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Will Subsidy Extension Pass? A Senate vote on a clean, three-year enhanced Exchange subsidy extension is scheduled for next week. And many Republicans are frustrated that their party is divided and no consensus can be reached on any compromise legislation. Any Republican bill would not be ready until after next week. That opens up the possibility that enough Republicans cross the aisle and vote with Democrats to extend the subsidies as is. House Speaker Mike Johnson, R-LA, has not yet committed to bring up the bill, but Democrats and some moderate Republicans could force a vote through a discharge petition. Given the lack of a real Republican bill, GOP lawmakers in both chambers are coming around to a temporary extension of enhanced Exchange subsidies. Conservative House and Senate Republicans either want fundamental reform or no action to extend the enhanced subsidies. Moderate Republicans in the House want either a clean

Nursing Home Staffing Rule In Dustbin The controversial rule seeking to impose nursing home staffing requirements has been officially repealed by the federal government after a judge struck down the Biden administration provision. The rule would have meant huge costs for the industry and actually either forced the shutter of smaller firms or led them to sell out to massive consolidators in the industry. The rule was a political sop to the unions as well. Additional article: https://www.modernhealthcare.com/politics-regulation/mh-cms-nursing-home-staffing-mandate-repealed/ (Some articles may require a subscription.) #nursinghomes #staffing #medicaid #medicare https://www.fiercehealthcare.com/regulatory/hhs-closes-book-controversial-nursing-home-staffing-mandate New ACCESS Model Tests Chronic Care In Medicare The Centers for Medicare and Medicaid Servies (CMS) announced a new payment model on December 1. The ACCESS (Advancing Chronic Care with Effective, Scalable Solutions) Model tests an outcome-aligned payment approach in Medicare. The model is aimed at expanding access to new technology-supported care options that help people improve their health and prevent

Exchange Subsidy Debate Still Dominates Hill The Exchange subsidy debate continues to dominate Capitol Hill. Sen. Amy Klobuchar, D-MN, predicted Sunday that the Senate will hold a vote on extending Exchange subsidies. “That vote will happen. And whether it will pass is in the hands of Donald Trump and the Republicans,” Klobuchar told CNN. Senate Majority Leader John Thune, R-SD, has committed to a vote, while House Speaker Mike Johnson, R-LA, has not. House Minority Leader Hakeen Jeffries, D-NY, is pressing centrist Republicans to help Democrats extend the tax credits before they expire at the end of the month by signing on to his discharge petition to force a vote in the House. Moderate Republicans in the House say they have their own discharge petition but are waiting to see what the Senate does. Many are critical of President Trump’s equivocation on the subsidies – in one breath he is ready to

Populist Trump Attacks Health Plans President Donald Trump has turned to attacking health plans in the wake of a concerted effort from Democrats accusing him and the GOP of not doing enough to tackle affordability. Trump was thought to be preparing an enhanced subsidy extension plan, but it is either delayed or won’t happen due to opposition from GOP conservatives in Congress. Trump is said to have supported a two-year extension with some reforms of the enhancements along with introducing subsidies for Health Savings Accounts for some to use.  In a recent social media post he directed his ire on healthcare affordability to health plans, saying: “The only healthcare I will support or approve is sending the money directly back to the people, with nothing going to the big, fat, rich insurance companies, who have made $trillions, and ripped off America long enough.” Of course, that is not true. But Trump may

What Is On GOP Menu For Subsidies? A good article in The Hill on Thanksgiving breaking down the GOP dilemma on what to do with the Exchange enhanced subsidy expiration that is looming. The issue pits moderate Republicans against conservative ones. There are competing proposals across the House and Senate. The dilemma: Extend the subsidies and endorse Obamacare or let the subsidies expire and deal with the electoral fallout in 2026. This could be major in dozens of moderate Republican swing districts in the House and several seats in the Senate. Here are some bills percolating on the Republican side: Moderates in both parties in House: One bill would extend the enhanced subsidies for two years but make some changes to assuage conservatives. Those earning less than $200,000 per year for a family of four would keep their subsidies and those earning between $200,000 and $300,000 for a family of four would

Deeper Dive On 2025 Medicare Drug Price Negotiations The Trump administration announced the results of the second round of Medicare drug price negotiations, taking credit for the 2025 process that it says led to much deeper price reductions than in 2024’s process. The 2025 set prices will go into effect in 2027. The administration said $12 billion in federal savings would occur due to the negotiations in 15 drugs. That is computed at 44% off of net (after rebates) costs, compared with 22% or $6 billion under Biden’s negotiations in 2024 for ten drugs. Under another calculation, the 2025 savings is $8 billion or 36%. Consumers would save an estimated $685 million in out-of-pocket costs. The medications are used by about 5.3 million Medicare beneficiaries. The negotiated savings range from 38% to 85% off the drugs’ list prices. Total spending on the drugs is about $42.5 billion. The administration reached agreement with brand drug makers

CMS Revamps Star Program For Medicare Advantage The Centers for Medicare and Medicaid Services published a draft Medicare Advantage (MA) and Part D rule for 2027 that would make sweeping changes in the MA Star program. Beginning primarily in the 2027 measure year (MY) or Star Year (SY) 2029, CMS proposes to remove 12 (really 14) measures, largely focused on administrative processes or those that no longer show variability in quality among plans. (The call center measures will be removed in MY 2026/SY 2028.) These are: Administrative/Operational measures removed: No longer showing variability: The above has the effect of transferring so-called Star power to clinical, drug, and remaining CAHPS survey and HOS survey measures. The Excellent Health Outcomes for All (EHO4all, the former Health Equity Index), will not be implemented for SY 2027 (MY 2025). The Reward Factor would be maintained for consistently high-performing plans. CMS also proposes to introduce

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

GLP-1 Drug Makers Go Direct With Employers Seeing the changes that are coming on drug prices, GLP-1 brand drug makers Eli Lilly and Novo Nordisk plan to sell their popular obesity drugs direct to employers rather than using the traditional drug sales channel that includes pharmacy benefits managers (PBMs) and rebates. In part, this is because price deals with President Trump drop drug costs considerably in Medicare and rebates will go away there. As well, this is to boost sales and get employer groups to keep or expand to obesity coverage for the drugs as opposed to use just for other disease states. The drug makers will offer Zepbound and Wegovy to companies starting Jan. 1 through Waltz Health, a firm that helps employers purchase cheaper medications. Lilly and Novo already sell direct to cash customers. While I have applauded the president on his drug agenda, I have doubted parts

Dems Want Medicare Drug Negotiations Expanded Democrats in the House have introduced a new bill that would expand Medicare’s ability to negotiate drug prices. The Lowering Drug Costs for American Families Act would allow Medicare to negotiate prices for more drugs each year, moving from 20 to 50, and make them applicable to the commercial market. #drugpricing #ira #branddrugmakers #medicare #partd #commercial #employercoverage https://www.fiercehealthcare.com/regulatory/house-democrats-introduce-bill-expand-drug-price-negotiation-commercial-market Hospitals See Claim Denials Increase MDaudit has found that average amounts of hospital’s denied inpatient and outpatient claims have increased by 12% and 14%, respectively. In addition, there has been an increase in payer’s audits. MDaudit looked at the first three quarters of 2025 data from its network of more than 1.2 million providers and 4,500 facilities. #healthplans #hospitals #claimsdenials https://www.fiercehealthcare.com/finance/payer-audits-denial-amounts-rise-again-2025-vendor-data-show PBM Reform Expected To Move Senate Finance Chair Mike Crapo, R-ID, and Ranking Member Ron Wyden, D-OR, plan to reintroduce a bipartisan package regarding pharmacy