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Government Funding Deal In Flux, But GOP To Push Democrats To Acquiesce This Weekend

While bipartisan talks continue, today saw the two parties argue over a government funding bill and the parties appear further apart in the Senate. Senate Minority Leader Chuck Schumer, D-NY, proposed a bill that would fund some parts of government for the year and others partially, enact some additional funding being negotiated between the parties, and provide a one-year extension of enhanced Exchange premium studies. Republicans rejected the Democratic proposal.

Instead, the Republicans will challenge Democrats to reject a bill based on the same bipartisan negotiations to fund some parts of government for the year and extend other funding to January. There would be no deal on subsidies. Senate Majority Leader John Thune, R-SD, has committed to a vote on subsidies later, but House Speaker Mike Johnson, R-LA, has refused to do so, and Democrats believe President Trump will also refuse a subsidy extension and continue his campaign to downsize government and lay off workers.

The GOP hopes that over the weeekend that eight Democratic senators will vote on the planned GOP measure to achieve the 60 votes needed for passage. The bill would then have to go to the House due to material changes.

Additional articles: https://www.medpagetoday.com/washington-watch/washington-watch/118374 and https://thehill.com/homenews/senate/5595759-senate-gop-democratic-offer-shutdown/ and https://thehill.com/homenews/senate/5595545-schumer-plan-government-shutdown/ and https://thehill.com/homenews/senate/5594333-government-shutdown-deal-democrats-trump/

#governmentshutdown #congress #trump #exchanges #healthcare #coverage

https://www.fiercehealthcare.com/regulatory/shutdown-tracker-cms-issues-billing-guidance-hhs-furloughs-32000-employees

Trump Announced GLP-1 Deals With Brand Drug Makers

The Trump administration announced two major drug-related reforms today.

The Centers for Medicare & Medicaid Services (CMS) announced a new model that aims to bring most-favored nation (MFN) pricing to the Medicaid space. Second, President Trump personally announced lower prices for self-pay and Medicare customers for GLP-1 and some other drugs.

CMS says it will launch the GENErating cost Reductions fOr U.S. Medicaid (GENEROUS) model. State Medicaid programs will be able to purchase certain drugs at prices that align with what is paid in other countries beginning in 2026. Through the model, CMS will negotiate with participating pharmaceutical companies to bring down prices.

In addition, Medicare will cover GLP-1 semaglutide and tirzepatide at much lower prices and this appears true for chronic conditions, these conditions with underlying obesity, and apparently obesity alone. “Until now, neither of these two popular drugs have been covered by Medicare for weight loss, and only rarely by Medicaid,” Trump said during a press conference in the Oval Office. “That ends starting today …. This will improve the health of millions and millions of Americans.” Medicare will pay $245 for semaglutide and tirzepatide, with $50 copays for the medicine for enrollees.

As well, in 2026, doses of Novo Nordisk and Eli Lilly’s blockbuster drugs for patients without insurance will be priced at $350 through TrumpRx for a month’s supply. Starter doses will be as low as $149 per month. They are currently well over $1,000 per month on a list basis. Starting doses of new pill versions of the treatments that will come to market will cost $149 a month.

There is confusion on whether GLP-1s indeed will be covered in Medicare for obesity alone and whether aspects of the announcement are mandatory or voluntary. In November 2024, the Biden administration proposed Medicare and Medicaid coverage of GLP-1s for obesity alone. The Trump administration did not finalize the rule, which reinterpreted obesity as a qualifying disease state in Medicare. The Trump administration argued at the time it would lead to huge cost increases at current prices.

But that may have changed with the new prices. Trump’s remarks and other officials seem to say that Medicare will be opened up to GLP-1 coverage for obesity alone. The government provided little details, however. Reports suggest that savings generated for existing prescriptions will be used to provide new coverage for GLP-1s to patients with obesity. A Novo-Nordisk press release says that Part D coverage for anti-obesity medicines will be enabled through a pilot program designed to cover a majoirty of Part D beneficiaries.” Does that voluntary program cover both extending the coverage to those with obesity alone as well as capping cost-sharing at $50 for everyone on the drug for any disease state? The latter copay issue would be similar to what Trump did in Trump 45 for insulin prices. Or, on the issue of coverage for obesity, will Trump do this via rule, effectively backtracking on striking down what Biden proposed.

Complicating all this is when will it begin. An Eli Lilly press release suggests the $50 cap in costs for enrollees begins as early as 2026. But benefit design and bids have long been put to bed.

Medicare was already expanding GLP-1 coverage from diabetes and heart disease to other disease states, such as prediabetes with obesity. Even with the discounts, liberal expansion of GLP-1 coverage could mean a huge surge in Medicare Part D costs. As well, note that the price is not nearly as low as other developed nations, which have prices below $200 and sometimes closer to $100 for a monthly supply.

Eli Lilly and Novo Nordisk also agreed to discount other medicines. Eli Lilly will provide Emgality at $299 per pen and Trulicity at $389 per month. Novo Nordisk will offer insulin products, including NovoLog and Tresiba, at $35 per month.

Both companies also committed to repatriating foreign revenue, applying MFN pricing to future drugs, and extending pricing to all state Medicaid programs. Novo Nordisk will invest an additional $10 billion in U.S. manufacturing, and Eli Lilly pledged at least $27 billion.

The agreement is separate from ongoing Medicare drug price negotiations.

In other news, a study by Epic Research found that 56% of semaglutide, 52% of liraglutide, and 55% of tirzepatide patients kept the weight off or lost additional weight after stopping GLP-1 use. The study tracked 188,722 patients who stopped taking the drugs after at least 90 days of use for treatment of obesity and had an initial weight loss of 5+ pounds. Complete weight regain occurred in 23% of semaglutide, 21% of tirzepatide, and 27% of liraglutide users at 24 months.

Additional articles: https://www.fiercehealthcare.com/regulatory/cms-unveils-new-model-aims-bring-most-favored-nation-pricing-medicaid and https://www.medpagetoday.com/publichealthpolicy/medicare/118344 and https://www.modernhealthcare.com/politics-regulation/mh-trump-eli-lilly-novo-nordisk-medicare-glp-1/ and https://www.beckershospitalreview.com/pharmacy/medicare-to-cover-glp-1s-under-trump-negotiated-pricing/ and https://www.beckershospitalreview.com/pharmacy/cms-launches-pilot-to-lower-medicaid-drug-costs-8-things-to-know/ and https://www.cms.gov/newsroom/press-releases/cms-announces-new-drug-payment-model-strengthen-medicaid-better-serve-vulnerable-americans and https://www.hhs.gov/press-room/cms-announces-new-drug-payment-model-to-better-serve-vulnerable-americans.html and https://thehill.com/policy/healthcare/5593083-trump-administration-glp-1-novo-nordisk-eli-lilly/ and https://www.epicresearch.org/articles/two-years-after-stopping-glp-1s-most-patients-sustain-at-least-some-weight-loss

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#medicare #medicaid #partd #commercial #employergroup #gp1s #weightlossdrugs #drugpricing

https://www.healthcaredive.com/news/lilly-novo-trump-obesity-drug-pricing-deal-zepbound-wegovy/804937

Humana Reports Q3 Financial News

Medicare Advantage (MA)-dominant Humana reported Q3 financial news today. Humana, the second biggest MA player, slashed its earnings guidance as enrollment ticks above initial expectations during open enrollment. It now projects to have about 425,000 fewer Medicare MA enrollees next year, not 500,000 fewer as previously anticipated. Investors worry that these additional members, driven by generous benefits, will increase medical expense more than projected. Humana says it is confident in projections despite higher enrollment numbers but says it can throttle back enrollment with several levers if needed.

Operating expenses surged to $32.25 billion, up 11.75% year over year. Humana is spending more (hundreds of millions more) to better operations and increase Star ratings. Its Star Year 2026 rating actually dropped from a very low 25% of enrollment in 4 Star or greater plans to an even lower 20%.

Third-quarter net income declined 59.6% to $194 million. Revenue rose 11.1% to $32.6 billion. The medical loss ratio (MLR) rose to 91.1% from 89.1% a year ago. This was consistent with projections.

One analyst asked the burning question on Stars — why Humana didn’t crosswalk MA members out of one major contract suffering from low ratings to other contracts. Humana says that would be a short-term financial gain that could have negatives, including member attrition and hurt future Star performance. Humana says it will break up the master contract over time.

Additional articles: https://www.fiercehealthcare.com/payers/humana-slims-expectations-membership-losses-2025-425k and https://www.healthcaredive.com/news/humana-medicare-advantage-growth-confident-q3-2025/804661/ and https://www.beckerspayer.com/financial/humana-posts-195m-q3-profit/

(Some articles may require a subscription.)

#medicareadvantage #humana #margins #stars #quality

https://www.modernhealthcare.com/insurance/mh-humana-medicare-advantage-centerwell/

Is UnitedHealthcare Gaming Medical Expense Regulation?

A new study published in Health Affairs finds that UnitedHealthcare pays its owned providers at sister company Optum 17% more than those it does not own. And if United controls 25% or more of a market, that percentage increases to 61%. Researchers said the results suggest the company may be sidestepping government rules regarding calculation of medical expenses against premiums. If those rules are violated, rebates need to be sent to the government, employers, or individuals depending on the type of coverage. In effect, higher payments to owned providers would boost the so-called medical loss ratio (MLR) and more likely hit or exceed the required spending (usually 80% or 85%).

United says the study is wrong. And the study clearly has some limitations. It looked at just 14 CPT medical codes and about 385,000 transactions. But these were frequently performed and high-cost procedures in the commercial world. And to arrive at the over-reimbursement calculation, United payments were compared to what other large insurers, such as CVS’ Aetna, Cigna and Elevance Health, paid providers.

Notwithstanding United’s declarations to the contrary, the research would seem to be legitimate and reach a correct conclusion. It has long been a secret that vertically integrated health plans tend to sign lucrative deals with their own sister companies so as to inflate medical expense. It frees these organizations from a great deal of rebates and keeps the revenue in the family. It happens with payments to owned providers, at-risk payments to owned providers, higher payments to their own pharmacy benefits managers and specialty pharmacies, and payments to its own service entities. The good news is that transparency rules are now bringing some light to all this and congress is looking at the backroom deals.

Additional articles: https://www.healthcaredive.com/news/unitedhealthcare-pays-optum-doctors-more-than-other-doctors-study/804600/

#verticalintegration #healthplans #minimummlr #unitedhealthcare

https://www.fiercehealthcare.com/payers/study-suggests-unitedhealthcare-pays-optum-docs-more-other-providers

Government Shutdown End In Sight?

After bipartisan weekend talks, Senate Majority Leader John Thune, R-SD, said Monday that he is “optimistic” lawmakers can strike a deal to reopen the government by the end of the week. He added that a stopgap spending bill could fund government through January or later to allow time to mark up and pass appropriations bills. The House will have to re-pass the temporary funding bill as it expires on November 21. Insiders say that Democrats could give in on their position to include Exchange subsidy extensions if a bill is pre-negotiated, likely with the president, or if GOP leaders announce a commitment to hold an up or down vote on an extension.

Meanwhile, Rep. Marjorie Taylor Greene, R-GA, says Republicans deserve much of the blame for rising premiums, saying Republicans should have reformed the Affordable Care Act (ACA) sooner. “The Democrats passed Obamacare, but yet the Republicans have never done anything to correct the problems that exist with it. … And I don’t think it’s an easy thing to fix. … However, it’s something that we should have a plan for, and [House Speaker] Mike Johnson, for a month now, cannot give me a single policy idea. … And I’m angry about that.”

As well, four moderate House lawmakers, two on each side of the aisle, on Monday proposed a framework to temporarily extend the Exchange enhanced premium subsidies, including a sunset period and an income cap for high earners. 

Additional articles: https://thehill.com/homenews/senate/5587098-thune-shutdown-spending-bill/ and https://thehill.com/homenews/house/5584132-democrats-gop-end-shutdown/ and https://thehill.com/homenews/house/5584704-greene-maher-republicans-health-care-premiums-shutdown/

#governmentshutdown #trump #congress #exchanges #healthcare #coverage #aca #obamacare

https://thehill.com/policy/healthcare/5587204-obamacare-tax-credits-extension-proposal/?tbref=hp

Trump Administration Finalizes 340B Rebate Pilot

The Trump administration has approved eight drugmakers’ rebate plans for the 340B drug discount pilot program that kicks off January 1. The pilot covers a selected group of 10 drug products from eight manufacturers who have submitted plans meeting specific criteria approved by the Health Resources and Services Administration (HRSA). The covered drugs include Eliquis, Enbrel, Farxiga, Imbruvica, Januvia, Jardiance, Stelara, Xarelto and multiple Novolog and Fiasp products.

The program offers upfront discounts, but the administration wants to reform and bring greater transparency to the program to ensure it meets the intent of serving lower income Americans with discount drugs. Trump officials believe this will be accomplished with the greater scrutiny that will occur with retrospective rebates vs. upfront discounts.

Numerous studies conclude that the program does not meet the original intent and that hospitals and other facilities do not in fact lower costs for the lower income and instead pad margins with the discounts. Some studies show that drug prices at 340B qualifying hospitals are actually higher than at those who do not qualify.

The pilot comes at a time when the Congressional Budget Office (CBO) revealed that the 340B program has exploded into a multibillion-dollar subsidy for thousands of nonprofit hospitals, driving up healthcare costs for patients, contributing to the federal deficit, and delivering little measurable benefit to patients in need. The analysis shows 340B spending rose from $6.6 billion in 2010 to almost $70 billion in 2023. During that same time, brand drug spending across the rest of the market grew at just 4% per year.

The CBO says culprits for the surge in spending include hospital consolidation, the surge of contract pharmacies, upside-down incentives that allow pocketing of the discount and thereby incentivizing use of high-cost brand drugs, and a lack of basic transparency/reporting or requirement to pass savings on to patients.

Additional articles: https://www.fiercehealthcare.com/providers/hrsa-approves-8-drugmakers-plans-340b-rebate-model-pilot-program and https://www.healthcaredive.com/news/new-cbo-report-340b-ballooning-costs-congress-must-act-dan-crippen-cbo/804109/ and https://www.healthaffairs.org/content/forefront/340b-drug-pricing-program-capped-safety-net-grant and https://www.healthcaredive.com/news/340b-rebate-models-approved-hrsa/804370/

(Some articles may require a subscription.)

#drugpricing #340b #hospitals #branddrugmakers

https://www.modernhealthcare.com/politics-regulation/mh-340b-rebate-pilot-abbie-merck-hrsa/

Cigna Reports Strong Financial News

The Cigna Group reported among the strongest news of any major health plan today. It posted a $1.9 billion profit in Q3, up from $739 million during the same period last year. Revenue reached $69.7 billion, a 9.5% increase year over year. Adjusted income from operations was $2.1 billion, less than 1% lower than third-quarter 2024. Its services entity Evernorth grew tremendously, including specialty pharmacy growth. Insurer Cigna Healthcare generated $10.8 billion in adjusted revenue, down 18.3% year over year – largely due to the sale of its Medicare Advantage line. Excluding that, adjusted revenues for the insurance business were up 6% compared to Q3 2024. The medical loss ratio reached 84.8%, a 2.4% increase year over year.

Cigna executives said the company is expecting pressure on its margins with its announcement that it will begin phasing out rebates.

In related news, if Express Scripts and other pharmacy benefit managers (PBMs) thought moving to phaseout rebates would stop regulatory and congressional action, they were wrong. Lawmakers applauded the move but say they will push for passage of their reforms.

Additional articles: https://www.beckerspayer.com/financial/cigna-reports-1-9b-q3-profit/ and https://www.modernhealthcare.com/politics-regulation/mh-pbm-legislation-bills-express-scripts-rebates/ and https://www.fiercehealthcare.com/payers/cigna-reaffirms-2025-outlook-posts-19b-profit-q3 and https://www.modernhealthcare.com/insurance/mh-cigna-earnings-evernorth-health-express-scripts/

(Some articles may require a subscription.)

#healthplans #cigna #margins

https://www.healthcaredive.com/news/cigna-pharmacy-model-lower-earnings-q3-2025/804156

CVS Health and Centene Report Q3 Financial News

CVS Health, hit by a literal financial meltdown, reported relatively good recovery news for Q3 2025. Its troubled Aetna insurance business and pharmacy benefit management Caremark are recovering. Because of this, CVS Health is forecasting double-digit earnings growth in 2026.

CVS Health had $103 billion in revenue for Q3. Revenue was up 7.8% year over year. The company recorded a Q3 net loss of $3.99 billion, compared with net income of $71 million, or 7 cents per share, in the same period for 2024. The decline was due to a $5.7 billion goodwill impairment charge from the healthcare delivery unit. Aetna had $36 billion in revenue in the third quarter, up 9% year over year. The medical cost ratio dropped from 95.2% to 92.8%. 

Centene raised its yearly profit guidance despite ongoing struggles with health insurance Exchange spending and huge cuts to the federal health programs that are the foundation of its business. Centene posted a $6.6 billion loss in Q3 after incurring a one-time impairment charge related to ongoing market headwinds. The goodwill impairment charge was $6.7 billion and tied in part to the changes in the One Big Beautiful Bill Act. But Centene is making good progress on its turnaround. The company’s medical loss ratio was 92.7% in the third quarter, up from 89.2% at the same time last year but down sequentially.

Revenues were $49.7 billion in the quarter, which also beat Wall Street forecasts. By comparison, Centene reported $42 billion in revenue and $713 million in profit in the prior year quarter. Through the first nine months of 2026, the company posted $145.1 billion in revenue and $5.6 billion in losses. It brought in $122.3 billion in revenue and $3 billion in profit through the first three quarters of 2024.

Centene also emphasized its commitment to the Exchange line of business, saying even a smaller population after a subsidy expiration will still make coverage more affordable for many.

In other news, UnitedHealth Group is projecting its Medicare Advantage (MA) enrollment will decrease by 1 million people in 2026. That is up from a 600,000-member decrease it projected in July.

Additional articles: https://www.fiercehealthcare.com/payers/centene-posts-66b-loss-writedown-cost-pressures-continue and https://www.modernhealthcare.com/insurance/mh-centene-marketplace-congress-medicare-medicaid/ and https://www.healthcaredive.com/news/centene-value-writedown-q3-2025-medicaid-centene/804074/ and https://www.beckerspayer.com/financial/centene-ceo-prescription-drug-plans-steering-medicare-revenue/ and https://www.beckerspayer.com/financial/cvs-health-reports-4b-q3-loss-but-raises-earnings-outlook/ and https://www.beckerspayer.com/financial/centene-posts-6-6b-loss-but-steep-revenue-increase-for-q3/ and https://www.modernhealthcare.com/insurance/mh-cvs-health-earnings-oak-street-health/ and https://www.beckerspayer.com/payer/medicare-advantage/unitedhealth-projects-1-million-member-drop-in-medicare-advantage-enrollment/

(Some articles may require a subscription.)

#healthplans #centene #cvshealth #margins

https://www.fiercehealthcare.com/payers/cvs-health-hikes-earnings-forecast-despite-57b-impairment-charge-q3

United Reports Financial News; Big Plans Tighten Belts

Investors cheered news from UnitedHealth Group that its efforts to get back to margins are working. United raised its full-year guidance Tuesday when announcing its Q3 results. United reported that net earnings fell 59.4% to $2.54 billion and earnings from operations dropped 50.4% to $4.31 billion. Revenue grew 12.2% to $113.16 billion. But these figures beat Wall Street expectations.

United’s strategy has been to massively retrench in both Medicare Advantage (MA) and standalone Part D (PDP). United expects all its government lines of business to contract – MA, PDP, Medicaid, and the Exchanges. It expects to shed 600,000 in MA and has expanded some markets in the Exchanges but exited less profitable ones. Utilization and medical expense continues to be a challenge as its medical loss ratio was just short of 90% across all business lines. However, revenues from services entity Optum grew 8.3% to $69.2 billion. Earlier, the services entity was reporting struggles. United says it will have solid earnings growth in 2026.

In other news, struggling Aetna is looking for ways to tighten networks to ensure all providers in the continuum of care, from primary care to specialty to hospitals, are aligned around value-based models. The insurer is building a team around provider experience and improving satisfaction.

Elevance Health’s new out-of-network care policy may reduce healthcare costs but also rankle providers. Elevance will penalize in-network facilities that use out-of-network providers.

Additional articles: https://www.fiercehealthcare.com/payers/why-aetna-putting-focus-provider-experience-it-navigates-medicare-advantage-headwinds and https://www.modernhealthcare.com/insurance/mh-unitedhealth-group-guidance-aca-enrollment/ and https://www.modernhealthcare.com/providers/mh-elevance-health-out-of-network-charge-explained/ and https://www.healthcaredive.com/news/unitedhealth-2025-guidance-raise-q3-beat-ma-aca/803856/ and https://www.beckerspayer.com/financial/unitedhealth-posts-2-3b-profit-for-q3-raises-outlook/

(Some articles may require a subscription.)

#healthplans #margins #medicareadvantage #medicaid #managedcare #exchanges #unitedhealthcare #cvsaetna #elevancehealth

https://www.fiercehealthcare.com/payers/unitedhealth-boosts-2025-outlook-back-q3-earnings-beat

Cigna’s Express Scripts Is Eliminating Rebates

Spurred on by demands from the Trump administration to reform, Cigna’s Express Scripts pharmacy benefits manager (PBM) is phasing out prescription drug rebates for brand drugs. Rebates are issued by brand drug makers and usually do not go to consumers at the point of sale, causing brand drugs to have a high cost at the pharmacy. The rebates are issued by Big Pharma to gain preferred placement on drug formularies.

Cigna will eliminate rebates in many of its commercial health plans in 2027. The phaseout will expand to Express Scripts clients starting in 2028 as the default option. The PBM’s phaseout program could mean a major transformation of the PBM industry, moving billions of dollars to offset consumer costs at the expense of rebates to insurers and employers as well as some amounts retained by PBMs.

The new model will save members an average of 30% each month on brand-name medications. Patients will pay the lowest available cost — whether the PBM’s negotiated rate, the consumer’s benefit copay, the cash price, or a direct-to-consumer price.

In addition, Express Scripts will adopt a cost-plus reimbursement model for pharmacies, paying them based on their cost for medications with a dispensing fee added in.

Additional articles: https://www.fiercehealthcare.com/payers/cignas-express-scripts-set-shift-away-pbm-rebates and https://www.modernhealthcare.com/insurance/mh-cigna-drug-rebates-health-plans-2027/ and https://www.beckerspayer.com/payer/cignas-evernorth-unveils-rebate-free-pharmacy-model/

(Some articles may require a subscription.)

#pbms #branddrugmakers #rebates #cigna #expressscripts

https://www.healthcaredive.com/news/evernorth-express-scripts-new-pbm-model-cost-plus/803864/