Major Drug Policy Developments
Major drug policy developments this week.
First, the hospital lobby scored a major victory when a court ordered the new 340B rebate pilot paused. The Trump administration is seeking to experiment with rebates as opposed to upfront discounts to curb the growth in the discount drug program. The administration rightfully alleges that the program is unaccountable and does not meet the original safety net purpose.
The judge ordered a preliminary injunction against the “hastily assembled” pilot set to kick off on Jan. 1 on the basis it “likely” violates the Administrative Procedure Act’s (APA’s) arbitrary and capricious standard.
The judge noted Congress did authorize the federal government to create a rebate model, but regulators had not followed the APA’s requirements in doing so.
Second, Rep. Anna Paulina Luna, R-FL, says she is hopeful Congress will codify President Trump’s executive order on capping prescription drug prices next year. As you know, I believe that is essential.
Third, The Wall Street Journal finds that mail-order pharmacies owned by UnitedHealth and Humana dispensed Medicare prescription refills earlier and more frequently than industry peers. The analysis found mail-order pharmacies filled 9% of Medicare prescriptions between 2021 and 2023 but accounted for 37% of excess dispensing. Too-frequent refills across all pharmacies cost Medicare and patients $3 billion during that period, the newspaper reported.
Fourth, in 2025 the Food and Drug Administration approved 73 first-time generic drugs, many impacting major disease states. This is a boon for consumers but will hit brand drug makers’ margins.
Additional articles: https://www.fiercehealthcare.com/providers/hospital-groups-file-lawsuit-enjoin-pharma-supported-340b-rebate-pilot and https://www.beckershospitalreview.com/pharmacy/73-drugs-lost-exclusivity-in-2025/ and https://www.beckerspayer.com/payer/unitedhealth-humana-mail-order-pharmacies-led-in-excessive-medicare-refills-report/ and https://thehill.com/homenews/house/5665539-luna-hopes-congress-action/
(Some articles may require a subscription.)
#340B #drugpricing #generics
MA Marketing Pullback
A good Modern Healthcare article covers the pullback on ads and marketing for the 2026 Medicare Advantage (MA) enrollment season, a trend that started in 2025. MA plans shuttered poor performing products and offerings in certain geographies as well as the generosity of added benefits. In addition, they eliminated broker commissions for certain regions, contracts, and products. MA plans are favoring commissions on existing members over new ones. Special Needs Plans (SNPs) were also prioritized in marketing activities.
Meanwhile, a federal judge in Idaho found that the state’s insurance agency’s actions against MA plans’ withholding of commissions is likely preempted by federal law. The court paused the Idaho insurance department’s enforcement efforts under Idaho’s unfair competition law against UnitedHealthcare.
In other news, at least 32 payers cut jobs in 2025 due to financial challenges.
Additional articles: https://www.beckerspayer.com/payer/medicare-advantage/federal-judge-blocks-idaho-from-enforcing-medicare-advantage-commission-rules-against-unitedhealthcare/ and https://www.beckerspayer.com/workforce/5-payers-cutting-jobs-2025/
(Some articles may require a subscription.)
#medicareadvantage #marketing #agents #brokers #margins
https://www.modernhealthcare.com/insurance/mh-medicare-advantage-marketing-enrollment-period
Rural Hospital Fund Program Launched
The Trump administration announced the formal launch of its $50 billion rural health fund created through the One Big Beautiful Bill Act (OBBBA). The program is meant to offset some of the major revenue losses rural hospitals will see from Medicaid and Exchange reductions.
#hospitals #obbba
https://thehill.com/policy/healthcare/5665432-rural-health-transformation-program/?tbref=hp
Elevance Health Program Under Assault
Fourteen House lawmakers are calling on federal officials to investigate Elevance Health’s new policy that will penalize hospitals that use out-of-network providers. The lawmakers argue the approach is anti-competitive and undermines the No Surprises Act (NSA).
#nsa #elevancehealth #claims
Exchange Enrollment Holding Up, But …
As of Dec. 23, more than 15.6 million people have enrolled in plans on federally run Exchanges for 2026, down from about 16 million at the same point last year. Still, the dropoff so far is less than anticipated due to the expiration of enhanced premium subsidies and a huge trend increase in premiums in general.
The state’s facing the greatest coverage losses as of now in terms of the increase in uninsured residents:
— Mississippi: 65%
— South Carolina: 50%
— Tennessee: 41%
— Texas: 39%
— Georgia: 39%
Additional article: https://www.beckerspayer.com/payer/aca/states-facing-steepest-coverage-losses-as-aca-subsidies-expire/
#exchanges #healthcare #coverage
https://www.beckerspayer.com/payer/aca/aca-enrollment-drops-slightly-to-15-6m/
— Marc S. Ryan
