employees, or agents, or any other person.