White House To Unveil Exchange Subsidy Compromise
The White House is expected to reveal a plan to address rising medical costs as well as the expiration of the enhanced Exchange subsidies. It was expected today but was delayed to address concerns by GOP conservatives.
The plan is said to include an extension of the premium subsidies for two years but would include income limits for the subsidies and minimum premium requirements. Incomes are said to go as high as 700% of the poverty limit to still get a subsidy. The plan also would call on Congress to appropriate funds for cost-sharing reductions (CSRs). These were defunded by Trump 45 and led to increases in Silver premium subsidies, actually a greater cost to the government.
The plan also would endorse a conservative approach where Americans would have an option to receive part of their tax credit in a tax-advantaged savings account if they move down to a lower-premium health plan.
Health Affairs has a good blog on the history of the Exchanges, tax credits, subsidy enhancements, and Democratic and GOP extension and reform proposals.
Additional articles: https://www.fiercehealthcare.com/regulatory/white-house-poised-reveal-healthcare-cost-plan-media-reports and https://www.healthaffairs.org/content/forefront/extending-enhanced-premium-tax-credits-things-stand
(Some articles may require a subscription.)
#exchanges #healthcare #coverage
https://www.politico.com/news/2025/11/23/white-house-to-propose-new-health-care-framework-00666701
CMS Will Appeal RADV Audit Rule Decision
The Centers for Medicare and Medicaid Services (CMS) says it will appeal a federal judge’s ruling striking the Biden-era Risk Adjustment Data Validation (RADV) audit rule. CMS Administrator Dr. Mehmet Oz wants to aggressively audit plans for risk adjustment overpayments and was relying on the rule to proceed with audits.
I think the decision to toss the rule was a good one. The Biden administration violated regulatory procedures, rejected the continuation of the fee-for-service adjuster, and sought to apply recoupment retroactively. It also sought to extrapolate penalties from samples. The rule clearly exceeded the agency’s authority.
(Article may require a subscription.)
#riskadjustment #radv #medicareadvantage #overpayments #cms
https://www.modernhealthcare.com/insurance/mh-medicare-advantage-audit-cms-radv-lawsuit
GLP-1 Drug Maker Lilly Has $1 Trillion Market Cap
Bolstered by its robust growth and high prices of its GLP-1 weight-loss drugs, Eli Lilly reached a $1 trillion market capitalization, the first healthcare company in the world to join the exclusive club. The others are tech firms.
Its main rival, Novo Nordisk, is getting crushed in the market.
My one point here: about $700 billion of the market cap is attributable to the huge price burden Americans have compared with the rest of the developed world. Americans are being abused by an American company.
#glp1s #weightlossdrugs #branddrugmakers #drugpricing
Health Affairs Covers PA Reforms
A good Health Affairs blog covering recent federal and state prior authorization reforms.
(Article may require a subscription.)
#priorauthorization #healthplans
https://www.healthaffairs.org/content/forefront/prior-authorization-reform-heats-up
Site Neutral Payments In Medicare Rule
Healthcare policy group KFF goes into details about the modest site-neutral payment reform in the final outpatient hospital 2026 rule. The outpatient reimbursement for drug administration services (such as chemotherapy) will be reduced by 60% when provided in off-campus hospital outpatient departments (HOPDs). Earlier, payments were reduced for services provided in relatively new off-campus HOPDs (beginning in 2017) and for clinic visits provided in all other off-campus HOPDs (beginning in 2019). Under site neutral payments, the same rates are paid for like services whether at the hospital, ambulatory centers, clinics, or physician offices.
The move is modest but welcome. Applying site neutral policies to all hospital outpatient would save at least $157 billion over ten years. More importantly, huge savings would also occur in the commercial world as those rates are based on Medicare.
#siteneutral #hospitals #medicare #commercial #employercoverage
— Marc S. Ryan
