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Plans Announce PA Initiatives To Forestall Regulatory Action After commitments by Trump administration officials to reform prior authorization (PA), about fifty health plans, including some of the biggest, met with Health and Human Services (HHS) Secretary Robert F. Kennedy, Jr. and Centers for Medicare and Medicaid Services (CMS) Administrator Dr. Mehmet Oz to unveil their plans to streamline PA and tackle claims denials. The health plans represent as many as 75% of America’s insured. The Blue Cross and Blue Shield Association and trade group AHIP also attended the meeting. Health plans will commit to reduce the number of codes that are subject to PA and to establish a standard framework to increase how many authorizations are adjudicated electronically and in real time. PA changes will occur by 1/1/2026, with electronic PA reforms in one year later. The plans also will increase education on PA and appeals, accountability, and transparency around

Budget Reconciliation In Senate Still In Limbo After going to bat for deeper healthcare cuts for conservatives, Senate Majority Leader John Thune, R-SD, is facing an uprising on the right and left. Three conservatives – Mike Lee, Rick Scott, and Ron Johnson, are threatening to be off the bill unless deeper cuts occur, including in healthcare. Rand Paul appears already against the bill due to a provision that increases the debt limit. This would sink the bill. At the same time, at least three moderates or pragmatists – Lisa Murkowski, Josh Hawley, and Susan Collins – remain very concerned about the depth of certain cuts, especially provider tax restrictions. Thune wants to vote on the bill next week. Rural providers, particularly hospitals, continue to argue the bill jeopardizes their livelihoods and that hospitals in under-served areas could shutter. An impasse over the state and local tax deduction threatens passage of

Opposition To Healthcare Cuts In Budget Bill All of healthcare is lining up against the cuts to healthcare in the budget reconciliation bill. A new study from the Urban Institute and Robert Wood Johnson (RWJ) Foundation breaks down how providers (hospitals, physicians, and drugs) are impacted in each state by the reductions to Medicaid and the Exchanges. Over the next decade, the bill would decrease spending by $321 billion to hospitals, $81 billion to physicians and $191 billion for drugs. Spending for other healthcare services would decline by $205 billion. If the Exchange premium tax credits expire, spending would decline by an additional $262 billion — hospitals an additional $103 billion cut, physicians an additional $39 billion cut, and drugs an additional $50 billion cut. Spending on other healthcare services would drop an additional $70 billion. Now, I have little doubt on the math of what Urban and RWJ did.

Budget Reconciliation Bill Flounders Senate Majority Leader John Thune, who won his position with backing from prominent conservatives, threw his weight behind budget-cutters in the reframing in the Senate of the House bill. But the move seems to have backfired on him. He has two conservative holdouts on the bill. He also has an uprising from moderates and pragmatic conservatives due to the Medicaid reductions, which are even deeper than the House had included. Thune essentially ignored a fundamental part of his caucus. The moderates are worried about impacts on states and providers as well as what will happen to the uninsured rate. At least three moderates or pragmatic conservatives – Josh Hawley, Susan Collins, and Lisa Murkowski – have been vocal on the cuts and expressed doubts about voting for the bill. But there are still others that could vote against them due to the Medicaid cuts. Right now,

More Senate Budget News The Congressional Budget Office (CBO) reaffirmed that the One Big Beautiful reconciliation bill will cost the healthcare sector a $1 trillion reduction over ten years. The Senate bill adds to limitations in the House bill on provider taxes (phasing them down and capping them to 3.5% over time for expansion states) and slightly tightens eligibility further. It also cuts certain existing state-directed payments to hospitals where the House just limited future payments. Healthcare policy group has good summaries comparing the Senate and House versions for Medicaid and Affordable Care Act (ACA) cuts. Additional articles: https://thehill.com/homenews/ap/ap-business/ap-trump-tax-bill-would-widen-deficits-by-2-8t-after-factoring-in-economic-impacts-cbo-says/?tbref=hp and https://thehill.com/homenews/senate/5353963-senate-medicaid-taxes-green-energy/ and https://www.kff.org/tracking-the-medicaid-provisions-in-the-2025-budget-bill/ and https://www.kff.org/tracking-the-affordable-care-act-provisions-in-the-2025-budget-bill/ (Article may require a subscription.) #budgetreconciliation #congress #trump #spending #medicaid #coverage https://www.modernhealthcare.com/politics-regulation/mh-gop-tax-plan-cost-cbo Fitch Downgrades Health Insurers Fitch Ratings has downgraded the health insurance industry’s outlook to deteriorating from neutral because of rising utilization and Medicaid and Exchange cuts in the budget reconciliation bill. Additional article:

Senate Reconciliation Bill Sets Up Showdown The Senate version of the House-passed budget reconciliation bill has been unveiled and will create a showdown within the Senate and eventually with the House. The measure preserves the House reductions to Medicaid but goes further. Beginning in 2027, the legislation would lower healthcare provider taxes to 3.5% (from 6%) in states that chose to expand Medicaid. It also expands those who would be required to work as a condition of Medicaid eligibility. The Senate version says adults with dependent children older than 14 will also have to prove they work, attend school, or perform community service for 80 hours a month. The House-passed version would exempt all adults with dependent children. A number of moderates and pragmatic conservatives could be off the bill, with Sen. Josh Hawley, R-MO, and Sen. Susan Collins, R-ME, already speaking out. Hawley dislikes the provider tax changes as

Democrats Propose Bills To Defend Medicaid Democratic senators have proposed as many as 13 bills regarding Medicaid as the GOP continues its debate over changes to the budget reconciliation bill cuts to the low-income healthcare program. Some of the bills tackle fraud, waste, and abuse (FWA), while others protect expansion of coverage and insulate providers. #budgetreconciliation #medicaid #trump #congress #coverage https://www.fiercehealthcare.com/regulatory/democrats-make-pitch-medicaid-improvements-big-beautiful-bill-debate-heats Trump Pushes Big Pharma To Lower Price With his deadline for brand drug makers to come forward with lower prices, the Trump administration is pushing pharmaceutical companies to begin negotiations to reduce prices. If they do not, the government will begin the process of implementing most-favored-nation (MFN) pricing. “Under President Trump’s direction, HHS is demanding that pharmaceutical companies end their obstruction and come to the table—just as they already do with nearly every other economically comparable nation—to negotiate fair, transparent pricing for Americans,” a Health and Human Services (HHS)

Medicare Advantage Abuses in Focus A big day for coverage involving abuses in Medicare Advantage (MA). First, Scan CEO Sachin Jain has a good Health Affairs Forefront blog on MA enrollment issues. Jain recounts the fact that there are behind-the-scenes compensation schemes between some large MA plans and brokers and marketing organizations that lead to steerage of enrollees into plans, often when it is not in their best interest. He notes enrollment in low-rated plans is a problem. The Department of Justice filed a complaint against certain brokers and MA plans, alleging plans paid hundreds of millions of dollars in illegal kickbacks to brokers in exchange for enrollments into the plans’ products. Jain proposes a change in how compensation is made for enrollment by favoring high-performing plans and perhaps making compensation is budget neutral. Second, healthcare policy group KFF posted an issue brief regarding expected Star bonus payments in 2025. It

Public Supports Trump Drug Pricing Plan A survey commissioned by the Pharmaceutical Reform Alliance and conducted by National Research Inc. finds that a majority of voters are in favor of lawmakers and candidates who they believe will take on Big Pharma price-gouging. Most say they support President Trump’s most-favored-nation drug pricing policy, where prices in the U.S. are set based on the lowest price in other developed nations. #drugpricing #mfn #irp #trump https://thehill.com/homenews/5343025-survey-voters-big-pharma-most-favored-nation Will Senate Go After Medicare? Despite discussing proposals to rein in Medicare Advantage (MA) overpayments in the budget reconciliation bill, some Republicans are saying there is little appetite to add such cuts in. This comes from senators who sought their inclusion. In addition, the House has passed tweaks to the bill they adopted to ensure consistency with Senate Byrd reconciliation rules. Additional article: https://www.politico.com/news/2025/06/10/house-gop-reveals-list-of-tweaks-to-megabill-00398669 and https://thehill.com/homenews/house/5345047-house-gops-technical-changes-trump-agenda-bill/?tbref=hp #medicareadvantage #riskadjustment #overpayments #budgetreconciliation https://thehill.com/homenews/senate/5344838-medicare-advantage-reform-less-likely Reasons Beneficiaries Disenroll From Medicare Advantage A

Senate Now Zeroing In On Medicare Advantage The Senate appears to be zeroing in on Medicare Advantage (MA) overpayments for the budget reconciliation bill to achieve greater savings and perhaps reduce Medicaid cuts. MA plans and lobbies are lining up to oppose it, saying the reductions will impact enrollees. Sen. Bill Casidy, R-LA and Chairman of the HELP Committee, is one GOP senator examining it, which has bipartisan support (not that Democrats will vote for the bill). Exactly what would be included is open. One report says the provision would save $100 billion over the 10-year horizon and would limit the ability to include old or unrelated medical conditions in the cost of care. Another proposal would save as much as $275 billion over 10 years. Very high estimates suggest total overpayments from risk adjustments are $43 billion annually (although I have great doubt about that number). The Centers for