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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/

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#healthcare #healthplans #healthcarereform #affordability

https://thehill.com/policy/healthcare/5701982-health-care-costs-insurance-ceos-testimony

UHG To Give Profits Back To Exchange Enrollees

In an effort to forestall charges against it over healthcare affordability, UnitedHealth Group announced today that it plans to give profits from its Exchange plans back to customers in 2026. Several top executives from the biggest plans will appear before two House committees Thursday as the GOP seeks to insulate itself from the affordability crisis. UnitedHealthcare offers plans on the exchanges in 30 states, and it expanded its service area in 11 of those regions. It is unknown how much money that is or if United will make a profit.

Additional articles: https://www.modernhealthcare.com/insurance/mh-unitedhealth-aca-rebates-congress/ and https://www.fiercehealthcare.com/payers/unitedhealth-ceo-hemsley-says-insurer-will-rebate-aca-profits-consumers and https://www.healthcaredive.com/news/unitedhealth-to-return-aca-profits-to-customers-hemsley/810183/ and https://www.modernhealthcare.com/politics-regulation/mh-stephen-hemsley-david-joyner-congress/

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#unitedthealthcare #healthplans #congress #affordability #exchanges

https://thehill.com/policy/healthcare/5699770-unitedhealth-group-affordable-care-act-profits

Bipartisan Lawmakers Announce Deal To Keep Government Open

A bipartisan deal was announced that would keep the federal government open for the rest of federal fiscal 2026 (to Septemeber 30) and enact long-sought healthcare changes. Given the bipartisan and bicameral nature of the deal, the bill likely can be passed by the end of July when the government would otherwise partially shut down. But some fear conservatives in each chamber could oppose the deal on budgetary grounds.

Medicare telehealth coverage would be extended for two years. The Medicare hospital-at-home program would be extended for five years. The bill would also move further toward site-neutral payments in Medicare.

Medicare Advantage (MA) plans would be required to maintain accurate provider lists and patients who visit providers erroneously due to bad data would only have to pay in-network rates. The bill doesn’t include limits on MA prior authorization.

The bill also boosts pay to physicians participating in Medicare alternative payment models and enacts pharmacy benefits manager (PBM) reform (including transparency and flat compensation fees).

The package does not address extending the enhanced Exchange subsidies in any form. Medicare physician pay is not broached, either. Trump’s “Great Healthcare Plan elements are not included but would likely be in a GOP only reconciliation bill later.

Additional article: https://www.fiercehealthcare.com/regulatory/house-appropriations-committee-releases-health-funding-proposal

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#governmentshutdown #congress #healthcare #coverage #pbms #medicare #siteneutral #medicareadvantage

https://www.modernhealthcare.com/politics-regulation/mh-pbm-telehealth-extension-congress-health-funding

— Marc S. Ryan

Exchange Compromise Appears To Be Fizzling

Prospects for a compromise bill in the Senate on an enhanced Exchange subsidy extension compromise appear to be fizzling. I have said the chance is at best 50-50 and now those odds are even dwindling. The negotiating group has failed to reach agreement on two of the biggest sticking points – allowing some or all of the dollars to move to health savings accounts (HSAs) and stricter “Hyde amendment” abortion restriction language. Meanwhile, some Democrats are also arguing the minimum premium of $5 or $10 per family per month is unaffordable for those who are low income. The GOP argues zero premiums have led to fraudulent enrollment.

On the home front, states and plans are waiting to see what the fallout of an average 26% premium hike and 114% hike for subsidized individuals will mean. The latest statistics say that enrollment is only down 800,000 from his time last year. But states are seeing drop-offs happening as people were required to pay their first premium before their January or February effective date. We will see what the real fallout is.

Meanwhile, Donald Trump is touting the $50 billion rural health fund as one solution to the affordability crisis. The funding was not the president’s idea but a last-minute add to get certain senators to vote yes. Vulnerable Republicans in 2026 joined him at a White House event.

Additional articles: https://www.nbcnews.com/politics/congress/senate-aca-funding-talks-fizzle-higher-premiums-take-effect-millions-rcna254227 and https://www.cbsnews.com/news/senators-aca-premium-tax-credits-extension-bipartisan-deal-stalled/ and https://www.politico.com/live-updates/2026/01/15/congress/the-senates-bipartisan-health-care-talks-are-on-shaky-ground-00732678 and https://www.politico.com/news/2026/01/15/democrats-make-pitch-to-keep-no-premium-obamacare-plans-00729669 and https://kffhealthnews.org/news/article/aca-obamacare-premium-payments-prices-marketplace-plans-hard-choices/ and https://www.modernhealthcare.com/insurance/mh-aca-enrollment-premium-payments/ and https://thehill.com/policy/healthcare/5692996-trump-rural-health-fund-affordability/

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#exchanges #healthcare #coverage #affordability

https://thehill.com/homenews/administration/5692760-trump-rural-health-roundtable

Trump’s “Great Healthcare Plan”

President Donald Trump made a major healthcare announcement today, calling his reform framework “The Great Healthcare Plan.” But the announcement provided few details and leaves much of the work to Congress. GOP lawmakers do appear to be crafting ideas to limit exposure on healthcare unaffordability, but extending the expired enhanced subsidies may not be part of the deal.

Here is the very skeletal outline of the president’s proposals:

• Codifying both his proposed drug price models adopting most-favored-nation (MFN) pricing as well as the concessions deals he gained from 16 of 17 big drugmakers.
• Expanding over-the-counter and generic drug introduction.
• Existing subsidies in the Exchanges appear as if they will go directly to Americans in need and dollars deposited in individual Health Savings Accounts (HSAs).
• The cost-sharing reduction subsidies would again be appropriated after Trump himself zeroed it out in Trump 45. The move would save taxpayers at least $36 billion and reduce the most common Obamacare plan premiums by over 10%. A small cohort could be harmed.
• The plan would “end the kickbacks” from pharmacy benefits managers (PBMs) that are paid to what Trump calls the large brokerage middlemen “that deceptively raise the cost of health insurance.” This is a reference to big GPO buying firms, the largest owned by some of the biggest PBMs.
• The plan also would expand insurer transparency, including on medical claims denials, claims payments, wait times, prices, and more.
• Insurers would need to provide rate and coverage comparisons upfront on their websites in “plain English” to help consumers more easily shop for plans.
• Disclosure of medical loss ratios would also be mandated.

President Trump deserves a great deal of credit on drug price reform, but otherwise the deal is not well thought out and does not tackle the true reason for a lack of affordability – price in the market. I will give more details in a blog soon.

Additional articles: https://www.fiercehealthcare.com/regulatory/trump-takes-aim-insurance-industry-unveiling-great-healthcare-plan and https://www.beckerspayer.com/policy-updates/trump-pitches-healthcare-policy-outline-aimed-at-lowering-costs-3-takeaways/ and https://www.cnn.com/2026/01/15/politics/trump-health-care-plan and https://apnews.com/article/trump-health-care-insurance-congress-savings-accounts-b7b4caae9ad14fda4646c42d3858202b and https://www.cnbc.com/amp/2026/01/15/trump-congress-aca-subsidies-health-care.html and https://www.whitehouse.gov/articles/2026/01/president-trump-unveils-the-great-healthcare-plan-to-lower-costs-and-deliver-money-directly-to-the-people/ and https://www.whitehouse.gov/wp-content/uploads/2026/01/The-Great-Healthcare-Plan.pdf and https://thehill.com/policy/healthcare/5691065-trump-health-care-affordability-plan/ and https://www.healthcaredive.com/news/trump-great-healthcare-plan-affordability-aca/809759/ and https://www.medpagetoday.com/publichealthpolicy/healthpolicy/119456

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#healthcare #healthcarereform

https://www.modernhealthcare.com/politics-regulation/mh-trump-great-healthcare-plan-drugs-premiums

CMS Actuary Releases 2024 Healthcare Spending

Each year, the Centers for Medicare and Medicaid Services (CMS) Office of the Actuary releases annual healthcare expenditures for the prior year. This year the release was delayed due to the government shutdown.

The Actuary found that the U.S. spent $5.28 trillion on healthcare in 2024, a 7.2% increase from the prior year. The robust growth shows the challenges ahead for healthcare. It was the second consecutive year costs trended up more than 7%. Healthcare accounted for 18% of gross domestic product (GDP) in 2024, up slightly from 2023.

Spending on hospital care grew 8.9% to $1.6 trillion. Spending on physician and clinical services increased 8.1% to $1.1 trillion. The Actuary said prices are a factor but non-price factors, such as utilization, were the driver. CMS’ actuaries attributed about 1% of the gain to population growth, 2.5% to price increases, and 3.6% to remaining nonprice factors.

I will have a deep dive into the Actuary’s report next week at my blog site.

The Census Bureau also released healthcare statistics this week based on the 2024 Current Population Survey. The typical working family in the U.S. spent $3,960 on healthcare-related costs in 2024, including premiums and out-of-pocket expenses. One in eight working families spent more than 10% of their income on healthcare. Ten percent of working families paid more than $14,800 in premiums and out-of-pocket costs. The low income and those from rural areas spent the greatest percentage of income on healthcare.

Additional articles: https://www.modernhealthcare.com/politics-regulation/mh-health-spending-2024-cms/ and https://www.healthcaredive.com/news/us-healthcare-spending-2024-cms-health-affairs/809578/ and https://www.medpagetoday.com/publichealthpolicy/medicare/119435 and https://www.beckershospitalreview.com/finance/average-us-family-spent-nearly-4k-on-healthcare-in-2024-report/

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#healthcare #expenditures #nhed #cms

https://www.fiercehealthcare.com/finance/cms-us-total-healthcare-spending-rose-72-53t-2024

Exchange Compromise Is Slipping

Sen. Bernie Moreno, R-OH, a leading supporter of a compromise on extending enhanced Exchange premium subsidies, says a deadline of the end of January has been set for having a compromise framework ready and that the main holdup remains abortion. The earlier goal of having a bill this week will not be met.

Meanwhile, the Republican Study Committee, the largest caucus of conservatives in the House, unveiled a framework for a second reconciliation bill. Such a bill would only need a majority in each house to become law. The bill addresses affordability broadly and includes some provisions on healthcare.

• Exchange subsidies would migrate from going to health plans in the Exchange to Health Savings Accounts (HSAs).
• Cost-sharing reduction subsidies in the Exchange would be appropriated again, although that was ruled out of compliance with the Senate’s Byrd rule on the One Big Beautiful Bill Act passage in 2025.
• Pharmacy benefit manager (PBM) reform would be implemented.
• Penalties would be assessed on states that do not prohibit immigrants in the country illegally from enrolling in Medicaid.
• Other new regulations and cuts to Medicaid would also be included.

Additional article: https://thehill.com/homenews/house/5686728-gop-housing-health-energy-reforms/?tbref=hp

#exchanges #healthcare #coverage #pbms #medicaid

https://thehill.com/homenews/senate/5687461-senate-obamacare-compromise-deadline

Trump May Veto Subsidy Bill If Passes; Exchange Enrollment Down So Far

The Centers for Medicare & Medicaid Services (CMS) reports that about 22.8 million consumers have signed up for 2026 individual market Exchange coverage through Jan. 3. This is surprisingly robust with 12 more days to enroll. About 21.4 million enrolled in 2024 and about 24.3 million enrolled in 2025. About 23.6 million people enrolled in the Exchanges plans through Jan. 4, 2025. The 800,000 drop so far is likely less than most had expected. The Congressional Budget Office (CBO) said 2.2 million will lose coverage in 2026 due to the expiring enhanced subsidies. The CBO said an average of 3.8 million more uninsured people annually would result from 2026-2034.

The results so far include 15.6 million Exchange selections in the 30 states using the HealthCare.gov platform for the 2026 plan year and 7.2 million plan selections in the 20 states and the District of Columbia with state-based Exchanges (SBEs) that are using their own eligibility and enrollment platforms. Total nationwide plan selections include 2.8 million new consumers and 20 million consumers who had active 2025 coverage.

Meanwhile, President Trump says he may veto any subsidy extension that passes Congress.

In other news, interesting Politico coverage on Sen. Bernie Moreno, a MAGA Republican who is leading the fight for some sort of compromise on Exchange subsidies. He says reviving Obamacare subsidies would be “putting America first.”

Further, three states have extended open enrollment – Connecticut, Illinois, and Pennsylvania. Pennsylvania says it is shedding a thousand people daily due to premium hikes, which could lower the 22.8 million reported by CMS.

Additional articles: https://www.reuters.com/business/healthcare-pharmaceuticals/trump-says-he-may-veto-extension-obamacare-subsidies-2026-01-12/ and https://www.politico.com/news/2026/01/12/bernie-moreno-obamacare-talks-00719585 and https://www.beckerspayer.com/payer/aca/3-states-extending-open-enrollment/ and https://www.beckerspayer.com/payer/aca/pennsylvania-aca-exchange-losing-1000-enrollees-daily-after-subsidies-expire/ and https://www.cms.gov/newsroom/fact-sheets/marketplace-2026-open-enrollment-period-report-national-snapshot-0

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#exchanges #coverage #healthcare

https://www.fiercehealthcare.com/regulatory/legislators-revive-aca-debate-hill-trump-seeks-meeting-insurers

J&J Becomes Latest Drug Firm To Strike Price Deal

Johnson & Johnson arrived at a deal with the Trump administration to lower prices for certain prescription drugs in exchange for tariff relief. As with other deals, J&J will offer specific drugs for sale directly to consumers at significant discounts through the Trump administration’s TrumpRx website. It will offer its drugs to the Medicaid program at comparable prices to other developed countries. It will also give the most-favored-nation (MFN) price on new drug introductions.

J&J said it is planning two new U.S. manufacturing facilities as part of a previously announced $55 billion investment.

#drugpricing #branddrugmakers #mfn  

https://thehill.com/policy/healthcare/5681535-johnson-johnson-trump-drug-prices/?tbref=hp

The Courageous 4 Becomes The Courageous 17

The House voted 230-196 to extend enhanced Exchanges premium subsidies for three years as is, with 17 GOP lawmakers joining Democrats. This was after four GOP members signed on to a discharge petition to force a vote. House Speaker Mike Johnson, R-LA, and other leaders are livid, but the members were courageous to buck their party to cast a vote they believed in. They tried very hard to get the GOP leaders to agree to a compromise and even simply to hold a vote. Johnson broke his word on the vote under pressure from head-in-the-sand conservatives.

The measure is not expected to pass the Senate as a similar bill failed to reach 60 votes there, but a compromise continues to be negotiated in the upper chamber between moderates on both sides of the aisle, which then would face a rocky road back in the House with the GOP leaders. I have predicted chances at best are 50-50. I covered the details of a potential compromise in the newsfeed yesterday. The vote today certainly helps on the momentum front.

Additional articles: https://www.healthcaredive.com/news/house-votes-revive-enhanced-aca-subsidies/808871/ and https://www.modernhealthcare.com/politics-regulation/mh-aca-subsidies-house-vote-insurance/ and https://www.medpagetoday.com/publichealthpolicy/washington-watch/119347 and https://thehill.com/homenews/house/5680184-obamacare-tax-credits-bill-passes-house/ and https://thehill.com/homenews/senate/5679302-democrats-push-thune-obamacare-vote/ and https://www.beckershospitalreview.com/finance/house-approves-3-year-aca-subsidy-extension/

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#exchanges #healthcare #coverage

https://www.fiercehealthcare.com/regulatory/legislators-revive-aca-debate-hill-trump-seeks-meeting-insurers