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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.

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#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/

Clover Wins Star Suit

In a stunning decision, a federal judge in Georgia ruled in favor of Clover Health in its lawsuit challenging its 2026 Medicare Advantage (MA) Star Ratings. What’s more the judge seemingly has thrown out 20 measures in the program. The judge ordered just Clover’s 2026 ratings, impacting 2028 payments, to be recalculated. But it is hard to see how this could not impact all contracts if the ruling is upheld.

Clover’s ratings dropped considerably in Star Year 2026, with 93% of its members enrolled in plans with ratings below four. This cost Clover $120 million in bonus revenue. Clover’s two-prong argument that the court agreed with was that the Centers for Medicare and Medicaid Services (CMS) did not have the authority to collect data and score some measures and did not adequately notice changes for others.

The Supreme Court recently threw out the so-called Chevron doctrine in the 2024 Loper decision. Chevron gave wide deference to executive agencies in rulemaking. I argued that Chevron usurped policymaking from Congress. The question now is did the judge take the Loper decision too far? CMS is asking for the decision to be reconsidered and will undoubtedly appeal.

The suit’s decision is here: https://litigationtracker.law.georgetown.edu/wp-content/uploads/2026/01/Clover-Insurance-Company-v.-Department-of-Health-and-Human-Services-et-al_2026.05.27_ORDER-ON-MOTION-FOR-SUMMARY-JUDGMENT.pdf

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#cms #stars #quality #medicareadvantage

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

Non-Network Plans Could Thrive

Non-network plans have been approved as qualified health plans on the Exchanges under a new rule and a number of prominent healthcare companies, including Sidecar Health, may offer such plans in the future. Non-network plans do not hold contracts or negotiate prices with hospitals and doctors, but outline for enrollees how much they will pay for specific services. Usually, such prices are based on average local prices.

The Trump administration has argued that such plans encourage innovation and lower costs. Opponents argue that such plans will boost costs for other enrollees if such plans end up as benchmark plans in the Exchanges. Further, they say healthier people could be attracted to such plans and increase risk in more comprehensive ones. Last, they also say such plans could end up being expensive for many due to limited benefits.

States do have the choice to approve the offering of such plans on the Exchange in their states. To qualify under the new regulation, non-network plans must demonstrate that a sufficient range of providers accepts the plan’s benefit amount as full payment.

Additional article: https://www.modernhealthcare.com/insurance/mh-cms-aca-exchanges-non-network-plans/

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#exchanges #trump #regulation #healthplans

https://www.beckerspayer.com/payer/aca/non-network-insurer-eyes-aca-exchange-as-cms-clears-the-way/

KHN Covers Alternative Insurance

As traditional insurance coverage premiums spike, many are turning to alternative insurance coverage. Kaiser Health News looks at the issue. These policies are not qualified health plans under the Affordable Care Act (ACA) and often have limits and gaps. This coverage is different from cheaper, qualified coverage on the Exchanges, such as catastrophic coverage as well as reforms made by a recent rule proposed by the Trump administration. One popular alternative as premiums spike are so-called sharing initiatives, many of the Christian-based.

#healthcare #coverage

https://kffhealthnews.org/health-industry/alternative-health-plans-growth-sharing-ministries-short-term-aca-premiums/

Feds To Use AI To Audit States

The Department of Health and Human Services (HHS) will use artificial intelligence to review state audits of federal funding recipients, including Medicaid agencies. HHS told governors that its new Audit Enforcement and Risk Oversight initiative will review the previous five years’ worth of audits of state agencies. The agencies are required to conduct audits of state programs and grantees if expenditures of federal funds are over $1 million.

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#fwa #trump #hhs

https://www.modernhealthcare.com/politics-regulation/mh-hhs-ai-medicaid-audit-states-funding

340B Hospital Lawsuit: The Pot Calling The Kettle Black

Three health systems – Mount Sinai in New York, Michigan Medicine, and University of Kansas City Health — have filed federal lawsuits against CVS Health. The hospitals allege that CVS and sister companies diverted about $250 million from 2020 and 2025 in savings generated through the 340B drug pricing program.

The 340B program requires brand drug makers to offer discounted prices to hospitals and safety net providers. Oftentimes, various healthcare entities are part of the adjudication and documentation process. The complaint alleges that CVS health companies used a series of intercompany service transactions to divert the funds and retain them when they should have been given to the hospitals.

I have argued that vertically integrated companies use all sorts of inter-company transfers to retain dollars within the family. So, I don’t doubt that what is alleged is possible. At the same time, the lawsuit is ironic. Substantial evidence exists concluding that hospitals benefit from the discounts but do not pass enough of the savings through as lower costs to needy consumers. In fact, 340B hospitals are found to have higher overall prices than those who are 340B qualified. So, the suit is a bit of the pot calling the kettle black.

Additional articles: https://www.fiercehealthcare.com/payers/hospitals-allege-contracted-cvs-health-subsidiaries-pocketed-their-340b-savings and https://www.modernhealthcare.com/providers/mh-cvs-340b-lawsuit-mount-sinai-michigan/

#drugpricing #340b #hospitals #cvshealth

https://www.beckerspayer.com/legal/health-systems-sue-cvs-over-alleged-250m-340b-scheme/

— Marc S. Ryan