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SOTU Has Little On Healthcare

President Trump touted his accomplishments in his State of the Union address Tuesday but spent little time on affordability in healthcare. In the speech he did hit two main topics, but just for a total of five minutes of the marathon speech.

• The Great American Health Plan announcement – Trump doubled down on his desire to shift subsidy and support dollars from insurers to individuals to pick their own healthcare. In the speech and his original announcement, few details have been given about exact mechanisms for the proposal. It is more of an outline than a real plan. He shied away from mentioning the expired enhanced Exchange subsidies.
• Lower prescription drug prices – He also championed the work he has done on prescription drug prices. Here he has amassed a more comprehensive record, with a series of executive orders, most-favored-nation (MFN) model proposals for Medicaid and Medicare, and price negotiations with drug makers to lower prices.

I was not impressed with the vagueness of his health insurance coverage proposal but have given Trump a great deal of credit on moving the drug price needle. No one has been able to really do the latter before.

#trump #healthcare #coverage #drugpricing

https://www.healthcaredive.com/news/trump-state-of-the-union-healthcare-2026/812962

CBO: Medicare Part A Trust Fund Bust in 2040

The Congressional Budget Office (CBO) has updated its estimates around the solvency of the Medicare Part A Trust Fund and now expects the fund to go bust in 2040. The balance will grow each year through 2031, but then spending will begin to overtake revenue until it eventually runs out in 2040. This is 12 years less than the last estimate.

The culprits are:

• Lower taxes in the One Big Beautiful Bill Act (OBBBA).
• Accelerating medical cost and spending in both traditional Medicare and Medicare Advantage (MA).

The CBO’s projection is better than the Medicare’s trustees’ last projection, which said the fund would be depleted by 2033.

Additional article: https://www.fiercehealthcare.com/regulatory/cbo-estimates-medicare-trust-fund-will-run-out-2040

#medicare #spending #insolvency

https://www.healthcaredive.com/news/medicare-trust-fund-expire-2040-cbo-gop-obbb/812937

Exchange Enrollment Expected To Drop

While actual enrollment during the open enrollment season in the Exchanges did not drop a great deal, the cost of not extended enhanced subsidies is now appearing to take hold. State Exchanges as well as health plans are reporting cancellations as well as lack of premium payments, which could send rolls dropping dramatically throughout the year. As one example, the biggest Exchange plan nationwide, Centene, says it expects its rolls to drop over one-third this quarter. Cigna, Elevance Health, Molina Healthcare, and UnitedHealthcare anticipate collectively losing approximately 3.4 million exchange members by the end of 2026. 

(Article may require a subscription.)

#exchanges #enrollment #healthplans #coverage

https://www.modernhealthcare.com/insurance/mh-aca-exchanges-membership-premium-payments

Congress Inches Toward Site Neutral Payments

Congress didn’t pass site neutral payments in Medicare but did make some incremental progress toward the reform in the FFY 2026 appropriations bill that was recently passed. This could lead to cuts to the tune of billions of dollars in hospital reimbursements in the future.

The bill requires health systems to obtain unique National Provider Identifiers, or NPIs, for their outpatient departments by 2028. This will have the effect of giving the government detailed information about outpatient care provided at hospital-owned facilities — and its cost — to support broader site-neutral policies.

The Trump administration did implement site neutral payments for drug administration via regulation this year. That follows some other modest reforms several years ago. Site neutrality pays the same rate to provider regardless of the site the service is performed at – physician office, ambulatory surgery center, off-campus hospital outpatient department, or on-campus hospital outpatient department.

(Article may require a subscription.)

#hospitals #siteneutral #medicare

https://www.modernhealthcare.com/politics-regulation/mh-congress-outpatient-pay-site-neutral-reform/

— Marc S. Ryan

SNPs Up; Major Plan Terminations In MA

Two new articles on the 2026 open enrollment season in Medicare Advantage (MA).

A Modern Healthcare analysis says membership in Special Needs Plans, or SNPs, is now 8.2 million as of Feb. 1, up 12.2% from a year before. While enrollment growth overall slowed from 2025 to 2026, SNP growth actually went up. SNP growth was 10.1% in 2025. About a quarter of all enrollees are now in SNPs.

A study in JAMA examined the major contraction in MA and rates of forced moves. It found that one in 10 MA enrollees were forced to disenroll from their current product choice heading into 2026 due to insurer exits or contractions. That is a ten-fold increase from historic averages and is up from 6.9% in 2025. Among the 28.6 million MA enrollees that were part of the study sample, 2.9 million were forced to find new coverage for 2026, with an estimated 25.8 million able to retain their current plan.

Smaller insurers accounted for 48.8% of forced disenrollments. Twelve states had more than 20% of their MA enrollees facing forced disenrollment.

The 2.9 million figure is similar to other studies, including one that estimated an impact to 2.6 million.

You can read my analysis on the 2026 enrollment season here: https://www.healthcarelabyrinth.com/2026-medicare-advantage-enrollment-season-good-news-bad-news/

Additional article: https://www.modernhealthcare.com/insurance/mh-medicare-special-needs-plan-enrollment-2026/

(Some articles may require a subscription.)

#medicareadvantage #enrollment

https://www.beckerspayer.com/payer/medicare-advantage/10-of-medicare-advantage-enrollees-forced-to-switch-plans-for-2026-study/?origin=PayerE&utm_source=PayerE&utm_medium=email&utm_content=newsletter&oly_enc_id=1115F9468978C5V

— Marc S. Ryan

More Bad News On Affordability Front

A new Commonwealth Fund report finds that middle-income workers and their families are spending an average of 10.1% of median income on their health premiums and deductibles. The 2024 data from the employer-sponsored insurance market show that premium contributions for family coverage ranged from an average of $5,584 in Oregon to $9,148 in California. In 19 states, the average premium and deductible contribution topped 10% of that state’s median income. Costs varied by region, industry, and employer size. Five states’ costs breached the affordability metric under the Affordable Care Act (ACA), which could trigger coverage in the Exchanges.

The researchers recommend employers adjust out-of-pocket requirements and premiums based on the income of employees. The report also notes one of my key reform recommendations – a shift in the broader trends around healthcare pricing and spending.

#healthcare #coverage #affordability

https://www.fiercehealthcare.com/payers/family-premiums-account-10-income-19-states-commonwealth-fund

UHG Still Made The Most

Despite major financial challenges, UnitedHealth Group still made the most of the major national health plan vertically integrated behemoths in 2025. UHG brought in just over $12 billion in earnings for 2025. That was followed by Cigna at about $6 billion, with Elevance Health at almost $5.7 billion. CVS Health was at about $1.8 billion and Humana at about $1.2 billion. Centene lost $6.7 billion. Most of the plans see 2026 as yet another transition year with improving results.

#healthplans #margins

https://www.fiercehealthcare.com/payers/unitedhealth-group-was-most-profitable-payer-difficult-2025-industry

GOP Worried On Affordability

Some Senate Republicans are worried that the GOP leadership is not doing enough on the affordability issue as the 2026 midterms approach. Right now, the House is almost assuredly going back to the Democrats, while the Senate is favored for the GOP but getting too close for comfort.

Sen. John Kennedy, R-LA, has been urging Republicans to pass a second reconciliation bill to pass additional healthcare measures. President Trump has dismissed the idea of yet another bill, but House Republicans want to pass a second one as well. Lawmakers could still do so over the president’s objections.

#healthcare #coverage #midterms

https://thehill.com/homenews/senate/5738150-republicans-affordability-midterms

2026 Medicare Advantage Enrollment Finally Published

After a long delay, the Centers for Medicare and Medicaid Services finally published results for January and February for Medicare Advantage (MA). While many predicted that the program would contract, I had said that enrollment would be flat or one of the lowest growths we had seen recently. Some analysts suggested that there would be a decline because of the mass exodus of large plans from certain markets and efforts by them to shed huge enrollment.

But despite the huge challenges in the program, MA showed some resiliency. Enrollment in February 2025 was 34.941 million. In December 2025, MA had 35.700 million members. In February, we saw 35.814 million. January numbers showed a contraction from December of about 400K. We know January 2025 numbers had some issues. That could also be the case for January 2026. But February 2025 to February 2026 numbers showed a growth of 873K or 2.5%. The open enrollment slump was not close to the 1M some had said it might be.

It appears that seniors and the disabled continued to see the value of MA compared with traditional Medicare and sought out the best plan they could, including with their existing insurer or smaller and regional players in place of big national plans.

UnitedHealthcare is down over 900K. Humana is up about 1.2M. Elevance Health is down over 300K, with CVS Aetna down over 100K.

#medicareadvantage #enrollment

https://www.cms.gov/data-research/statistics-trends-and-reports/medicare-advantagepart-d-contract-and-enrollment-data/monthly-enrollment-plan

Aledade Touts Primary Care and VBC Growth

Value-based enablement company Aledade added more than 700 primary care practices to its network for 2026 and sees strong momentum for value-based care (VBC) growth.

Aledade has more than 3,000 primary care organizations across the country with over 3 million patients in VBC programs. These include Medicare Shared Savings Program (MSSP), Medicare Advantage (MA), Medicaid, and commercial contracts.

Transition to VBC from transaction payments has been slow with a mixed record on savings and better outcomes. See my blog today on VBC: https://www.healthcarelabyrinth.com/the-2027-aca-exchange-rule-the-good-and-bad/ .

In other news, Humana President and CEO Jim Rechtin said the company is looking to expand its primary care footprint. He says a strategic acquisition should be announced soon. But as I noted earlier and Becker’s says in its article, the biggest national health plans are under heavy criticism about sweet-heart deals of plans and pharmacy benefits managers (PBMs) with sister company entities. A Health Affairs analysis found that plans using their own providers can inflate medical spending figures and limit their rebate responsibilities. United’s ambulatory surgery center (ASC) acquisitions led to steep price increases for competing insurers. The study’s authors want disclosure of internal payment arrangements.

Additional article: https://www.beckerspayer.com/m-and-a/humana-ceo-hints-at-upcoming-primary-care-deal/

#healthplans #verticalintegration #providers #vbc

https://www.fiercehealthcare.com/providers/aledade-grows-value-based-care-network-3000-primary-care-practices