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Assessing Premium Subsidy Extension Modern Healthcare does a good job assessing the prospects of extending the enhanced premium subsidies for at least one year. There are a group of moderates seeking the extension but conservatives in each house seem to be very uninterested. House Speaker Mike Johnson, R-LA, is saying it is on the table but is non-committal.  The wild card is whether Democrats will demand the extension as part of some grand funding compromise on keeping the government open. But would that actually work against them politically in the midterms? (Article may require a subscription.) #exchanges #budgetreconciliation #obbba https://www.modernhealthcare.com/politics-regulation/mh-aca-subsidies-gop-expiring-2026 House Opposes PA In Traditional Medicare The House Appropriations Committee threw water on the fire when it voted to defund a plan that would have prior authorization (PA) in traditional Medicare on certain high-cost, abused services. Enough Republicans joined Democrats in passing an amendment to a funding bill that would

Uninsured Rate Remains Steady Healthcare policy group KFF finds that the uninsured rate held steady at 8.0% in 2024 and remains near a historic low. The analysis uses new data from the Census Bureau and matches other findings. While Medicaid redeterminations meant losses there, private sector and Exchange coverage did pick up most of the losses. As the Medicaid continuous enrollment policy came to an end, states resumed Medicaid redeterminations. Medicaid coverage dropped by 1.3 percentage points from 2023 to 2024 while private coverage increased by 0.7 percentage points, including a 0.5 percentage point increase in direct purchase coverage. In another analysis of Exchange coverage, KFF also found that 48% of adults under age 65 enrolled in individual market (direct purchase) coverage are either employed by a small business with fewer than 25 workers, self-employed entrepreneurs, or small business owners. KFF also published key facts about Medicaid, including that over

United Cuts Commissions In MA But Predicts Stars Improvement Troubled UnitedHealthcare is ceasing or cutting commissions on new sales of more of its products. This will impact 18% of its products for 2026. United will pay only partial commissions for another 2% of its MA products. The insurer will continue to compensate brokers for renewals. United will not pay for new enrollments into its Institutional Special Needs Plans and will continue to zero out commissions for standalone Part D (PDP) drug plans. But in good news for the nation’s biggest MA plan, United told investors today that it expects roughly 78% of its MA enrollees to be in plans rated 4 Stars or greater. This information came from Stars Plan Preview 2, which started today. It still will shed about 600,000 members next year to hit finance targets. Humana told investors it expects ratings to improve but gave no details.

Democrats On Attack On Budget Bill Cuts Democrats are seizing the opportunity to muddy Republicans on the budget reconciliation bill vote and the lack of enhanced subsidy extensions in the Exchanges. A report commissioned by Sens. Ron Wyden, D-OR, and Jeanne Shaheen, D-NH, was compiled by the Georgetown University Center on Health Insurance Reforms. The report finds the following: In other news, the American Hospital Association alleges that major pharmaceutical companies colluded to devise a plan to replace 340B drug program discounts with rebates. It sent a letter to the Justice Department and the Federal Trade Commission urging an investigation of several brand drug makers. This is a desperate act by the hospital lobby, which is fearful of losing one of several government giveaways. Additionally, hospitals are pressing for action on and changes to several health policies, including overturning an $8 billion reduction to the Medicaid Disproportionate Share Hospital (DSH)

Mercer Survey Confirms Employer Healthcare Struggles A new survey and study from consulting firm Mercer adds to the growing worry about the status of employer coverage. It says employers are likely to see healthcare costs increase significantly next year. Mercer polled more than 1,700 employers and found that total health benefit costs per employee are expected to rise by an average of 6.5% in 2026 after cost management and 9% before such measures. This 9% gross trend is consistent with the 8% to 9% seen in other studies and surveys. These trends are the highest in a decade. And this will mean the fourth-straight year of increased spending growth following a decade of more moderate cost hikes. Reasons for the major trends are the following: Mercer says 56% of employers intend to take cost-cutting measures for 2026, up from 48% in 2025. Deductibles and other cost-sharing will be increased. Mercer

2026 MA Pullback Starts A number of high profile exits from Medicare Advantage (MA) and standalone Part D (PDP) were announced today. Elevance Health announced it will cut some MA plans and fully exit the PDP program. The PDP exit is not surprising but sends a message that the program is in trouble after some political yet bad policy changes made by Democrats to Part D cost-sharing the Inflation Reduction Act. The changes have destabilized an already fragile program. Elevance has 400,000 PDP members and is the sixth-largest plan in PDP. Given its continuing financial woes, Elevance, too, will eliminate unprofitable MA plans and says that will impact 150,000 individual and group MA members. But Elevance will continue its investments in Special Needs Plans (SNPs) in 2026, a huge trend in the industry. Elevance currently has 2.3 million MA enrollees. In an another announcement, due to financial issues, Minnesota-based UCare

New Analysis on MA Overpayment I have argued that a small subset of big plans have given all of Medicare Advantage (MA) a bad name by suspect or fraudulent risk adjustment practices that give them major overpayments. A number of studies have singled out this small group of major plans. Now, the Alliance of Community Health Plans (ACHP), a group that represents local and regional nonprofit payers, has come out with a study building on these earlier findings. ACHP says that UnitedHealthcare, the biggest MA insurer, collected up to $785 more per beneficiary than local nonprofit plans in 2023, costing Medicare more than $6 billion in excess payments that year. Humana, the second-biggest MA payer, collected $423 more per beneficiary that year than if those members were in ACHP member plans, costing Medicare an additional $4 billion. UnitedHealthcare’s average risk scores were 36.2% higher and Humana’s were 19.2% higher than

Government Shutdown Looms Congress has returned to Washington and the GOP has no plan to keep the government running at the end of the month. Democrats are pushing the GOP to have a four-leaders meeting to discuss a consensus, but the House and Senate majorities are pushing other agendas right now. Democratic votes would be needed to keep the government going unless budget reconciliation was used again. That is a tall order if not impossible. The Senate GOP has floated a short-term spending patch to give more time to discuss FFY 2026 funding. But some conservatives in the House and Senate want a full-year extension at FFY 2025 spending levels with additional spending cuts. There is some bipartisan interest in negotiating a healthcare package before the end of the year. Senators are already discussing this. On the docket is the possibility of extending the Exchange premium subsidy enhancements, but conservatives

MA Controls Healthcare Growth For Enrollees While opponents of Medicare Advantage (MA) are on a campaign to strip MA of all sorts of revenue and bolster the future of the antiquated traditional fee-for-service (FFS) program, many studies show the value of MA from a cost and quality perspective. Now, the UCLA Center for Health Policy Research concludes that Californians enrolled in MA face slower growth in healthcare costs compared to those in FFS. Between 2013 and 2023, average monthly healthcare costs were $269 in counties with MA enrollment above 20%, compared with $481 in counties below 20%, or a 44% lower cost. Counties with higher MA enrollment saw an 11% increase in monthly healthcare costs over the decade (from $245 to $273), while counties with lower enrollment saw a 54% increase (from $361 to $557). #medicareadvantage #medicare https://www.beckerspayer.com/uncategorized/medicare-advantage-plans-keep-senior-care-costs-down-in-california-ucla MA Star Lawsuit Wrap-up This Modern Healthcare article tallies wins and losses

More Suits On No Surprises Act UnitedHealthcare joins the ranks of Elevance Health and Aetna in suing prominent provider entities over the No Surprises Act. United is suing Radiology Partners and its Arizona-based affiliate, Sonoran Radiology, alleging the companies have been “abusing” the No Surprises Act’s independent dispute resolution process. They argue the radiology provider behemoth is “funneling millions into the pockets of its private-equity owners.” The lawsuit comes after a Health Affairs study that shows that providers overwhelmingly win disputes and are awarded extremely high payments. Another new study also shows that surprise bills have fallen under the act based on data from states that had some protections and those that did not before the national law took effect. The study also notes that the prediction that the process would lower prices and save has not materialized. The fact remains the law needs major reform, including requiring the qualifying