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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

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

(Some articles may require a subscription.)

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

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