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Seismic Changes To ACA and Exchanges Proposed Building on changes in the One Big Beautiful Bill Act (OBBBA) and other regulatory changes in 2025, the Trump administration’s 2027 Affordable Care Act (ACA) and Exchange rule aims to make additional seismic changes in healthcare. Among the major changes include: Proponents argue the changes are needed to reduce costs and provide more affordable options. Critics argue the changes will simply erode the Exchanges financial position and increase risk. Additional articles: https://www.fiercehealthcare.com/regulatory/cms-plans-roll-back-limits-non-standard-aca-plan-options and https://www.beckerspayer.com/payer/aca/cms-proposes-aca-implementation-rule/ and https://www.cms.gov/newsroom/press-releases/cms-proposes-regulations-lower-health-care-costs-expand-consumer-choice-protect-taxpayers and https://www.cms.gov/newsroom/fact-sheets/hhs-notice-benefit-payment-parameters-2027-proposed-rule #exchanges #healthcare #coverage #trump #cms #regulations https://www.modernhealthcare.com/politics-regulation/mh-aca-exchange-rule-2027-standardized-coverage Kaiser Reports Good Financials Kaiser Permanente reported good financial news for Q4 and 2025. It tripled its operating income although operating expenses surged. It reported operating income of $1.4 billion last year, up from $569 million in 2024. The turnaround is tied to investments in operational improvements. Kaiser Permanente and its subsidiaries wrapped 2025 with a 10.3% bump

Centene Reports Financial Results Centene Corporation posted a $1.1 billion loss in Q4 2025 and $6.7 billion loss for 2025 as it sees elevated costs overall and shrinking membership in Medicaid. It had $3 billion in profit in 2024. Its medical loss ratio was 94.3% in Q4, up from 89.6% a year ago. Adversity is increasing. While it did post a loss in Q4, results still surpassed Wall Street analysts’ predictions. Centene issued a higher earnings outlook for 2026 than analysts expected as well. As with Molina, which reported negative results for 2025 and financial expectations in 2026 that are half of analyst forecasts, Centene said states’ Medicaid payment rates haven’t kept pace with costs. Acuity is also rising in the Exchanges. Both Centene and Molina stock dropped. Additional articles: https://www.modernhealthcare.com/insurance/mh-molina-medicaid-acquisitions-medicare-advantage/ and https://www.modernhealthcare.com/insurance/mh-centene-earnings-medicare-medicaid/ and https://www.healthcaredive.com/news/centene-loss-q4-2025-2026-outlook-cnc/811564/ and https://www.beckerspayer.com/financial/centene-posts-6-7b-loss-in-2025/ (Some articles may require a subscription.) #healthplans #margins #centene #molina #medicaid #exchanges https://www.fiercehealthcare.com/payers/centene-reports-11b-loss-q4-elevated-medical-costs-continue-strain-finances Cheering

TrumpRx Unveiled; Novo Nordisk Reports Bad 2026 Guidance TrumpRx was unveiled Thursday. The president negotiated deals with 16 of the 17 largest brand drug makers and part of the arrangement includes steep discounts on TrumpRx for self-pay Americans. The initial launch includes discounted products from AstraZeneca, Eli Lilly, EMD Serono, Novo Nordisk and Pfizer. Additional manufacturers that have signed agreements will have products added to the platform over time. Right now, 43 prescription drugs treating various different conditions at varying discounts are on the website. Medications for asthma, infertility and obesity are among those available. The savings range between 33 and 93 percent off the list price of the drugs. Trump has been driving other changes as well, including deploying models for most-favored-nation (MFN) pricing in Medicaid and Medicare. The deals he struck already gained MFN in Medicaid and such pricing on new drugs that come to market. Some criticize

FTC Settles With Cigna’s Express Scripts The Federal Trade Commission (FTC) and Cigna’s Express Scripts pharmacy benefits manager (PBM) reached a settlement that resolves allegations that the PBM artificially drove up prices for insulin. Cases continue against CVS Caremark and OptumRx. Express Scripts will implement a number of reforms, including: The FTC expects the settlement to lower out-of-pocket costs for drugs by $7 billion over a decade. Additional articles: https://www.fiercehealthcare.com/regulatory/ftc-evernorth-near-settlement-case-over-insulin-prices and https://www.healthcaredive.com/news/express-scripts-ftc-reach-settlement-insulin-lawsuit/811369/ and https://www.beckerspayer.com/legal/ftc-deal-over-insulin-prices-forces-cignas-express-scripts-to-overhaul-policies/ (Some articles may require a subscription.) #pbms #drugpricing #employers https://www.modernhealthcare.com/insurance/mh-cigna-express-scripts-ftc-pbm-lawsuit CMS Hypes ACO Growth And Potential The Centers for Medicare and Medicaid Services (CMS) issued a fact sheet regarding latest statistics around Medicare Accountable Care Organizations (ACOs). As of January 2026, 14.3 million Medicare beneficiaries are estimated to receive care coordinated by ACOs, up from 13.7 million in 2025 or a 4.4% increase. This includes those in Medicare Shared Savings Program ACOs and entities participating in

Partial Shutdown Over The House voted 217-214 to approve a final spending package for FFY 2026 — 21 Republicans defected from and 21 Democrats supported the bipartisan measure. President Trump has already signed the bill. A number of key healthcare reforms are included. I reported on a list of them in the Newsfeed on January 30. Among the big items are a set of pharmacy benefit manager (PBM) reforms, including extensive reporting, transparency, and government oversight as well as requirements to pass rebates earned from drug makers to health plans, employers, and patients. PBMs will now have to charge a set fee for services. The bill requires the groups to report detailed data on drug pricing, rebates, pharmacy reimbursement, and payments retained by PBMs and their affiliates and authorizes audits and enforcement/recoupment actions. In addition, telehealth was extended for two years and acute hospital-at-home by five years. Additional articles: https://www.modernhealthcare.com/politics-regulation/mh-congress-government-funding-bill-pbm-telehealth/

Government Funding Bill Still Not Passed; Due Up Tuesday in House With Democrats off the Senate funding package to end a partial government shutdown, Speaker Mike Johnson, R-LA, is still expressing optimism about the House approving a funding package Tuesday. The Rules Committee is now meeting to pass a rule, which then clears the way to have a party-line vote on the Senate package. But with the ability to lose but one vote given a slim majority, Johnson’s optimism may be a bit too, well, optimistic. However, Johnson says he is not asking President Donald Trump to call those Republican holdouts to get the deal over the finish line. This package and an earlier one funds all but the Homeland Security department through September 30. That is funded for two weeks, giving time for Democrats and Republicans to discuss concerns over ICE and Homeland Security conduct. Additional article: https://thehill.com/homenews/house/5719277-johnson-trump-gop-holdouts-funding/?tbref=hp #governmentshutdown

Partial Government Shutdown Will Occur Despite Deal But Could Have Limited Impact — Hopefully! The Senate passed a compromise provision to fund the government for all agencies yet to be funded and two weeks for the Department of Homeland Security. That will give time for parties to negotiate over some constraints on immigration officers. The Senate passed legislation Friday on a strong bipartisan vote. The government technically shuts down at midnight tonight, but the House will be back on Monday to vote on the amended package. House Speaker Mike Johnson, R-LA, wants to suspend the rules to take up the bill to get funding moving quickly Monday. That requires a two-thirds vote, requiring about 70 Democrats to sign on in support. In part, Johnson wants to do this because he could have defectors among conservatives and he is challenging Democrats politically to oppose the measure. If he cannot suspned the

Exchange Enrollment Down About 23M have enrolled in Exchange coverage as open enrollment has all but closed out. That’s down about 5% from 2025 but more than the 21.3M in 2024. Interestingly, the reduction is not what many thought it would be after the expiration of the enhanced premium subsidies. About 3.4 million are new enrollees, while 19.6 million are returning. About 15.8 million people enrolled on the federal Healthcare.gov platform, while 7.2 million enrolled on the state-based Exchanges. Some states that stepped in with subsidies of their own saw strong growth, as did others who did not – such as Texas. Nine states had enrollment growth, while 41 saw declines. For the 30 HealthCare.gov states, the data is through Jan. 15. For the 20 state-based exchanges plus D.C., the data is through Jan. 10. There are a few states that extended open enrollment and thus the enrollment numbers could

Elevance Reports Caution, But Better News Than United Elevance Health reported 2025 financial news today and its status is better than imploding UnitedHealth Group. That led to a recovery to some degree in its stock price today. Elevance beat The Street on profit in Q4 2025 but missed on revenue. The company reported $547 million in profit for Q4, up from $418 million in Q4 2024. However, its $49.3 billion in Q4 revenue fell short. It did have almost 10% growth year over year. For the full year, Elevance Health brought in $197.6 billion in revenue, up 12.8% from 2024’s $175.2 billion. Profits were down by 5.3% compared to 2024, decreasing from $6 billion to $5.7 billion. Elevance did report that it will see declining revenue in 2026, though. And profit could be constrained as well. This is tied to shedding of membership to right the financial ship as well as governmental

CMS Defends Flat Rates But Contraction Coming; UnitedHealth Crashes The Trump administration’s top Medicare official is defending the meager proposed Medicare Advantage (MA) increase for 2027, saying the administration is a big supporter of MA. Large plans stocks dropped dramatically today after the after-hours’ announcement yesterday. Analysts, trade groups, and plans are saying that yet another major contraction could occur in 2027. Benefits, products, and geographies began contracting in 2024, with major changes in 2025 and 2026. While the economic growth rate was generous, the administration proposed two risk adjustment changes that will take nearly all of the 5% trend away. Some expect a contraction of enrollment from the 2026 enrollment season when statistics come out soon. I have doubted this, but it very well could happen. Trump officials justify the risk adjustment changes and flat hike as an effort to combat overpayments in the program. In other news, UnitedHealth