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GLP-1 Drug Makers Go Direct With Employers

Seeing the changes that are coming on drug prices, GLP-1 brand drug makers Eli Lilly and Novo Nordisk plan to sell their popular obesity drugs direct to employers rather than using the traditional drug sales channel that includes pharmacy benefits managers (PBMs) and rebates. In part, this is because price deals with President Trump drop drug costs considerably in Medicare and rebates will go away there. As well, this is to boost sales and get employer groups to keep or expand to obesity coverage for the drugs as opposed to use just for other disease states.

The drug makers will offer Zepbound and Wegovy to companies starting Jan. 1 through Waltz Health, a firm that helps employers purchase cheaper medications. Lilly and Novo already sell direct to cash customers.

While I have applauded the president on his drug agenda, I have doubted parts of the approach because it did not lower price and eliminate rebates for the commercial sector. But this shows that the Trump efforts could over time drop price there. I still think national reform is best, but you have to give credit to Trump for moving intractable Big Pharma – slowly but apparently surely.

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#drugpricing #glp1s #weightlossdrugs #branddrugmakers #pbms

https://www.modernhealthcare.com/insurance/mh-novo-nordisk-eli-lilly-waltz-health

Dems Want Medicare Drug Negotiations Expanded

Democrats in the House have introduced a new bill that would expand Medicare’s ability to negotiate drug prices. The Lowering Drug Costs for American Families Act would allow Medicare to negotiate prices for more drugs each year, moving from 20 to 50, and make them applicable to the commercial market.

#drugpricing #ira #branddrugmakers #medicare #partd #commercial #employercoverage

https://www.fiercehealthcare.com/regulatory/house-democrats-introduce-bill-expand-drug-price-negotiation-commercial-market

Fiery Senate Hearing Casts Doubt On Subsidy Extension

Democrats and Republicans battled at a Senate Finance Committee hearing today on the future of the enhanced Exchange subsidies set to expire at the end of the year. The tone and tenor of the GOP suggested that a clean extension was very much in doubt, at least without major sweeping conservative changes to healthcare, if it happened at all.

Republicans largely indicated they wanted to see the subsidy enhancements expire and instead work on conservative reforms, including expansion of Health Savings Accounts to allow individuals to purchase healthcare of their choice. This comports with President Trump’s views that subsidies should be sent to Americans directly. Sen Bill Cassidy, R-LA and Chair of the HELP Committee, has proposed pairing beefed up HSAs with low-level, high-deductible Bronze Exchange plans. HSAs currently cannot be used to pay for premiums.

Democrats argue the HSA payments would be nowhere close to buy affordable and comprehensive insurance. They also indicated that time does not allow a major overhaul – millions are nearing a doubling of their premiums.

Where Republicans have some solid points is that the fallout from the expiration of the temporary enhancements do point to larger issues with the Affordable Care Act in terms of affordability. Republicans say markets have become overly regulated and very inflationary.

GOP moderates favor a short-term, one-year extension of the enhanced subsidies with some small changes to appeal to conservatives. They say broader reforms can be tackled later.

Additional articles: https://www.modernhealthcare.com/politics-regulation/mh-republicans-hsa-aca-subsidies-insurance/ and https://www.modernhealthcare.com/politics-regulation/mh-senate-finance-committee-hsa-aca-subsidies/ and https://thehill.com/policy/healthcare/5611836-trump-republicans-aca-subsidies-health-care-plan/ and https://www.healthcaredive.com/news/aca-subsidy-unlikely-republican-opposition-senate-finance/805942/

#exchanges #healthcare #coverage

https://www.fiercehealthcare.com/regulatory/republicans-press-hsa-expansion-aca-subsidy-reform-senate-hearing

Trump Says He Wants Direct Subsidies In Healthcare

President Donald Trump declared on social media that he would only consider approving legislation that provides direct healthcare payments to Americans. “THE ONLY HEALTHCARE I WILL SUPPORT OR APPROVE IS SENDING THE MONEY DIRECTLY BACK TO THE PEOPLE, WITH NOTHING GOING TO THE BIG, FAT, RICH INSURANCE COMPANIES, WHO HAVE MADE $TRILLIONS, AND RIPPED OFF AMERICA LONG ENOUGH,” Trump wrote on Truth Social. “THE PEOPLE WILL BE ALLOWED TO NEGOTIATE AND BUY THEIR OWN, MUCH BETTER, INSURANCE. POWER TO THE PEOPLE! Congress, do not waste your time and energy on anything else. This is the only way to have great Healthcare in America!!! GET IT DONE, NOW,” he added.

Senate Minority Leader Chuck Schumer, D-NY, dismissed Trump’s statement as “unhinged ramblings” that will “do nothing to lower” costs. He added the president has no idea how anything works.

Meanwhile, Senate Health, Education, Labor, and Pensions Committee Chair Bill Cassidy, R-LA, is working on a bill that would allow the federal government to contribute directly to individual health savings accounts to help people afford insurance in the Exchanges. Cassidy’s proposal would allow people who sign up for Bronze Plans on the marketplaces to get prepaid accounts to make up for the projected lapse in enhanced subsidies next year. “Who would not want to spend 100 percent of the dollars on the patient choosing the health care she wants, as opposed to 100 percent going to insurance companies and the 80 percent being spent on health care … and that health care is what the insurance company decides that you need?,” Cassidy told reporters.

Of course, both Trump and Cassidy have looked past any number of problems with the schemes. Will the Affordable Care Act (ACA) be changed? While costs are high in the Exchanges, their scheme could force premiums up even more as insurers would be uncertain as to enrollment in the devolved system. The system would be more complicated than even the current one. Do either understand that the premium subsidies and cost-sharing subsidies are only obtained on behalf of the enrollee? What are the insurance alternatives if any? Isn’t Cassidy leveraging the same Exchange system?

As usual, the GOP here is endorsing stunts rather than real reform for affordable, comprehensive coverage.

Additional article: https://thehill.com/homenews/senate/5611143-schumer-trump-health-care-payments/?tbref=hp

#healthcare #exchanges #aca #obamacare #coverage

https://thehill.com/homenews/administration/5610525-trump-direct-healthcare-payments/?tbref=hp

Capitol Hill Abuzz With Exchange Negotiations

Washington, D.C is abuzz with at least some compromise talk on finding a way to extend the enhanced Exchange subsidies Dr. Mehmet Oz, administrator of the Centers for Medicare and Medicaid Services (CMS), said that the Trump administration is “willing to look at all options” regarding the subsidies. “But we have some major flaws with the way these COVID-era subsidies were added. And just so everyone’s on the same page in this issue, our goal is to get people covered,” he added.

At the same time, President Donald Trump wants to send payments to Americans directly instead of to insurers and allow them to purchase their own insurance. The president said he has been talking with Democrats about a direct health care payment plan as one way to tackle rising health insurance premiums. “The insurance companies are making a fortune,” he said. “Their stock is up over a thousand percent over a short period of time. They are taking in hundreds of billions of dollars, and they’re not really putting it back, certainly like they should.” Not quite, Mr. President.

Republicans on the House Ways and Means Committee are considering a bill that aligns with Trump’s pitch, yet they want to tackle what they see as huge fraud in the Exchange program.

Last, Sen. Chris Murphy, D-CT, said he believes it was a mistake for Democrats to reopen the government without a solution on the subsidies.

Additional article: https://thehill.com/policy/healthcare/5608268-dr-oz-comments-aca-flaws/ and https://www.beckerspayer.com/payer/aca/house-republicans-weigh-sending-aca-dollars-to-consumers/ and https://thehill.com/homenews/senate/5608324-murphy-criticizes-democrats-aca-government-funding/

#exchanges #healthcare #coverage

https://thehill.com/policy/healthcare/5608731-trump-democrats-direct-healthcare

Aetna Delays And Changes Downcoding Policy

After major pushback from lawmakers and providers, Aetna is easing a controversial “downcoding” policy for inpatient Medicare Advantage (MA) claims. The insurer said the policy’s start date has been delayed to Jan. 1, 2026 and that its severity review would now apply to urgent or emergent inpatient hospital stays that include at least one midnight but fewer than five. As part of the reimbursement approach, Aetna will approve these inpatient stays without a medical necessity review and cover the claim at a rate that aligns with observation services. Stays of five or more midnights will not be subject to a severity review in the updated policy.

Additional articles: https://www.fiercehealthcare.com/payers/american-hospital-association-urges-aetna-rescind-new-inpatient-policy-payment and https://www.modernhealthcare.com/insurance/mh-aetna-medicare-advantage-downcoding-policy/

(Some articles may require a subscription.)

#aetna #hospitals #claimsdenials #priorauthorization

https://www.beckerspayer.com/payer/aetna-delays-new-inpatient-reimbursement-policy/

Healthcare Costs Continuing to Surge

WTW’s 2026 Global Medical Trends Report indicates that healthcare increases remain “significantly higher” than the 7.6% seen in 2024. Further, healthcare cost increases are projected to rise 9.6% in the U.S. in 2026, only a little less than the 9.7% experienced this year.

Globally, the average cost of health benefits is predicted to rise 10.3%, up from 10% in 2025 and 9.5% in 2024.

Employers add that they believe elevated costs will continue for more than three years, driven by medical costs, regional pressure on pharmacy and outpatient services, and global structural factors. About three-quarters said new medical technologies as the top reason for medical inflation, followed by the decline of public health systems (52%) and advancements in pharmaceuticals (49%).

Cancer tops the list of cost drivers globally.

#healthcare #costs

https://www.healthcaredive.com/news/us-healthcare-cost-increases-expected-to-fall-in-2026/805340

Government to Reopen – Finally!

The House passed the Senate bill to reopen government this evening on a vote of 222 to 209. Six Democrats joined the vast majority of Republicans to pass the bill. Two Republicans voted with Democrats. The bill extends some expiring healthcare programs and delays cutbacks. But it did not include an extension of enhanced Exchange premium subsidies. The Senate leader has promised a vote in mid-December, while the House speaker has yet to make a commitment.

Despite the Democrats’ focus on the subsidy extension, little has been proposed on healthcare reform by either party outside of President Trump’s efforts on drug pricing. Republicans are rumored to be compiling a reform plan that could be pared with some subsidy extension, but in the past the changes meant millions losing coverage.

In other news, hidden in the government funding bill was a provision that overrides budget sequestration rules that may have led to $500 billion in Medicare cuts over ten years.

Additional articles: https://www.modernhealthcare.com/politics-regulation/mh-house-stopgap-funding-bill-aca-subsidies/ and https://www.fiercehealthcare.com/regulatory/shutdown-has-highlighted-washingtons-retreat-big-ideas-healthcare and https://www.modernhealthcare.com/politics-regulation/mh-stopgap-funding-bill-medicare-cuts-shutdown/

#governmentshutdown #congress #trump #exchanges #healthcare #coverage #medicare #healthcarereform

https://thehill.com/homenews/house/5603344-house-bill-government-shutdown

With Government Shutdown Ending, GOP Struggles With Obamacare

With the government funding bill almost assuredly to pass the House Wednesday, the GOP will next have to turn to what to do with the expiring enhanced Exchange subsidies and perhaps some healthcare reform in general.

Senate Majority Leader John Thune, R-SD, promised a vote on the subsidies by mid-December, but House Speaker Mike Johnson, R-LA, refuses to make any commitment on a vote. Moderate GOPers in the Senate and about several dozen moderates in swing districts in the House GOP caucus want a vote and some sort of extension. Various potential compromises are being discussed including an income cap, minimum premiums, and an extension vs. permanency.

The GOP may also want to pass healthcare reform changes but have yet to truly put up a plan. Conservatives, such as Rep. Majorie Taylor Greene, R-GA, have been pressuring the Speaker to pass yet another budget bill with reductions and reforms. They have criticized the GOP leadership for having no plan.

The GOP has never crafted a healthcare plan that did not mean millions losing coverage. The party favors individual purchasing, health savings accounts, ICHRA health reimbursement, and alternative plans that fall short of comprehensive coverage.

The president this weekend proposed that subsidies that go to insurance companies go directly to those in need, but the treasury secretary had to quickly point out there is no real plan for this.

#healthcare #coverage #exchanges #obamacare #aca

https://thehill.com/newsletters/the-movement/5599435-shutdown-health-care-republicans

Trump Wants Healthcare Subsidies To Go To Individuals But Has No Detailed Plans

Over the weekend, President Donald Trump declared that his solution for the Exchange subsidy stalemate and high costs in healthcare generally is to have subsidies go directly to individuals to purchase healthcare. But Treasury Secretary Scott Bessent said Monday that there is really no formal plan. Apparently, it was just musings from the president, along with a frontal assault on what he called “money sucking insurance companies.”

The president’s social media post stated: “I am recommending to Senate Republicans that the Hundreds of Billions of Dollars currently being sent to money sucking Insurance Companies in order to save the bad Healthcare provided by ObamaCare, BE SENT DIRECTLY TO THE PEOPLE SO THAT THEY CAN PURCHASE THEIR OWN, MUCH BETTER, HEALTHCARE, and have money left over. In other words, take from the BIG, BAD Insurance Companies, give it to the people, and terminate, per Dollar spent, the worst Healthcare anywhere in the World, ObamaCare. Unrelated, we must still terminate the Filibuster!”

But of course, terminating Obamacare (the Medicaid expansion and Exchanges) would send millions onto the rolls of the uninsured. The subsidies would be meaningless for those unable to access healthcare via employer coverage, especially those with significant health risks. And the proposal does little to nothing on affordability itself.

Republicans are supposedly putting together a reform plan, including encouraging individual options and health savings accounts, banning Silver loading in the Exchanges perhaps by funding cost-sharing subsidies, and expanding employer-funded health reimbursement accounts to help consumers buy individually. The GOP also may expand short duration plans and association plans as well as further limit provider taxes and other spending in Medicaid.

The Affordable Care Act does need some reforms to bring more affordability, but the Republican plans remain a mishmash of prior proposals that fell short of comprehensive reform and coverage.

Additional articles: https://www.axios.com/2025/11/08/trump-affordable-care-act-subsidies-shutdown and https://www.modernhealthcare.com/politics-regulation/mh-republicans-aca-site-neutral-payments-shutdown/ and https://thehill.com/homenews/administration/5596505-donald-trump-filibuster-reform-health-insurance-democrats-government-shutdown/ and https://thehill.com/policy/healthcare/5597877-government-shutdown-aca-debate/?tbref=hp

(Some articles may require a subscription.)

#aca #obamacare #exchanges #medicaid #healthcare #coverage

https://www.cnbc.com/2025/11/08/trump-republicans-health-insurance.html