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ACA Exchange Risk Adjustment Settlements Total $11.7 Billion

Health insurers will shuttle $11.17 billion between them due to the 2025 ACA Exchange risk-adjustment settlements. The settlements recognize differences in risk in the program in a given year. UnitedHealthcare will pay $335 million while Centene will receive $751 million, Elevance Health $312 million, Aetna $216 million, and Oscar Health $189 million.

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#exchanges #riskadjustment

https://www.modernhealthcare.com/insurance/mh-aca-exchange-risk-adjustment-payments-2025/

Paragon Proposes Reforms

The influential Paragon Health Institute released a new report calling for federal funding cuts or tax reforms impacting all health plan lines of business and coverage areas. People pay attention to what Paragon says given its influence and impact on government regulations since 2025 as well as in the One Big Beautiful Bill Act (OBBBA).

In summary, Paragon wants to see the following changes:

• Cuts to the federal matching rate in Medicaid, especially equalizing matching rates for historic and expansion populations and lowering the floor to 40%
• Further cuts to Medicaid provider taxes, state directed payments, and intergovernmental transfers
• State and Medicaid managed care penalties for fraud or improper billing patterns
• Site neutral payments in Medicare
• Better target various hospital subsidies
• Redesign the 340B program
• Reversing the 2022 Part D redesign, which destabilized the standalone Part D (PDP) program and to some degree Medicare Advantage (MA)
• MA risk adjustment, benchmark, and quality bonus changes to reduce payments
• Reform Medigap
• Minimum premium payments in the Exchanges
• End automatic re-enrollment into Exchange coverage
• Broker and agent reform in the Exchanges
• Fund cost-sharing reduction subsidies in the Exchanges to save dollars
• Reform Exchange premium tax credits
• Relax medical loss ratio requirements
• Cap the tax exclusion for employer-sponsored health insurance

#medicare #medicaid #exchanges #employercoverage #healthcarereform #healthcare #coverage

https://paragoninstitute.org/medicare/restoring-fiscal-sustainability-to-federal-health-programs-reforming-the-incentives-that-drive-health-care-spending/

MA Star Bonus To Exceed $13B

Healthcare policy group KFF reports that federal spending on Medicare Advantage (MA) quality bonuses will reach at least $13.4 billion in 2026, compared with $12.7 billion in 2025. This is more than four times higher than in 2015. More than two-thirds of Medicare Advantage enrollees (68%) are in plans that qualify for the quality bonus in 2026, down from 75% in 2025. This is the lowest since 2018. The increase ties to more enrollment not better ratings.

In another briefer, KFF updates on MA coding intensity.

Additional article: https://www.kff.org/medicare/decoding-medicare-advantage-coding-intensity/

#medicareadvantage #radv #riskadjustment #stars #quality #cms

https://www.kff.org/medicare/medicare-will-spend-more-than-13-billion-on-the-medicare-advantage-quality-bonus-program-in-2026/

House Wants To Rein In Private Equity

A bipartisan House bill would require extensive reporting on private equity firms’ healthcare holdings and ownership structures. The reporting is aimed at identifying financial arrangements that may impact the financial health of the healthcare entity as well as impacts on healthcare delivery. The bill is similar to state laws on transparency in private equity. Other states have gone deeper and ruled out certain financial arrangements by private equity for acquired healthcare entities.

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#healthcare #congress #privateequity

https://www.modernhealthcare.com/politics-regulation/mh-private-equity-healthcare-congress-transparency

States Sue on Work Requirements

Democratic governors and attorneys general from 25 states and Washington, D.C. are suing the Trump administration over the proposed Medicaid work requirements regulation. States argue the rule narrows exemptions for medically frail Medicaid beneficiaries and creates administrative barriers that could cause eligible people to lose coverage. The plaintiffs say the rule goes well beyond the statute by requiring people with serious health conditions to prove their condition significantly impairs their ability to meet work requirements.

Additional: https://www.beckershospitalreview.com/legal-regulatory-issues/25-states-sue-trump-admin-over-medicaid-work-requirements-7-things-to-know/ and https://www.modernhealthcare.com/politics-regulation/mh-medicaid-work-requirement-lawsuit-democrats-bonta/

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#medicaid #workrequirements #states

https://thehill.com/policy/healthcare/5946392-lawsuit-trump-medicaid-exemptions/

Exchange Enrollment Falls Dramatically

A number of analyses have predicted that Exchange enrollment nationally will fall in 2026 after dropping from 24.3M in 2025 to 23.1 in January 2026. The analyses said that enrollment would drop to as low as 17.5M as people would not be able to afford their premiums throughout the year. Sure enough, the predictions seem to have come true, and the news may be being buried.

Today, a Health and Human Services (HHS) website posted an analysis on fraudulent and phantom enrollments and deep in the release were latest enrollment figures. HHS says around 19.2 million people are enrolled in the Exchanges as of now, a drop of about 4M since January.

HHS says millions are inappropriately receiving subsidies, including individuals misstating their income to gain access to free plans and phantom enrollees (those who are unknowingly enrolled in free plans by unscrupulous brokers or are auto enrolled). HHS says improper, phantom and fraudulent enrollment peaked at 5.6 million people in 2025.

While it did not trace the enrollment losses exactly to efforts to reduce inappropriate enrollments, HHS says it has deployed new regulations and tools to root out fraud and inappropriate enrollments. Administration program integrity efforts stopped about 1.5 million enrollees from receiving subsidies they did not qualify for and ended or blocked another 1.4 million through February 2026. HHS says 2.6 million improper and phantom enrollments remain.

#exchanges #enrollment

https://aspe.hhs.gov/reports/aca-exchange-enrollment-2026#:~:text=Enrollment%20that%20is%20improper%20or,by%20brokers%20or%20auto%20enrolled

Cassidy Wants 340B Reform

Sen. Bill Cassidy, R-LA, unveiled a draft for 340B reform today and challenged the public to offer comments for the possible passage of legislation later in the year. This would be the first time any statutory changes to 340B would be made in 15 years.

There are numerous reforms aimed at controlling costs, reining in inappropriate use of the program, reducing duplicative discounts, and ensuring savings are actually passed through to needy consumers. The hospital lobby and others oppose any changes. Numerous studies show that 340B hospitals tend to have higher prices than non-340B ones. Changes would include the ability of drug makers to offer upfront discounts or retrospective rebates, claims submission, and mandatory pass-through of the rebates. There would also be a set number of contract pharmacies within each geographic region that a qualifying provider could have.

Additional article: https://www.fiercehealthcare.com/providers/cassidys-new-plan-reform-340b-rebates-contract-pharmacy-limits-and-more

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#340b #drugpricing #hospitals #branddrugmakers

https://www.modernhealthcare.com/politics-regulation/mh-bill-cassidy-340b-bill-rebate-claims

CMS Actuary: $9T Healthcare In Our Future

The Centers for Medicare and Medicaid Services (CMS) Actuary released annual outyear growth projections for healthcare. The actuary says U.S. healthcare spending will hit just short of $9 trillion by 2034. That will be 20.6% of gross domestic product (GDP).

While final numbers for 2025 will be tallied by December, the actuary also said healthcare spending was about $5.7 trillion in 2025, up 7.3% from about $5.3 trillion in 2024. That was about 18% of GDP. This is the third straight year of over 7% growth.

The average growth over the decade will be about 5.4%, which is lower than previous projections. But healthcare spending will continue to grow faster than the rest of the economy during the decade period projected.

Utilization increases have been one of the major culprits for aggressive trends the past few years. This will continue in 2026 and may taper off thereafter. Retail prescription drug spending is forecast to grow at the fastest clip over the next decade. Growth in retail prescription drug spending is expected to be 5.7% per year on average for 2025 to 2034, with hospital spending growth at 5.2% per year on average, and physician and clinical services spending growth at 5.5% per year on average during this period.

The insurance rate will go from 91.8% in 2024 to:

• 90.8% in 2026
• 90.4% in 2028
• 90.5% in 2034

The uninsured rate will rise 8.2% to 9.5%.

Interestingly, the impact of the One Big Beautiful Bill Act’s reductions to Medicaid and the Exchanges as well as the expiration of enhanced premium subsidies are expected to be more modest than Congressional Budget Office (CBO) projections.

In other news, healthcare policy group KFF issued a briefer on Medicare spending based on the Medicare Trustees’ June 9 annual report.

Additional articles: https://www.fiercehealthcare.com/finance/us-health-spending-set-reach-9t-2034-cms-report and https://www.healthcaredive.com/news/us-health-spending-spikes-57t-2025/823660/ and https://www.healthaffairs.org/content/forefront/nhe-projections-through-2034-growth-assumptions-policy-consequences and https://www.kff.org/medicare/key-facts-about-medicare-spending-trends-and-projections-from-the-2026-medicare-trustees-report/ and https://www.cms.gov/files/document/national-health-expenditure-projections-results-presentation.pdf and https://www.cms.gov/files/document/nhe-projections-forecast-summary.pdf and https://www.cms.gov/files/document/nhe-projections-infographic.pdf

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#healthcare #spending #cms

https://www.modernhealthcare.com/politics-regulation/mh-us-health-spending-2034-cms/

Less Than 50% Are Healthcare Cost Secure

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

https://www.fiercehealthcare.com/payers/gallup-poll-claims-less-50-american-adults-can-afford-healthcare

States Worried Rural Funding Could Be Clawed Back

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.

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#cms #healthcare #ruralhealthcare #obbba

https://www.modernhealthcare.com/politics-regulation/mh-cms-rural-health-fund-clawbacks

— Marc S. Ryan