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Democrats On Attack On Budget Bill Cuts

Democrats are seizing the opportunity to muddy Republicans on the budget reconciliation bill vote and the lack of enhanced subsidy extensions in the Exchanges. A report commissioned by Sens. Ron Wyden, D-OR, and Jeanne Shaheen, D-NH, was compiled by the Georgetown University Center on Health Insurance Reforms.

The report finds the following:

• The Congressional Budget Office (CBO) estimates 4.2 million people will lose coverage in the Exchanges if the enhanced subsidies expire. This is in addition to losses of 2.4 million due to the budget bill and 1.8 million from a recent Trump rule tightening Exchange enrollment and eligibility. This last item has had other estimates of as low as 900,000 impacted.
• Individuals who remain in Exchange plans will see their net premiums increase by 75% on average.
• Enrollment in Exchange plans could decrease by as much as 57%.
• Significant coverage losses and shifts in the Exchange risk pool will mean a median rate increase of 18% in 2026.

In other news, the American Hospital Association alleges that major pharmaceutical companies colluded to devise a plan to replace 340B drug program discounts with rebates. It sent a letter to the Justice Department and the Federal Trade Commission urging an investigation of several brand drug makers. This is a desperate act by the hospital lobby, which is fearful of losing one of several government giveaways.

Additionally, hospitals are pressing for action on and changes to several health policies, including overturning an $8 billion reduction to the Medicaid Disproportionate Share Hospital (DSH) Program in 2026 and more in future years.

Additional articles: https://www.fiercehealthcare.com/regulatory/leading-democrats-press-details-impacts-expiry-aca-subsidies and https://www.modernhealthcare.com/politics-regulation/mh-340b-program-rebate-model-aha/

(Some articles may require a subscription.)

#budgetreconciliation #healthcare #coverage #aca #exchanges #hospitals #340b #uninsured

https://www.fiercehealthcare.com/providers/ahead-congress-funding-deadline-hospitals-target-expiring-pay-adjustments-aca-credits

Mercer Survey Confirms Employer Healthcare Struggles

A new survey and study from consulting firm Mercer adds to the growing worry about the status of employer coverage. It says employers are likely to see healthcare costs increase significantly next year.

Mercer polled more than 1,700 employers and found that total health benefit costs per employee are expected to rise by an average of 6.5% in 2026 after cost management and 9% before such measures. This 9% gross trend is consistent with the 8% to 9% seen in other studies and surveys. These trends are the highest in a decade. And this will mean the fourth-straight year of increased spending growth following a decade of more moderate cost hikes.

Reasons for the major trends are the following:

•  Medical treatments and therapies have become more sophisticated and more costly.
• Provider markets are increasingly consolidated, which means higher reimbursements/costs.
• Inflation broadly across the economy.

Mercer says 56% of employers intend to take cost-cutting measures for 2026, up from 48% in 2025. Deductibles and other cost-sharing will be increased.

Mercer says these steps in 2026 indicate a reversal of a trend over the past several years where employers have tried to shelter employees from higher costs.

Employers also will seek to better manage costs of the priciest claims and reviewing health programs to ensure they are providing value. Further, about two-thirds of large firms said they plan to enhance access to behavioral health as a strategy to manage overall costs.

See my recent blog on this topic: https://www.healthcarelabyrinth.com/my-biggest-worry-erosion-of-coverage/

#employercoverage #healthcare

https://www.fiercehealthcare.com/payers/mercer-survey-employers-anticipate-highest-health-benefit-cost-increase-15-years-2026

2026 MA Pullback Starts

A number of high profile exits from Medicare Advantage (MA) and standalone Part D (PDP) were announced today.

Elevance Health announced it will cut some MA plans and fully exit the PDP program.

The PDP exit is not surprising but sends a message that the program is in trouble after some political yet bad policy changes made by Democrats to Part D cost-sharing the Inflation Reduction Act. The changes have destabilized an already fragile program. Elevance has 400,000 PDP members and is the sixth-largest plan in PDP.

Given its continuing financial woes, Elevance, too, will eliminate unprofitable MA plans and says that will impact 150,000 individual and group MA members. But Elevance will continue its investments in Special Needs Plans (SNPs) in 2026, a huge trend in the industry. Elevance currently has 2.3 million MA enrollees.

In an another announcement, due to financial issues, Minnesota-based UCare will exit the MA market in 2026 except for SNPs. It has about 187,000 MA members in Minnesota and Wisconsin. It is the second largest MA carrier in the market.

Further, Oregon-based Samaritan Health Plans will exit MA in 2026. Samaritan has nearly 14,000 MA members in its HMO and D-SNP plans.

So, expected displacement for 2026 is already increasing. We know that United has already said it will seek to shed more than 600,000 lives in 2026 by ending unprofitable plans. CVS Health’s Aetna announced it will end nearly 90 Medicare Advantage plans across 34 states in 2026. Most are Preferred Provider Organizations (PPOs).

All told, with the latest announcements, it appears the displacement number is likely about 1 million already for 2026 and that will rise. In 2025, up to 2 million were displaced. In normal years, less than 100,000 face the requirement to change.

Additional articles: https://www.modernhealthcare.com/insurance/mh-ucare-medicare-advantage-plans-2026/ and https://www.modernhealthcare.com/insurance/mh-elevance-health-medicare-advantage-plans-2026/ and https://www.beckerspayer.com/payer/medicare-advantage/ucare-to-exit-medicare-advantage-market-in-2026/ and https://www.beckerspayer.com/payer/medicare-advantage/oregon-payer-to-exit-medicare-advantage-market/

(Some articles may require a subscription.)

#medicareadvantage #margins #enrollment #2026 #partd #pdp #elevancehealth

https://www.fiercehealthcare.com/payers/elevance-healths-stock-dips-company-reveals-plans-exit-standalone-part-d-some-ma-markets

New Analysis on MA Overpayment

I have argued that a small subset of big plans have given all of Medicare Advantage (MA) a bad name by suspect or fraudulent risk adjustment practices that give them major overpayments. A number of studies have singled out this small group of major plans. Now, the Alliance of Community Health Plans (ACHP), a group that represents local and regional nonprofit payers, has come out with a study building on these earlier findings.

ACHP says that UnitedHealthcare, the biggest MA insurer, collected up to $785 more per beneficiary than local nonprofit plans in 2023, costing Medicare more than $6 billion in excess payments that year. Humana, the second-biggest MA payer, collected $423 more per beneficiary that year than if those members were in ACHP member plans, costing Medicare an additional $4 billion. UnitedHealthcare’s average risk scores were 36.2% higher and Humana’s were 19.2% higher than nonprofit health plan members of ACHP. Earlier studies show annual overpayments for United were $14 billion in 2021.

ACHP wants a new system of accounting for members’ health needs based on patient demographics, such as age, sex, disability status, and on a small list of substantiated health conditions.

Additional articles: https://www.healthcaredive.com/news/unitedhealthcare-humana-medicare-advantage-risk-adjustment-gaming-achp/759120/ and https://www.fiercehealthcare.com/payers/achp-unveils-plan-streamline-ma-risk-adjustment-combat-upcoding-gamesmanship

#medicareadvantage #fwa #riskadjustment #radv #overpayments

https://www.beckerspayer.com/payer/medicare-advantage/medicare-advantage-risk-adjustment-a-failing-system-report

Government Shutdown Looms

Congress has returned to Washington and the GOP has no plan to keep the government running at the end of the month. Democrats are pushing the GOP to have a four-leaders meeting to discuss a consensus, but the House and Senate majorities are pushing other agendas right now. Democratic votes would be needed to keep the government going unless budget reconciliation was used again. That is a tall order if not impossible. The Senate GOP has floated a short-term spending patch to give more time to discuss FFY 2026 funding. But some conservatives in the House and Senate want a full-year extension at FFY 2025 spending levels with additional spending cuts.

There is some bipartisan interest in negotiating a healthcare package before the end of the year. Senators are already discussing this. On the docket is the possibility of extending the Exchange premium subsidy enhancements, but conservatives are likely to oppose that.

#ffy2026 #budget #spending #congress

https://www.politico.com/news/2025/08/28/democrats-press-gop-leaders-for-meeting-as-shutdown-looms-00534355

MA Controls Healthcare Growth For Enrollees

While opponents of Medicare Advantage (MA) are on a campaign to strip MA of all sorts of revenue and bolster the future of the antiquated traditional fee-for-service (FFS) program, many studies show the value of MA from a cost and quality perspective. Now, the UCLA Center for Health Policy Research concludes that Californians enrolled in MA face slower growth in healthcare costs compared to those in FFS.

Between 2013 and 2023, average monthly healthcare costs were $269 in counties with MA enrollment above 20%, compared with $481 in counties below 20%, or a 44% lower cost. Counties with higher MA enrollment saw an 11% increase in monthly healthcare costs over the decade (from $245 to $273), while counties with lower enrollment saw a 54% increase (from $361 to $557).

#medicareadvantage #medicare

https://www.beckerspayer.com/uncategorized/medicare-advantage-plans-keep-senior-care-costs-down-in-california-ucla

More Suits On No Surprises Act

UnitedHealthcare joins the ranks of Elevance Health and Aetna in suing prominent provider entities over the No Surprises Act. United is suing Radiology Partners and its Arizona-based affiliate, Sonoran Radiology, alleging the companies have been “abusing” the No Surprises Act’s independent dispute resolution process. They argue the radiology provider behemoth is “funneling millions into the pockets of its private-equity owners.”

The lawsuit comes after a Health Affairs study that shows that providers overwhelmingly win disputes and are awarded extremely high payments. Another new study also shows that surprise bills have fallen under the act based on data from states that had some protections and those that did not before the national law took effect. The study also notes that the prediction that the process would lower prices and save has not materialized.

The fact remains the law needs major reform, including requiring the qualifying payment amount to have more weight in the process.

Additional article: https://www.fiercehealthcare.com/regulatory/study-suggests-no-surprises-act-protections-are-reducing-patients-out-pocket-costs

#nsa #nosurprisesact #transparency #providers #healthplans

https://www.beckerspayer.com/legal/unitedhealthcare-sues-radiology-partners-over-no-surprises-claims/

State Insurance Commissioners Between The Proverbial Rock And A Hard Place

Modern Healthcare has a good article reviewing the plight this year of the insurance commissioner. Healthcare costs are spiraling, in part due to utilization and in part higher prices throughout the sector. As well, the One Big Beautiful Bill Act (OBBBA) is anything but cheerful for most consumers reliant on the Exchanges. The bill will contract enrollment dramatically. This is leading to greater risk in the program and plan and product exits. The combination of the two have insurers putting in for massive rate hikes in the Exchange program.

Insurance regulators do have a hard task. They need to ensure that insurance rates are affordable and consumers have access to the market. They need to protect against excessive hikes. But they also need to ensure a stable and secure insurance marketplace and that means granting sufficient rate hikes to ensure fiscal soundness.

Pressures, especially political ones, abound right now on insurance regulators as they seek to approve sound yet high rate requests and throw out those that are truly excessive. Regulators do have some history in the Exchanges to look at. Exchanges have had a topsy-turvy  history as Democrats sought to expand coverage and Trump 45 and now 47 sought to contract it. All of this led to massive swings in enrollment, plan participation, networks, choice, and premiums over the years.

In related news, the Colorado General Assembly is considering borrowing $100 million from the state’s unclaimed property trust to assist insurance consumers if enhanced exchange subsidies expire at the end of the year.

(Article may require a subscription.)

#healthplans #margins #rates #exchanges #obamacare #aca

https://www.modernhealthcare.com/politics-regulation/mh-aca-premiums-regulators-oklahoma-colorado/

— Marc S. Ryan

United Probe Expansive

The U.S. Justice Department’s (DOJ) criminal division investigation into UnitedHealth Group has been bigger from the start or has expanded. Latest reports suggest that the company is under investigation into both how it reimburses its owned doctors as well as its pharmacy benefit’s manager’s (PBM — OptumRx) business and billing practices. Previously, it was reported the DOJ was investigating alleged Medicare Advantage (MA) risk adjustment fraud.

In the past, I have talked about how federal regulators might go after vertical integration in the healthcare industry and United is the biggest example. Vertically integrated companies are alleged to unfairly inflate price/cost and skirt the minimum medical loss ratio (MLR) rules by having non-arm’s-length agreements with their related companies to keep revenue and margin within the overall enterprise. Could the PBM and physician investigations be touching this concept? It could also be the case that the incentives given owned doctors as well as other pricing and relationships by the PBM violate fraud and other laws.

Additional articles: https://www.modernhealthcare.com/insurance/mh-doj-unitedhealth-optum-rx-medicare-billing/ and https://www.fiercehealthcare.com/payers/wsj-report-doj-interviewing-former-employees-about-medicare-billing-practices-unitedhealth

#fwa #unitedhealthcare #medicareadvantage #doj #antitrust

https://www.bloomberg.com/news/articles/2025-08-26/unitedhealth-ongoing-criminal-probe-is-broader-than-medicare?accessToken=eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJzb3VyY2UiOiJTdWJzY3JpYmVyR2lmdGVkQXJ0aWNsZSIsImlhdCI6MTc1NjIzNzE4NSwiZXhwIjoxNzU2ODQxOTg1LCJhcnRpY2xlSWQiOiJUMUVFT1ZHT1lNVEQwMCIsImJjb25uZWN0SWQiOiJCMUJDOTdEOTQ3MTg0OUExQkQ4MjIyN0MwMzJCRDQ4MiJ9.HLqQfvutk44IC3lA1IhaIxswFaW_hPb2bFX_nel9CVE&leadSource=uverify%20wall

The Errors Of The No Surprises Act

A great Health Affairs Forefront blog on the huge admin and steep payment costs in the No Surprises Act dispute resolution process. While Americans are being sheltered from surprise bills, the process is a mess and appears to be driving up overall costs in the healthcare system. Further, the process is being abused by a small sunset of greedy private equity-baced provider organizations.

A few findings from the blog:

• Providers have brought far more disputes than anticipated.
• They won 85% of the decisions in 2024.
• Providers receive fees that are three to four times the typical in-network rate.
• The high-volume of disputes is generating significant admin costs as well as higher payments. This will be recognized in overall healthcare costs and premiums.
• At least $5 billion in total costs have accrued through the end of 2024.
• In 2023 and 2024, 43% of resolved line-item claims were filed by two private equity-backed provider organizations: Radiology Partners and affiliates and Team Health. The top five provider organizations were responsible for 59% of line-item claims.

This is a tragedy and Congress needs to get a backbone and amend this provider-slanted law.

(Article may require a subscription.)

#nsa #nosurprisesact #transparency #providers #healthplans #surprisebilling

https://www.healthaffairs.org/content/forefront/substantial-costs-no-surprises-act-arbitration-process