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2024 saw another major surge in healthcare spending coming out of the COVID pandemic One of my Christmas traditions is to write about the release of the Centers for Medicare and Medicaid Services (CMS) Actuary’s National Healthcare Expenditure Data (NHED) for a given calendar year. This usually is released in the middle of December each year for the prior year, but alas the government shutdown meant the data were published in January. It literally takes CMS about a year to capture, calculate, and categorize all the data for a year given the size and labyrinthine complexity of our healthcare system. Each year as well, usually in the first half of June, the CMS Actuary updates healthcare spending projections for ten outyears. Why is this so important? First, it is the main comprehensive source of data for calculating the history and future of healthcare spending. Most other studies rely in some

Trump delivers on MFN with far-reaching Medicare and Medicaid models President Donald Trump issued an executive order early on in Trump 47 that set the course for most-favored-nation (MFN) pricing for drugs in America. He tried to do this in a small way in Trump 45, but the Biden administration pulled back on it. In part, it was not well thought out, and it came out at the tail end of his first administration. Since the executive order, Trump notched drug price deals with 16 of the 17 top brand drug makers. The drug makers said they would grant MFN pricing in Medicaid for all drugs and would introduce new drugs at MFN prices in America. He also got lower self-pay prices. Now, with an announcement just before Christmas, he has delivered further on his promise by announcing three new models that officially move toward MFN pricing in America. The

Tump’s TikTok video is more hype than serious reform President Donald Trump made a major healthcare announcement last week — calling his reform the “The Great Healthcare Plan.” The plan was more of a skeletal framework, but themes do tie to policy priorities in either the House or Senate GOP caucuses, which could pass in 2026. What Trump announced would need congressional action and likely will be included in a second reconciliation bill being prepared by the GOP caucuses. What are the main tenets of the president’s proposal? Other proposals How would all this get done? The GOP caucuses would likely include some or all of the recommendations by Trump in a second reconciliation bill. The reconciliation process does not need 60 votes in the Senate but there are some limits on what can and cannot be included in such measures. The House (via the Republican Study Committee, the largest

Note: This blog is published in partnership with Lilac Software. Learn more about Lilac’s Stars solutions at the link at the end of the blog. Seismic changes in Star ratings means MA plans need strategic planning and investments. Medicare Advantage (MA) plans continue to worry about the impacts of the proposed Stars regulatory changes and what they will mean to Star ratings and benefits in the future. This is occurring as the industry as a whole continues to struggle financially and has had to retrench from a geography, product, and benefit perspective. The major investment that has occurred has been in Special Needs Plans (SNPs) the past two years, but some of the regulatory changes do not bode well for Stars for plans that will have SNP lives or a high concentration of dual eligibles. Refresher on proposed changes Major measure realignment: Beginning primarily in Measure Year (MY) 2027 or

NOTE: This blog is published in partnership with Lilac Software. See more about Lilac’s offerings at the end of this blog. MA plans celebrate the sunset of the SNP-CM measure, but little really changes Many Medicare Advantage (MA) Special Needs Plans (SNPs) breathed a sigh of relief when the SNP Care Management measure was proposed to be sunset as of Star Year 2029/Measure Year 2027. Just one more year of the measure. The measure tracked the timely conduct of initial and annual reassessment Health Risk Assessments (HRAs). But I say — wait one moment! Even if the Star measure goes, SNP program audits and regulation remain and the HRA is the foundation of how plans ensure quality in their SNP care management program as well as program audit and regulatory compliance. Back on September 25 and 29 I published detailed blogs on the tremendous SNP enrollment growth as well as

Progress on drug price reform is remarkable True to an earlier announcement, the Trump administration has taken the first steps toward more expansive coverage of GLP-1 weight-loss drugs in Medicare and Medicaid. When he came into office, President Trump made the decision not to finalize a proposed rule by the Biden administration that would have expanded coverage for obesity alone in Medicare and Medicaid. At the time, it was the right call. Given GLP-1 prices, expansion could have significantly impacted the finances of the government programs. What has changed? But a great deal has changed since that decision. Trump issued several executive orders to begin to reform drug pricing, including all aspects of the drug channel and introducing most-favored-nation (MFN) pricing. After threatening tariffs on brand drugs manufactured abroad, he has struck more than a dozen deals with brand drug makers that lower costs in Medicaid and introduce lower prices

The GOP cannot escape the real affordability crisis in healthcare Affordability will be the election theme for the 2026 midterms. This will apply across Americans’ lives. While real wages have indeed mostly kept up with prices of late, there is a serious concern among Americans that getting ahead is out of reach for many, especially younger generations. Affordability very much brought Donald Trump and the GOP to dominate Washington after the 2024 elecions and the same issue could very well be their undoing in 2026 elections. Affordability issue most pronounced in healthcare The affordability issue is most pronounced in healthcare. We have seen huge price and inflation trends in healthcare since coming out of the COVID pandemic and there is little sign that the aggressive trends will subside anytime soon. In the biggest world of healthcare, employer coverage, trends have been 6% to 9% the past few years. Family coverage

Even a master seer would have problems predicting what may occur in healthcare in 2026. In my last blog, I gave you my 2025 Healthcare Year In Review. After that, as I always do each year, I play Nostradamus to prognosticate about what will happen in the next 12 months in the world of healthcare. Despite my Irish last name, I do have French blood (well, 50% French Canadien, so I count it). But I don’t claim to be an oracle or seer like our 16th century physician, apothecary, and astrologer friend. I do take a page from Nostradamus, though, in that my healthcare predictions for 2026 (not really prophecies) will be sometimes deliberately vague (they include a lot of less thans, abouts, probabilities, mays, coulds, shoulds, perhaps, likelys and possibles) so as to amass a reasonable record for those tracking and putting together my forecasting report card for the history books. It

A busy year in healthcare with insurer woes, a new president, and a decidedly different healthcare policy approach. As is my tradition at year’s end, I reflect back on all that occurred in healthcare in the year. It was a big year in healthcare and the new administration portends another massive one next year. I will have my 2026 healthcare predictions blog later this week. So, here are the major healthcare happenings from 2025. You can go to various blogs at the blog tab of this website to learn more. Presidential transition The year began with a presidential transition, with Joe Biden exiting the White House and Donald Trump returning after four years in the political wilderness. Trump has taken a decidedly different approach to healthcare coverage, but at the same time has shocked some with efforts to reduce drug pricing and coercing definitive concessions from Big Pharma. Trump convinced

An incredible analysis from Wakely Consulting, one of the foremost actuarial firms in the Medicare world. Wakey finds that annual wellness visits (AWVs) can demonstrably help control costs among Medicare beneficiaries. As the firm notes, AWVs are meant to identify disease states and conditions as well as create a care plan to act as a long-term preventive action plan. Wakely looked at a sample of traditional fee-for-service (FFS) Medicare program claims from 2018 – 2023. Beneficiaries who met the criteria for the institutional, end-stage renal disease (ESRD), or new enrollee risk score models were excluded. As well, only Medicare beneficiaries in the community with full calendar year data were included. The final sample comprised 733,532 beneficiaries with data for each year. Wakley also took into consideration social determinant and disease state impacts. Wakely broke out the sample into the following: Wakley found that AWVs are considerably underutilized. About 45% of