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Healthcare Cost Projected To Soar

PwC says health plans expect commercial healthcare costs to climb 9% in 2027. Payers say increased use of artificial intelligence tools by health systems, hospitals and medical practices are in part to blame. AI is documenting greater specificity and reimbursable severity without proportionate increases in care intensity. Further, there is the growing use of expensive drugs, proliferation of mental health issues, and higher reimbursement demands.

A survey by Mercer says U.S. companies plan to charge more for employee health plans next year.

Additional articles: https://www.fiercehealthcare.com/payers/healthcare-costs-poised-jump-9-2027-health-plans-blame-ai-adoption-drug-prices and https://www.modernhealthcare.com/insurance/mh-health-insurance-costs-mercer-survey/

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#employercoverage #healthcare #costs

https://www.modernhealthcare.com/providers/mh-healthcare-costs-2027-pwc-report

Clover May Get Stars Reset

The Centers for Medicare and Medicaid Services (CMS) could reset Clover Health’s SY 2026 rating for its largest contract after it won a lawsuit challenging the validity of some 20 measures. The health plan announced that CMS has recalculated the rating and advised the plan to submit an alternaive 2027 bid.

If the recalculation is applied, all of Clover Health’s 156,000 Medicare Advantage members would now be enrolled in plans rated at least four of five stars, generating some $120M in bonus payments in 2027.

But the “recalculation” is code for “we were directed to do so by the court and we likely are appealing the ruling.” So a small positive step, but not definitive for Clover yet. In essence, we still have pending litigation.

After the recent Clover ruling, Humana advised the court in its lawsuit of the Clover decision. Now, the judge in the CareFirst lawsuit has also agreed to delay a ruling given the Clover case.

The possible resetting of Clover’s ratings opens up the possibility of further lawsuits if the ruling is not overturned or CMS adjusting many plans’ SY 2026 ratings. It leaves SY 2027 in flux as well.

Additional article: https://www.beckerspayer.com/payer/medicare-advantage/carefirst-pauses-medicare-advantage-star-ratings-lawsuit-in-wake-of-clover-win/

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#cms #medicareadvantage #stars #quality

https://www.modernhealthcare.com/insurance/mh-cms-clover-medicare-advantage-star-ratings

CMS Takes Tough Stance On Price Transparency Violations

More than 500 hospitals received warnings from the federal government since April for non-compliance on the hospital price transparency regulation. Further notices could be sent soon. Hospitals receive an initial 90-day warning with instructions to correct any deficiencies. A subsequent 45-day deadline is sent requiring a more concrete plan to address deficiencies. If hospitals remain out of compliance, sanctions can run as high as $5,500 per day or over $2 million per year.

Additional article: https://www.modernhealthcare.com/providers/mh-cms-hospital-price-transparency-data/

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#pricetransparency #hospitals #cms

https://www.fiercehealthcare.com/providers/hundreds-hospitals-warned-over-price-transparency-failings-ap-reports

Many Unaware Of Coming Work Rule

A Health Management Academy survey finds that about 55% of Medicaid enrollees say they are unaware of upcoming work requirements. Work requirements go into effect on January 1 under the One Big Beautiful Bill Act. Many enrollees don’t know they’ll need to report work, education or volunteer hours starting in less than six months in order to stay covered. Another 27% said they knew something about work requirements but were unsure of the details.

While the vast majority of Medicaid enrollees who can work are employed, many will lose eligibility due to lack of knowledge of requirements, paperwork burden, and administrative snafus by states.

#workrequirements #states #medicaid #obbba

https://www.healthcaredive.com/news/over-half-medicaid-enrollees-unaware-work-requirements-health-management-academy-survey/822228

Cities and County Sue Over Exchange Rule

A group of cities and a county are suing the Trump administration over the just-finalized Affordable Care Act (ACA) Exchange rule for 2027. The parties argue that elements of the regulation — such as multi-year catastrophic plans, higher out-of-pocket caps and non-network plans as qualified health plans — are unlawful. The lawsuits say they should not be implemented.

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#exchanges #aca #obamacare

https://www.modernhealthcare.com/politics-regulation/mh-hhs-lawsuit-aca-exchange-rule-2027

Why Not Mandatory GLP-1s In Medicare For Obesity?

A Health Affairs Forefront Blog argues that GLP-1 coverage for obesity should be made mandatory. I have given great credit to the Trump administration for reducing drug prices, including with GLP-1s. But the proposed BALANCE reform model failed to attract enough health plans in the voluntary program. The government funding and risk mitigation just did not solve the fundamental risk problem, especially for standalone Part D (PDP) plans. Instead, Trump healthcare officials are proposing the BRIDGE program through 12/31/2027 to have the government cover the cost of such drugs for obesity.

The authors argue that voluntary BALANCE failed to attract plans so other options exist:

• Stripping intellectual property rights from drug makers, which obviously would be challenged.
• Making coverage of GLP-1s for obesity available in Medicare.
• Make the BALANCE program mandatory.

(Article may require a subscription.)

#glp1s #weightlossdrugs #drugpricing #medicare #medicareadvantage #partd #pdp

https://www.healthaffairs.org/content/forefront/after-balance-why-voluntary-coverage-obesity-drugs-failed-and-comes-next

Paragon Says Over 6 Million Improper Exchange Enrollments

The influential conservative Paragon Health Institute says a quarter of all Exchange enrollments were improper in 2026, adding fodder for those arguing healthcare has rampant fraud and improper enrollments. Paragon argues taxpayers will improperly subsidize the program by nearly $25 billion. 

In other news, Colorado Democratic Gov. Jared Polis signed into law funding for healthcare insurance affordability. Colorado’s health insurance affordability enterprise already collects fees from health plans and hospitals to reduce premiums in the individual market. The new law would issue bonds to generate up to $100 million beginning in 2027. In addition, another $40 million will be earmarked from the marijuana tax cash fund. The law also establishes a premium reduction target of 18% for the reinsurance program.

Further, according to JD Power, national average satisfaction scores for commercial plans are down one point from a year ago and down three points from 2024. More than half of commercial plan members saw their premiums increase in 2026.

Additional articles: https://thehill.com/policy/healthcare/5908600-obamacare-improper-enrollments-report/?tbref=hp and https://www.healthcaredive.com/news/consumer-satisfaction-health-plans-low-jd-power/821851/

#exchanges #fwa #enrollment #affordability #employercoverage #commercial

https://www.beckerspayer.com/policy-updates/colorado-governor-oks-up-to-140m-for-health-insurance-affordability/

Republicans Run From Healthcare Cuts On Campaign Trail

Republican lawmakers are running from the massive healthcare cuts that were enacted as they crisscross districts back home in anticipation of the midterms. About the only one championing some changes is Maine Sen. Susan Collins, who campaigns on a $50B rural health fund but actually voted against the One Big Beautiful Bill Act (OBBBA).

At the same time, lawmakers seem all-in support for value-based care, even as some see a mixed record over the past several decades. They note healthcare spending continues to grow rapidly, and models seem to save little or nothing so far.

Additional article: https://www.modernhealthcare.com/insurance/mh-insurers-value-based-care-unitedhealth-cvs/

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#obbba #medicaid #exchanges #coverage #healthcare #ruralhealthcare #vbc

https://www.modernhealthcare.com/politics-regulation/mh-republicans-health-insurance-2026-election-midterms

Trump Administration Issues Work Requirements Regulation

The Trump administration issued draft regulations today that implement work requirements in Medicaid under the One Big Beautiful Bill Act (OBBBA). Able-bodied and non-pregnant adults aged 19 to 64 will be subject to the requirements, with exemptions in place for the medically frail, disabled, and others who are unable to meet the mandates. Individuals can meet the requirement by working, completing community service, or participating in a work program for at least 80 hours per month. States must implement the requirements prior to 2027.

The rule includes broader than expected definitions for “medically frail” people, who are exempt from the mandate. Individuals can also self-attest that they’re exempt once before states require documentation.

Critics argue that most on Medicaid work and that the mandate will lead to eligibility loss due to paperwork and a lack of knowledge of the requirements. States will also spend tens of millions to administer the program. Millions overall are expected to lose eligibility due to the work requirements as well as provider tax restrictions that will impact the generosity of eligibility at the state level.

Healthcare policy group KFF has issued numerous briefers at its site on work requirements.

CMS press release and fact sheet: https://www.cms.gov/newsroom/press-releases/cms-launches-nationwide-framework-implement-medicaid-work-requirements and https://www.cms.gov/newsroom/fact-sheets/medicaid-community-engagement-requirement-certain-individuals-interim-final-rule-comment-period-cms

Additional articles: https://www.modernhealthcare.com/politics-regulation/mh-cms-medicaid-work-requirement-rules-states/ and https://www.healthcaredive.com/news/cms-medicaid-work-requirements-final-rule-state-guidance/821631/ and https://www.beckerspayer.com/payer/medicaid/cms-finalizes-framework-for-medicaid-work-rules-8-things-to-know/ and https://thehill.com/policy/healthcare/5904780-medicaid-beneficiaries-work-requirements/ and https://www.kff.org/medicaid/medicaid-work-requirements-tracker-overview/

#medicaid #workrequirements

https://www.fiercehealthcare.com/regulatory/cms-outlines-national-framework-support-rollout-medicaid-work-requirements

Uninsurance Rate Holds Flat in 2025

The Centers for Disease Control and Prevention (CDC) reports that the uninsurance rate remained flat in 2025. This was despite the continuing insurance losses in Medicaid and the Exchanges.

Last year, 28 million or 8.3% of Americans were uninsured – just up 0.1% from 2024. More people are likely to lose coverage due to coming healthcare spending cuts.

#uninsured #healthcare #coverage

https://www.healthcaredive.com/news/uninsurance-rate-steady-2025-cdc/821488/