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Government Funding Stopgap House Republicans will vote this week on a shorter, 7-week funding resolution for FFY 2026 (which begins October 1) that includes some critical healthcare extensions, but nothing on extending the Exchange premium subsidy enhancements. The bill would need a simple majority in the House but 60 votes in the Senate. Congressional Democrats have suggested they may not support the measure unless it includes greater healthcare funding, including a rollback of some budget reconciliation bill cuts and extension of the subsidies. Additional articles: https://www.fiercehealthcare.com/regulatory/republicans-unveil-7-week-stopgap-hospital-funding-telehealth-extensions-no-aca-premiums and https://www.beckershospitalreview.com/finance/aca-subsidy-extension-left-out-of-7-week-stopgap-funding-bill/ (Some articles may require a subscription.) #governmentshutdown #congress #healthcare https://www.modernhealthcare.com/politics-regulation/mh-house-spending-bill-aca-subsidies-mike-johnson Hospitals Attack Aetna Proposed Inpatient Policy The hospital lobby has sent Aetna a letter urging it to rescind its planned “level of severity inpatient payment” Medicare Advantage (MA) policy, which is set to go into effect November 15. Under the policy, Aetna will approve inpatient stays without a medical necessity review but

Trump Marketing Curbs Worry Brand Drug Makers President Trump’s order to curb advertising for pharmaceutical drugs on television is creating anxiety for brand drug makers, advertising firms, and broadcasters. They say it could pose an existential threat to them. Media companies brought in $5 billion in advertising revenue from pharmaceutical companies in 2024. The order does not outright ban direct-to-consumer advertising of drugs. Trump does not have the authority to do that, but health chief Robert F. Kennedy, Jr. wants to ban them. But the administration is using its executive and regulatory authority to ensure “transparency and accuracy” in direct-to-consumer advertising, including requiring greater disclosures of side effects in television and other ads. The administration also has sent cease-and-desist letters to some large drug manufacturers to combat “egregious violations demonstrating harm” in the marketing of high-cost prescription drugs. The president is absolutely right on this one. #drugpricing #marketing #branddrugmakers https://thehill.com/policy/healthcare/5500949-trump-administration-pharma-advertising-curbs

Study Says Big Health Plans Will Continue Growth A new analysis from Morningstar has a fairly optimistic view of big health plan growth over the next decade but notes some headwinds. It says big plans will continue to grow market share. The study says Aetna, Centene, Cigna, Elevance Health, Humana and UnitedHealthcare will insure 56% of Americans by 2034. They had 41% in 2014 and 52% in 2024, so growth will be far more measured. United and Elevance will continue to lead the way. The study notes these plans have some critical competitive advantages and that there is continued outsourcing of government program lives. Headwinds noted, though, are elevated utilization impacting profits, increased uninsured rates due to the budget reconciliation healthcare cuts, and new regulatory scrutiny. The last headwind includes prior authorization reforms, claims scrutiny, and risk adjustment reform. A possible headwind may be a move to have vertically integrated

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