Health Plan CEOs Grilled On Affordability
It was a bipartisan bashing of health plan CEOs on Capitol Hill today as both parties sought to protect themselves from healthcare affordability fallout. While the GOP was more sympathetic to the plan executives, they engaged in a great deal of attacks as well. The issues covered included the following:
- Plan executives tried to promote many of the reforms they have made, including in prior authorization. For the most part, it seemed not enough for lawmakers.
- Plan executives argued correctly that the real problem is not plans but drug and hospital prices in America. Lawmakers paid little attention here and sought to turn it back on some of the nefarious practices of the Uber healthcare organizations in front of them.
- Four of five CEOs agreed the healthcare system is broken when asked. Blue Shield CEO Markovich indicated that the hearings highlighted the need for “systemic” change.
- Lawmakers on both sides of the aisle attacked the plans over vertical integration and the hidden costs it drives. Executives tried to defend on the issue by arguing the benefits. This fell flat. Consolidation and mergers were also featured as driving costs. Lawmakers argued hospital consolidation and private equity investors are inflating costs and premiums.
- There was major criticism of MA from both sides of the aisle, including on growing overpayments from risk adjustment abuse.
- The No Surprises Act was featured as in need of reform, with plan executives saying providers have high-jacked the dispute resolution, while lawmakers also attacked plans for their behavior in the program.
- Lawmakers had major criticisms of the pharmacy benefits managers (PBMs) most of the executives own and how business is conducted. Plans argued the benefits of PBMs as well as recent promotion of biosimilars.
- Rep. Greg Murphy, R-NC and a doctor, laid out the plans’ litany of sins, including ruining Medicare Advantage (MA), overly consolidating, mistreating providers, overpaying executives, manipulating the No Surprises Act, and abusing prior authorizations (PA). Murphy is fighting a brain tumor and just had brain surgery.
- The CEOs declined… to embrace Trump’s health plan as the answer to affordability.
- Democrats and Republicans battled over policy differences and the lack of extension of enhanced Exchange premium subsidies.
In other news, the House passed its final four appropriations bills and they now go to the Senate. This needs to happen soon to avoid a partial shutdown.
Further, lawmakers accused CVS Health of violating antitrust laws by restricting independent pharmacies from working with digital pharmacy competitors to protect its market position.
Last, Cigna said its plan to end drug rebates will reduce earnings by $500 million to $600 million.
Additional articles: https://www.modernhealthcare.com/politics-regulation/mh-health-insurance-ceo-hearings-live-updates/ and https://www.bloomberg.com/news/articles/2026-01-21/cvs-health-may-have-violated-antitrust-laws-republican-lawmakers-say and https://www.fiercehealthcare.com/payers/insurance-ceos-set-back-back-congressional-hearings-affordability and https://www.beckerspayer.com/payer/house-committee-accuses-cvs-of-impeding-pharmacy-competition/ and https://www.modernhealthcare.com/insurance/mh-cigna-earnings-drug-rebates/ and https://www.beckerspayer.com/payer/vertical-integration-is-destroying-peoples-ability-to-access-care-payer-ceos-face-bipartisan-congressional-grilling/ and https://www.beckerspayer.com/payer/cvs-health-cuts-prior-authorizations-expands-rebate-sharing/ and https://thehill.com/homenews/house/5701980-house-government-funding-bills/ and https://www.healthcaredive.com/news/house-budget-committee-healthcare-affordability-consolidation/810149/
(Some articles may require a subscription.)
#healthcare #healthplans #healthcarereform #affordability
https://thehill.com/policy/healthcare/5701982-health-care-costs-insurance-ceos-testimony
Fraud Settlements At Record Level
Healthcare fraud settlements totaled over $5.7 billion for the 2025 fiscal year, the highest amount ever. The amount is triple last year’s number. There were $6.8 billion in total judgments across industries, also the highest ever. Settlements covered Medicare, Medicaid, and Tricare. Big settlements included on Medicare Advantage (MA) risk adjustment, illegal dispensing, and kickback schemes.
Additional article: https://www.fiercehealthcare.com/finance/doj-false-claims-act-settlements-judgements-top-68b-fy2025
#fwa #cms #hhs #healthplans #providers
GLP-1 Growth
As of December 2025, GLP-1 prescriptions account for more than 7% of all prescriptions. Tirzepatide is the most prescribed anti-diabetic and anti-obesity medication (Mounjaro and Zepbound, respectively). It had the largest increase in total prescribing from September to December 2025.
#glp1s #weightlossdrugs #drugpricing
Democrats Lead Generic Ballot
Democrats are ahead of Republicans by 6 percentage points on a generic congressional ballot. The Emerson College poll reports 48.1 percent of respondents backed a Democratic candidate, 41.7 percent a Republican, and 10.2 percent were undecided in a hypothetical matchup. It will all come down to several dozen swing districts, but the picture looks gloomy for the GOP in the House and even worrisome in the Senate.
#2026midterms #trump #gop #dems
https://thehill.com/homenews/campaign/5699627-emerson-poll-democrats-ahead/?tbref=hp
Recent Healthcare Studies And Analyses
Some interesting recent studies and analyses.
Wakely just published a good review of Exchange enrollment nationwide so far, including state statistics. Enrollment is down from sign-ups a year ago, but not as much as one might expect. We could see more erosion as people struggle with premium payments.
Health Affairs Forefront blog has a great article on additional ways to reform Medicare Advantage (MA) Stars. I will assess this in an upcoming blog. Recommendations include focusing on clinical measures, assessing quality at the plan level, redesigning performance, and a transparency scorecard.
The Peterson-KFF Health System Tracker has a nice chart collection on U.S. healthcare spending changes over time.
Healthcare policy group has a new quiz on the Affordable Care Act (ACA). Take it at the link below.
Additional articles: https://www.wakely.com/blog/individual-aca-open-enrollment-insights-so-far/ and https://www.kff.org/affordable-care-act/affordable-care-act-quiz/ and https://www.healthaffairs.org/content/forefront/aligning-stars-modernizing-quality-incentives-and-increasing-transparency-medicare
(Some articles may require a subscription.)
#healthcare #healthcarereform #nhed #spending #aca #exchanges #stars #quality
https://www.healthsystemtracker.org/chart-collection/u-s-spending-healthcare-changed-time/
— Marc S. Ryan
