Unlikely Pair Attacking Vertical Integration
An unlikely pair of senators, Elizabeth Warren, D-MA, and Josh Hawley, R-MO, have teamed up to pass the “Break Up Medicine Act.” The bill would seek to break up major vertically integrated healthcare behemoths due to the cozy relationships companies within the master entity have with each other. The bill proposes prohibiting parent companies from owning a medical provider or management services organization and a PBM or insurer. It also proposes prohibiting parent companies of prescription drug or medical device wholesalers from owning a medical provider or management services organization.
#healthplans #verticalintegration
https://thehill.com/policy/healthcare/5732189-break-up-big-medicine-act
CVS Health Reports Good Financial News; Oscar Health Reports Loss
CVS Health beat The Street by outperforming to close out 2025 and expects its finances to improve further this year. Still, it is citing proposed 2027 Medicare Advantage (MA) rates as inadequate. It is advocating for a hike. It did say it supports upcoding reforms. CVS is less reliant on the specific risk adjustment activities than other big plans.
For the full year, profits were $1.8 billion, down from $4.6 billion in profit for 2024. Revenues grew significantly, however, increasing from $372.8 billion in 2024 to $402.1 billion in 2025. Full year medical loss-ratio (MLR) was 91.2%, down from 2024’s 92.5% ratio.
The company had $2.9 billion in profit for Q4, up from $1.6 billion in the prior year quarter. Revenues in the fourth quarter were $105.7 billion, also an increase from $97.7 billion in Q4 2024.
CVS expects its MA to be modestly lower in 2026, but that will help margins. It reiterated its 2026 guidance, which sent stocks lower as investors expected an uptick from previous announcements.
In other news, Oscar Health, a dominant player in the Exchange Marketplaces, reported a $352.6 million loss in Q4, up from a loss of $153.5 million in Q4 2024. Oscar Health also reported a loss for the full year of $443.6 million after posting a $25.4 million profit in 2024.
Additional articles: https://www.fiercehealthcare.com/payers/cvs-health-beats-street-both-earnings-revenue-q4 and https://www.fiercehealthcare.com/payers/oscar-posts-443m-loss-2025-ceo-says-company-poised-2026-profitability and https://www.modernhealthcare.com/insurance/mh-cvs-health-earnings-aetna-caremark/ and https://www.modernhealthcare.com/insurance/mh-cvs-earnings-fourth-quarter-2025-aetna/
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#cvshealth #aetna #oscarhealth #margins
https://www.healthcaredive.com/news/cvs-q4-2025-outlook-stable-ma-caremark/811781
Insurers Sent Subpoenas On Exchange Fraud
Republicans on the House Judiciary Committee have subpoenaed eight insurers for documents related to their efforts to head off fraud related to Exchange subsidies. The Trump administration believes that there are millions improperly enrolled in the Exchanges. It finalized a regulation in 2025 that sought to tighten eligibility and enrollment. Pieces of that rule have been stayed in federal court. The One Big Beautiful Bill Act (OBBBA) also reformed enrollment as does a new rule announced this week for 2027.
The subpoenas were to Blue Shield CA, Centene, CVS Health, Elevance Health, GuideWell, Health Care Service Corporation, Kaiser Permanente, and Oscar Health.
Additional articles: https://www.fiercehealthcare.com/payers/house-republicans-subpoenae-8-insurers-over-aca-fraud-protection-measures and https://www.modernhealthcare.com/politics-regulation/mh-house-cvs-kaiser-permanente-aca-fraud/ and https://thehill.com/policy/healthcare/5731987-aca-subsidies-fraud-probe-insurers/
(Some articles may require a subscription.)
#fwa #exchanges #enrollment #congress #cms #trump
— Marc S. Ryan
