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UnitedHealth Group Hits Financial Pothole

The fiscal crisis that other insurers saw in 2024 has now hit UnitedHealth Group. Its stock dropped sharply after the insurance giant slashed its earnings outlook for 2025. Not only did United’s stock drop, but so did the stock of other big health players. And the entire market went down as well Thursday.

United is now seeing the high utilization of other plans in its insurance business. This is especially explosive in Medicare Advantage (MA). MA costs have increased twice as much in 2025 as they did in 2024. United only just learned of this. Not only did its insurance business suffer, but so did its Optum services business, which saw its patient profitability drop as its health plan clients struggled with their finances.

Ironically, United went into the 2025 MA enrollment season excited to enroll a large number of beneficiaries. It performed well. The growth in lives will now add to financial problems.

Elevance Health, the second largest overall insurer, issued guidance early after the United news. It reaffirmed its 2025 guidance. Its assumptions on medical expense were reaffirmed too.

The industry hailed the 5 plus % hike for 2026 in MA, but as I noted struggles would continue due to high utilization across the board but especially in MA. This is the first sign that that is so.

In other news, a good Health Affairs Forefront blog discusses how MA leads to lower cost trends in all of Medicare because of MA policies as well the relationships the private program forms with physicians. Providers change behaviors and that “spills over” to traditional Medicare for savings. The authors think this is still true notwithstanding MedPAC’s arguments on overpayments and beneficial selection. It notes that the government should think twice before tying the hands of MA as it has done of late on prior authorization.

Additional articles: https://thehill.com/policy/healthcare/5254865-unitedhealth-group-stock-drops/ and https://www.beckerspayer.com/payer/elevance-assures-investors-with-reaffirmed-2025-earnings-guidance/ and https://www.modernhealthcare.com/finance/elevance-warns-about-financial-hit-amid-unitedhealth-miss and https://www.healthcaredive.com/news/unitedhealth-unh-cuts-2025-guidance-profit-underperforms-q1/745592/ and https://www.beckerspayer.com/payer/unitedhealth-cuts-earnings-guidance-amid-rising-medicare-advantage-costs/ and https://www.modernhealthcare.com/insurance/unitedhealth-group-earnings-2025-forecast and https://www.healthaffairs.org/content/forefront/medicare-advantage-helping-bend-cost-curve

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#medicareadvantage #healthplans #margins

https://www.fiercehealthcare.com/payers/unitedhealth-group-cuts-profit-outlook-citing-higher-expected-medicare-advantage-care-costs

Trump Executive Order Wants Deeper Drug Price Cuts

In yet another sign President Donald Trump will keep the Medicare drug price law, he issued an executive order that strives to get deeper price reductions in the second year of negotiations (2025 for an effective date of 2027).

The executive order is general. But it does commit to evaluating ways to ensure prices drop more than the average 22% seen in the 2024 negotiations, increase transparency, increase generic introduction and penetration, further importation, and reform pharmacy benefits managers (PBMs) and other middlemen. It also indicates special programs would be set up for the low income. The order will solicit information from the public and stakeholders.

On the other hand, Trump also said the actions would minimize any negative impacts of the maximum fair price on pharmaceutical innovation within the United States. This likely could mean protecting certain small molecule drugs longer from negotiations, which is known as the “pill penalty.” But that could also mean some shortening of large molecule drug protection. Healthcare policy group KFF lays out the impact to the number of drugs negotiated and lost savings if small molecule drug protection is extended. As I have said in the past, I have some sympathy for drug makers on the small molecule issue in terms of parity in the law.

Some are speculating that the order could throw out the entire gross and net price system by eliminating rebates.

The special program could leverage grant conditions at community health centers and other similar groups to lower costs of drugs by passing through discounts received. Others predict that there will be new conditions placed on 340B hospitals as well to pass through drug price reductions.

In two other encouraging signs, the order requires an evaluation of site-neutral payment reform and whether Medicare payment is encouraging a shift in drug administration volume toward costly hospital outpatient departments. Further, the Department of Labor will issue new transparency requirements to ensure that pricing and other arrangements of PBMs are made clear to employer groups that are self-insured.

In other news, Mark Cuban’s Cost Plus Drugs will target drug shortages through an agreement with those in the injectable drug market.

Additional articles: https://www.healthcaredive.com/news/trump-drug-pricing-executive-order-ira-pill-penalty/745539/ and https://insidehealthpolicy.com/daily-news/trump-targets-ira-drug-negotiation-imbalance-new-eo-offers-few-details and https://insidehealthpolicy.com/inside-drug-pricing-daily-news/drug-pricing-eo-reveals-plan-build-cgt-access-model-medicaid and https://www.healthaffairs.org/content/forefront/administration-lays-out-drug-pricing-plan-through-executive-order and https://www.kff.org/policy-watch/the-effect-of-delaying-the-selection-of-small-molecule-drugs-for-medicare-drug-price-negotiation/ and https://insidehealthpolicy.com/inside-drug-pricing-daily-news/eo-leverages-340b-insulin-medicare-pay-address-site-neutral and https://www.beckershospitalreview.com/quality/pharmacy/mark-cubans-drug-firm-targets-injectable-shortages/

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#drugpricing #trump #branddrugmakers #ira #transparency #generics #340b #siteneutral #pbms

https://www.fiercehealthcare.com/payers/trump-order-seeks-changes-medicare-drug-price-negotiation-program-pbm-reform

State AGs Want Healthcare Entities With PBMs Broken Up

A bipartisan group of state attorneys general wants Congress to pass legislation that would break up healthcare entities that own both pharmacy benefits managers (PBMs) and pharmacies. This targets UnitedHealth Group, CVS Health, and The Cigna Group, which control somewhere between 68% and 80% of the PBM market. At issue, too, is co-manufacturing of specialty medications.

More and more state regulation of PBMs is passing. There is a growing bipartisan consensus in Congress for the need to reform PBMs.

Additional article: https://insidehealthpolicy.com/inside-drug-pricing-daily-news/state-ags-demand-congress-ban-pbms-owning-pharmacies

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#pbms #drugpricing

https://www.modernhealthcare.com/politics-policy/cvs-caremark-express-scripts-arkansas-vermont

Drug Imports Will Get Tariffs

The Trump administration is preparing to levy tariffs on imported pharmaceuticals within the next month or two. This is after drugs got a reprieve recently. Lobbies for the generic and biosimilar industries say tariffs could deepen existing drug shortages, raise prices, and harm patient access.

In addition, the Department of Commerce has launched an investigation to assess the impact of pharmaceutical imports on U.S. national security.

Additional articles: https://insidehealthpolicy.com/inside-drug-pricing-daily-news/commerce-says-pharmaceutical-tariffs-coming-next-month-or-two and https://www.beckershospitalreview.com/hospital-management-administration/federal-government-launches-probe-on-drug-imports-5-notes/

#tariffs #healthcare #drugpricing

https://thehill.com/policy/healthcare/5245652-trump-tariffs-pharma-drug-shortages-trade-war-hhs-kennedy

Senate In A Quandary Over Spending Cuts

Conservatives and more moderate members are at odds in the upper chamber after President Trump and the House GOP held firm with a target of at least $1.5 trillion in spending cuts in the budget reconciliation process.

Commitments by Trump and Johnson to rightists in the House was the only reason the bill passed. But Senate Majority Leader John Thune says he has a number of moderates and pragmatic conservatives who have warned that deep spending cuts in healthcare and other areas could mean they are off any final budget bill. Two of the members are in tight re-election campaigns in 2026, which could significantly erode the Senate GOP majority if they lose.

That said, insufficient cuts could doom the bill in the House and perhaps even in the Senate.

#budgetreconciliation #spending #trump #congress

https://thehill.com/homenews/senate/5243579-senate-republicans-divided-budget-cuts/?tbref=hp

House Passes Senate Version Of Budget Reconciliation Framework

The House passed the Senate’s watered-down budget reconciliation framework on a party-line 216-214 vote. While the spending threshold in the bill did not change (it is de minimis), enough conservative Republicans jumped back on the bill after meetings with and pressure from House Speaker Mike Johnson, Senate Majority Leader Jon Thune, and President Trump. Conservatives are distrusting but got commitments from Trump and Johnson that as much as $1.5 trillion in cuts will be in the bill. Senate Leader Jon Thune gave a much softer commitment on levels of cuts.

The House vote likely means that Congress will go after deeper cuts than not. Also controversial is the Senate bill assumes “current policy” not “current law” for budget scoring, which many, including I, call a gimmick that could lead to huge increases in deficits and debt in the future.

The ongoing process will be messy and has great uncertainty.

Additional articles: https://insidehealthpolicy.com/daily-news/house-gop-passes-senate-amended-budget-setting-stage-medicaid-cuts-reconciliation and https://www.modernhealthcare.com/politics-policy/congress-passes-budget-teeing-up-huge-healthcare-cuts and https://www.fiercehealthcare.com/payers/house-budget-plan-advances-paving-way-major-medicaid-cuts

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#budgetreconciliation #trump #congress #spending

https://thehill.com/homenews/house/5241651-house-republicans-trump-budget-framework-vote

House GOP Abandons Budget Reconciliation Vote Tonight

House Speaker Mike Johnson, R-LA, abandoned a vote on Senate reconciliation bill framework after rebellion by conservatives would have sunk the vote. Conservatives are upset by the Senate framework that has almost no spending reductions. In addition, the bill adopts a current-policy vs. current-law scoring of spending and taxes.

The conservatives say the budget gimmick is disingenuous and would set a horrible precedent and drive up deficits and the national debt. The conservatives said they couldn’t move forward as they do not believe the Senate will agree to deep cuts if they pass the framework. The House GOP will now regroup on the issue and see if they can gather votes later in the week to pass the framework.

Additional article: https://www.modernhealthcare.com/politics-policy/house-budget-resolution-medicaid-tax-cuts

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#budgetreconciliation #congress #trump #spending #medicaid #healthcare

https://thehill.com/homenews/house/5241418-johnson-vote-trump-budget-blueprint-conservative-opposition

Trump Backs Deep Spending Cuts

Emerging from a meeting with Speaker Mike Johnson, R-LA, and House Republicans, President Trump declared he is supportive of major spending cuts. The meeting was meant to allay concerns of rightists in the House GOP caucus. Trump wrote on Truth Social: “I let them know that, I AM FOR MAJOR SPENDING CUTS! WE ARE GOING TO DO REDUCTIONS, hopefully in excess of $1 Trillion Dollars, all of which will go into ‘The One, Big, Beautiful Bill.’”

Trump urged the House GOP to support a watered-down budget reconciliation framework from the Senate in the meantime but promised to help assemble meaningful reductions, most of them likely from healthcare. Trump said he would “be pushing very hard” to get deeper cuts.

The budget bill looks to be a battle of the House and conservatives against the Senate and some more moderates who disagree on the level of spending reductions. Each chamber has tiny margins with which to work.

In other news, more evidence Medicare Advantage (MA) could be put on the table for cuts. Republicans support MA but increasingly are critical of risk adjustment overpayments and denial of care in the program.

Additional article: https://www.statnews.com/2025/04/08/republican-budget-plan-calls-for-medicare-advantage-reform-grow-unitedhealth/

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#trump #congress #spending #budgetreconciliation #healthcare #medicaid #medicareadvantage

https://thehill.com/homenews/administration/5239252-trump-says-hes-for-major-spending-cuts-after-meeting-with-house-gop-on-budget-proposal

Medicare Advantage Plans Getting Higher Rates For 2026

The 2026 Medicare Advantage (MA) Final Notice was released this evening by the Centers for Medicare and Medicaid Services (CMS). After the Advance Notice in January, MA plans complained about a paltry rate hike of 2.23%. They asked the Trump administration to intervene and either tweak the risk model change phase-in or the one related to medical education reductions.

Well, the Trump administration didn’t have to really do anything to drive up the 2026 rate. CMS did not change any policies on rates between the advance notice and final one. But the rate hike surged to 5.06% because the rate setting growth factor increased dramatically between the two notices. The change is projected to result in an increase of 5.06%, or over $25 billion, in MA payments to plans in CY 2026.

MA plans and actuaries warned that trends in the program were as high as 9% due to soaring utilization. Indeed, as all of the 2024 claims rolled in (especially Q4) between the first and second notice, the Effective Growth Rate in the rate formula went from 5.93% to 9.04%. The Effective Growth Rate captures per-capita Medicare cost increases. CMS says there is a 10.72% increase in per-capita costs for MA and 8.81% in traditional Medicare.

MA plans have to be happy overall. With the growth rate going up so much, it would have been very hard for the administration to make policy changes in addition to boost the rate higher. It would have been hit with attacks from providers who see either cuts or low hikes. For sure, providers will have issues anyway.

The trend is what the MA plans deserve due to the high cost trends. But, while it is relief, it still means some challenges in 2026 due to robust costs and anticipated further increases.

The development could, though, play a big part in mitigating further benefit reductions, cost-sharing increases, and geographic contractions. As well, it helps smooth financial recovery efforts. A 2.23% hike would have been a disaster for the industry.

Another interesting presentation change: the Biden administration always factored risk score trends at MA plans as part of the overall rate announcement. MA plans hated this as they think it is a recognition of higher risk from year to year — not a true part of a hike. The Trump administration did not include it in its table below (simply noting it in a footnote).

The final notice also stated that CMS will continue adapting the Star Ratings quality measurement and bonus program to the Universal Foundation of measures to streamline measurement across programs. CMS also will preserve the “Health Equity Index” Reward intact but change its name to the “Excellent Health Outcomes for All” Award. Given its effort to expunge diversity, equity, and inclusion from government, some wondered if the Trump administration would simply remove the HEI and leave the Reward Factor in place. The main obstacle was that the HEI as compared with the Reward Factor saves $670M in 2028, growing to $1.08 billion in 2031.

In other news, a new research study finds that intensive coding by MA plans raised enrollees’ risk scores and may have allowed plans to collect $33 billion more in the studied year compared with traditional Medicare. Coding differences that year helped push the average MA enrollee’s risk score 18.5% higher. The researchers found that MA plans also varied widely in their coding intensity and resulting revenue. UnitedHealthcare was singled out as a huge outlier.

I don’t always agree with all these analyses as there are reasons for lower risk scores in FFS tied to physician behavior. But I do think reform is coming and justifiably. The researchers note the impact of health risk assessments and manual chart reviews, which should be reformed.

In addition, the Congressional Budget Office (CBO) estimates that the Medicare Part A Trust Fund’s depletion date is now 2052, seventeen years later than its last report. CBO found that enrollees aren’t seeking hospital care as often as they used to, leading to savings. Medicare’s trustees will release their own findings this spring.

CMS documents: https://www.cms.gov/newsroom/fact-sheets/2026-medicare-advantage-and-part-d-rate-announcement and https://www.cms.gov/newsroom/press-releases/cms-finalizes-2026-payment-policy-updates-medicare-advantage-and-part-d-programs

Additional articles: https://www.fiercehealthcare.com/payers/cms-finalizes-506-medicare-advantage-benchmark-increase and https://insidehealthpolicy.com/daily-news/cms-gives-ma-plans-506-pay-bump-2026-finalizes-phase-risk-adjustment-model and https://www.medpagetoday.com/publichealthpolicy/medicare/115000 and https://www.beckershospitalreview.com/finance/cms-grants-medicare-advantage-25b-funding-increase/ and https://kffhealthnews.org/morning-breakout/medicare-has-enough-in-trust-fund-to-last-an-extra-17-years-cbo-reports/

(Some articles may require a subscription.)

#medicareadvantage #star #quality #rates #hei #healthequity #medicare #riskadjustment

https://www.modernhealthcare.com/policy/medicare-advantage-pay-rate-2026

Trump Administration Finalizes Pared Back MA And Part D Rule for 2026

The 2026 Medicare Advantage (MA) and Part D rule was finalized by the new Trump administration and it did not finalize many portions of the Biden administration proposed rule. These could be acted on after further review or never see the light of day again.

Significant things not finalized:

• New Star changes largely were not finalized, which includes new measures, some Health Equity Index-related clarifications, and removal of guardrails.
• The administration also did not finalize other health equity-related reforms.
• It did not finalize Biden’s proposal to expand GLP-1 weight-loss drugs to those with just obesity but no other underlying disease states (e.g., diabetes). While many could have benefited, it was clear that MA and especially standalone Part D (PDP) plans would have had huge financial outlays here if this were to have been finalized. It would have led to benefit cutbacks in other areas. We need to get drug prices down!
• No medical loss ratio (MLR) changes. Some good ideas in general, but they need to be better thought out.
• No major marketing reforms. This is concerning given what is happening on the enrollment front.

CMS did finalize several things and this is by no means a full list:

• Requiring claims payment for inpatient claims previously approved by prior authorization
• Appeals reforms
• Some supplemental benefit reform related to chronically ill (SSBCI) benefits, but not all proposals in this area
• Risk adjustment technical adjustments
• Some dual eligible experience and integration proposals
• Codifying various aspects of changes in Part D from the Inflation Reduction Act (IRA)
• Some Medicare Prescription Payment Plan codification — not all proposals were finalized
• Prescription Drug Event (PDE) claims submission timeframes
• Other Part D technical issues

The Final Notice for rates and other Star measures should be out Monday as well.

CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/contract-year-2026-policy-and-technical-changes-medicare-advantage-program-medicare-prescription-final

Additional articles: https://www.fiercehealthcare.com/payers/medicare-advantage-final-rule-excludes-anti-obesity-drug-coverage-under-medicare-medicaid and https://insidehealthpolicy.com/daily-news/trump-finalizes-prior-auth-hospital-stay-reqs-medicare-advantage-rule and https://insidehealthpolicy.com/daily-news/cms-declines-finalize-ma-ai-guardrails-expresses-interest-future-ai-regulation and https://thehill.com/homenews/5233357-medicare-medicaid-obesity-biden-trump/ and https://insidehealthpolicy.com/daily-news/cms-scraps-biden-plan-cover-anti-obesity-medications and https://www.modernhealthcare.com/policy/medicare-advantage-prior-authorization-ai

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#medicareadvantage #partd #cms #regulations #star #quality #glp1s #priorauthorization

https://www.modernhealthcare.com/politics-policy/medicare-obesity-drug-coverage-trump