Exchange Subsidy Deal 50-50
Some lawmakers are saying that there may be a 50-50 shot at obtaining an agreement to extend enhanced Exchange premium subsidies in January. But there are major obstacles. GOP leaders in each house are tending to gravitate toward the larger conservative side of their caucuses, which is dead set against an extension. Minority Leader Chuck Schumer, D-NY, wants either a clean extension or to hang the issue around the GOP’s neck in midterms.
Sen. Bill Cassidy is advocating the possibility of extending subsidies as well as seeding health savings accounts (HSAs) for some and giving Americans the ability to decide one way or another. Another leading compromise would extend for two years with some reining in of the generosity of the enhancements.
The bill could come to life in this way. Four GOP lawmakers in the House signed on to a Democratic discharge petition which will force a vote for a three-year extension in the House. That has failed to pass the Senate, but the bill could be used as a vehicle for a compromise crafted in the Senate. The bill would then go back to the House.
Meanwhile, there are no public signs, yet enrollment is falling demonstrably due to the expiration of subsidies. Federal data released on Dec. 5 showed sign-ups across all 50 states increased 7.5% (5.7M vs. 5.3M) compared with the same period in 2024. Centers for Medicare and Medicaid Services (CMS) Administrator Dr. Mehmet Oz posted on the social media Tuesday that more than 15.6 million people enrolled in a plan on the federal exchanges, down from 16 million last year — just a 2.5 percent decline.
But states are appearing to see falloffs, terminations, and changes to less robust plans. Time will tell.
In other news, a good article on changes to federal regulations since Trump 47 came in. Major streamlining, eligibility restrictions, 340B reform, site neutral reform, and major cost-savings pilots.
Additional articles: https://thehill.com/homenews/senate/5662800-gop-senator-health-care-deal/ and https://www.modernhealthcare.com/politics-regulation/mh-federal-health-regulation-2025-hhs-cms/
(Some articles may require a subscription.)
#exchanges #healthcare #coverage #regulations
Medicare Is Of Two Minds On Prior Authorization
A good article in MedPage Today on the schizophrenia of the Centers for Medicare and Medicaid Service (CMS) on prior authorization (PA).
The article talks to the major regulatory changes restricting PA in Medicare Advantage (MA) as well as the recent industry agreement to rein it in further.
At the same time, CMS is introducing the Wasteful and Inappropriate Service Reduction (WISeR) Model to reduce high-cost and perhaps abused procedures in the traditional Medicare program.
While MedPage and its readers likely may want no PAs at all, I have argued gutting PA in MA takes the managed care out of managed care.
#medicareadvantage #priorauthorization
https://www.medpagetoday.com/practicemanagement/reimbursement/119157
Health Affairs Discusses New MFN Models
Health Affairs Forefront Blog has a good overview of the proposed models aiming to implement international reference pricing (IRP) approaches for drugs under Medicare: the GLOBE (Global Benchmark for Efficient Drug Pricing) Model covers Part B, while the GUARD (Guarding U.S. Medicare Against Rising Drug Costs) Model covers Part D. Both models would be mandatory for any drug manufacturer wishing to participate in Medicare.
Both would increase rebates for certain single-source drugs and biological products “if the prices exceed those paid in economically comparable countries.” This is most-favored-nation (MFN) pricing. There are a number of rules for when a drug is subject to MFN. GLOBE focuses on the top 50 Part B drugs. GUARD focuses on products in 18 therapeutic categories. Each model also specifies that drugs meet a minimum Medicare spending threshold.
GLOBE is estimated to save $11.9 billion in Medicare Part B net spending during the 7-year model, GUARD would save $14.1 billion in Part D net spending over the model period.
(Article may require a subscription.)
Health Affairs Discusses State Directed Payments
Health Affairs Forefront Blog covers the recent changes to Medicaid state directed payments (SDPs) in the One Big Beautiful Bill Act (OBBBA). Usually financed by provider taxes, SDPs are used by states to increase reimbursement for Medicaid providers predominantly through Medicaid managed care plans. Proponents argue this strengthens access to care for low-income Americans and drives quality improvement in chronic disease. Opponents argue provider taxes and SDPs are much abused and are out of control.
(Article may require a subscription.)
#medicaid #providertaxes #obbba
— Marc S. Ryan
