A new West Health-Gallup Affordability Index survey classifies just 49% of American adults as “Cost Secure” down two percentage points from 2024 and down 12 percentage points from 2022. Forty-one percent of adults in 2025 are considered “Cost Insecure” and 10% of adults are considered “Cost Desperate.”
Affordability, and specifically healthcare affordability, is a top election-year issue.
#affordability #healthcare #coverage
After announcing the Rural Health Transformation with much fanfare, the Centers for Medicare and Medicaid Services (CMS) is now threatening clawbacks of funding or reductions of future allocations if states do not meet policy goals and requirements set out by the agency. CMS is rejecting and reshaping state plans under the $50 billion program.
States are struggling not only with the policy goals but also the speed by which the program must be implemented and dollars spent. While many of the Trump administration policy goals are noble, states and rural providers are focused more on efforts to balance budgets and keeping the doors open.
(Article may require a subscription.)
#cms #healthcare #ruralhealthcare #obbba
https://www.modernhealthcare.com/politics-regulation/mh-cms-rural-health-fund-clawbacks
— Marc S. Ryan
More news on the fallout from the Clover Health lawsuit it won on its Star Year 2026 ratings. As noted earlier this week, the Centers for Medicare and Medicaid Services (CMS) have recalculated Star ratings, giving contracts the “better of” the original rating or one that includes only measures that are consistent (sort of as CMS took some liberties) with the judge’s decision on Clover.
There are more losers than winners. About 5% of contracts and 10% of enrollment benefited, while about 37% of contracts and membership would have dropped if not for the hold harmless. The rest would have had no change.
As I have said, CMS really had no choice but to do what it did despite a $1 billion plus price tag. I think this will be fixed over time. Yours truly is quoted in the article saying that plans likely will be conservative when they submit updated bids for 2027.
(Article may require a subscription.)
#stars #cms #medicareadvantage #quality
https://www.modernhealthcare.com/insurance/mh-medicare-advantage-star-ratings-humana-clover
— Marc S. Ryan
Eli Lilly and Company ended 340B discount pricing for drugs for providers that have not agreed to submit claims for validating whether purchases meet the program’s requirements or may be double-dipping on other discount programs. Earlier this month, Lilly began enforcing the policy by telling its wholesalers to pull 340B pricing eligibility for certain non-conformers. Lilly said these were large and wealthy health systems. Hospitals are apoplectic and earlier derailed a 340b pilot that would have converted the upfront discounts to a retrospective rebate. Their fear: other drug makers follow suit and the Trump administration does not object.
Additional articles: https://www.fiercehealthcare.com/providers/eli-lillys-ultimatum-hospitals-send-340b-claims-data-june-1-or-lose-discounts
(Some articles may require a subscription.)
#340b #drugpricing #drugmanufacturers
https://www.modernhealthcare.com/providers/mh-eli-lilly-340b-drug-discounts-hospitals/
— Marc S. Ryan
CMS this evening announced it is recalculating some contracts’ SY 2026 Star Ratings based on the better of the current ratings or the measures included in the recent Clover decision. A judge struck up to 20 measures. CMS went out of its way to note that this does not set policy for SY 2027 ratings or beyond. I still expect an appeal or other intervention to bring back a fulsome Star program.
Congressional Medicare policy advisor MedPAC panned hospitals’ views that increased penetration of Medicare Advantage (MA) is impacting providers’ financial stability. Empirical analyses conducted by MedPAC staff showed no evidence of a significant association between MA market penetration and all-payer margins of hospitals, skilled nursing facilities (SNFs), and home health agencies. This does not appear to be the case in rural markets, either.
But MedPAC did find some changes in revenues, costs and utilization trends and some of it was in hospitals’ favor. MA enrollees’ average length of stay in fiscal year 2024 was actually 11.2% longer than fee-for-service (FFS) beneficiaries. This was related to those who were destined to be discharged to a post-acute care facility. And overall greater MA penetration was tied to dips in total SNF facility days and small declines in revenues and costs at SNFs and home health.
#medicareadvantage #providers #hospitals
https://www.fiercehealthcare.com/payers/medpac-offers-look-enrollment-hiccups-medicare-beneficiaries
Healthcare policy group KFF issued several issue briefers recently on carrier losses in the Exchanges.
The average number of issuers offering plans in the Exchanges has declined from 9.6 issuers per state in 2025 to 9.0 issuers per state in 2026. In total, 18 states experienced a net decrease in the number of issuers offering plans. Three in 10 counties have fewer participating insurers than last year. In 165 counties, only one issuer is offering plans, up from 93 counties in 2025.
Six carriers have announced that they will exit the Exchanges in 2027, either in some or all states that they are currently offering plans: Cigna Health, CareSource, PacificSource, Scott and White, Providence Health, and Taro Health.
In other news, Centene will offer buyouts to employees as it navigates a significant membership decline in both Medicaid and the Exchanges. During Q1, Centene reported a 6% decline in year-over-year membership to 26.3 million, driven largely by Exchange losses.
Additional articles: https://www.fiercehealthcare.com/payers/centene-offering-staff-buyouts-navigates-murky-aca-waters and https://www.modernhealthcare.com/insurance/mh-centene-buyouts-medicaid-aca-membership/ and https://www.beckerspayer.com/workforce/centene-offers-employee-buyouts/ and https://www.kff.org/affordable-care-act/tracking-insurer-participation-changes-in-the-aca-marketplaces-in-2027/
(Some articles may require a subscription.)
#exchanges #insurers #coverage #healthcare
The Trump administration and the Centers for Medicare & Medicaid Services (CMS) have proposed to codify the Biden-era Medicare Drug Price Negotiation Program — a fantastic turn of events that few would have predicted a few years ago despite Trump’s sympathies for drug price reform. They say the move will create a more transparent and sustainable process for lowering drug costs for millions of Medicare beneficiaries. There are a number of small concessions to drug makers as well.
I have given President Trump great credit for making a huge impact on drug pricing, more than any other recent president. This is more evidence.
Additional articles: https://www.cms.gov/newsroom/press-releases/cms-proposed-rule-locks-lower-prices-fosters-innovation-medicare-drug-price-negotiation-program and https://www.cms.gov/files/document/mdpnp-nprm-fact-sheet.pdf
#drugpricing #cms #medicare #partd #medicareadvantage #pdp
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/
(Some articles may require a subscription.)
#employercoverage #healthcare #costs
https://www.modernhealthcare.com/providers/mh-healthcare-costs-2027-pwc-report
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/
(Some articles may require a subscription.)
#cms #medicareadvantage #stars #quality
https://www.modernhealthcare.com/insurance/mh-cms-clover-medicare-advantage-star-ratings
