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
States Laws Clamp Down On Downcoding At Insurers
With more and more national insurers adopting a variety of automatic downcoding of claims programs backed by AI, a number of states have passed laws to clamp down on the practice. The laws include notification and transparency requirements. Other proposed laws would ban the practice outright.
The states include Arkansas and Virginia, which have already adopted new laws this year, as well as others considering it this or next year: Ohio, New York, Connecticut, New Jersey, and Utah.
(Article may require a subscription.)
#claimsdenials #downcoding #providers #healthplans
https://www.modernhealthcare.com/politics-regulation/mh-aetna-cigna-downcoding-policy-states
On Health Plan Profits and Medicaid Rates
Elevance Health told an investor conference that its Medicaid business is expected to reach a low point on profits in 2026. The company anticipates its Medicaid operating margin to decrease to negative 1.75% in 2026, following a negative 0.5% margin in 2025. The company says Medicaid will return to more sustainable margins in 2027, with a target between 2% and 4% over the long term.
In related news, a Healthcare Dive analysis says government programs are pushing down health insurers’ profitability. Changes in Medicaid and the Exchanges could mean further complications even as plans promise they have a reliable recovery plan.
The average operating margin of the seven major publicly traded payers dropped to 0.5% in Q3 2025, compared with 3% in the same period last year. Removing Cigna (which now has limited government program business), the insurers posted an average operating margin of negative 1.4% in Q3, compared to 2.2% last year.
In Medicaid and the Exchanges, plans are battling high costs due to increasing risk. Medicaid rates also trail rises in costs and are not recognized in rate-setting for some time. Medicaid margins will drop more before recovering. Plans are awaiting an enhanced Exchange subsidy extension or will see a huge surge in adverse selection and higher per-person claims costs. In Medicare Advantage (MA), plans have contracted due to a new risk model and high utilization, even with a more generous 2026 rate hike.
Additional article: https://www.beckerspayer.com/payer/medicaid/medicaid-margins-to-hit-low-point-in-2026-elevance-cfo-says/
#healthplans #exchanges #medicaid #medicareadvantage #margins
https://www.healthcaredive.com/news/health-insurer-profits-fall-q3-2025/804988
— Marc S. Ryan
