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KFF Finds $60B At Risk With Directed Payment Reforms Healthcare policy group KFF finds that an estimated $60 billion in federal Medicaid spending in 37 states (including the District of Columbia) would likely exceed new federal limits on state directed payments for hospital services once fully implemented under the One Big Beautiful Bill Act (OBBBA). The eight states with the biggest potential reductions in Medicaid payments to hospitals are: California ($7.4 billion), Illinois ($4.0 billion), Kentucky ($3.9 billion), Texas ($3.5 billion), North Carolina ($3.4 billion), Louisiana ($3.3 billion), Arizona ($3.0 billion) and Michigan ($2.6 billion). This accounts for about half of the total. While controversial, there is little doubt in my mind that intergovernmental transfers, provider taxes, and state directed payments have been abused by many states and some reforms are needed. Additional article: https://www.kff.org/medicaid/analysis-at-least-37-states-have-medicaid-state-directed-payments-for-hospital-services-that-could-be-reduced-by-the-2025-reconciliation-law-limits/ #medicaid #obbba #healthcare #coverage https://www.kff.org/medicaid/at-least-37-states-have-medicaid-state-directed-payments-for-hospital-services-that-could-be-reduced-by-the-2025-reconciliation-law-limits/ KFF Studies PA Denials A new analysis by healthcare policy

Aetna’s VBC Approach Paying Dividends CVS Health’s Aetna health plan is seeing its value-based care (VBC) investments paying off in terms of preventive care metrics and cost savings. The insurer looked at 20 different measures for individuals in its Medicare Advantage (MA) plans between VBC models and fee-for-service (FFS) reimbursement. It determined that VBC arrangements resulted in better results across 17 measures. About 43% more members controlled their HbA1C and 34% had controlled blood pressure. About 20% more patients were screened for colorectal cancer and there were 7% fewer hospitalizations. VBC providers generated $315 million in savings during plan year 2023, 2.6% higher than FFS providers. VBC risk arrangements vary. Providers in two-sided risk models had the strongest performance across multiple measures in the report. Aetna says that, given apprehension and differences in maturity in the provider market, it enters into various levels of VBC models with providers. Report: https://www.aetna.com/content/dam/aetna/pdfs/aetnacom/insights/aetna-medicare-vbc-whitepaper.pdf

Parts of No Surprises QPA Rule Struck A federal appeals court has ruled that the government’s methodology for calculating the qualifying payment amount (QPA) within the No Surprises Act’s arbitration process is partly unlawful. This could lead insurers to have to recalculate such future offers at higher rates. The court found that inclusion of so-called “ghost rates” in the calculation and excluding bonus and incentive payments did not meet the law. The law heavily favors providers already. The move could mean higher benchmark payments in general over time. But it could also move the last best offers of plans up in the arbitration process. Would that sway some arbitrators to award to plans? So far, the awards are 85% in favor of plans and at payment amounts that are well higher than before the law went into effect. It is driving higher prices overall. Additional articles: https://www.beckershospitalreview.com/legal-regulatory-issues/5th-circuit-strikes-down-parts-of-no-surprises-qpa-rule-rejects-air-ambulance-challenge/ and https://www.beckerspayer.com/policy-updates/the-never-ending-no-surprises-saga/ (Some

Trump Administration Defends Exchange Paring The Trump administration went on the offensive today arguing that studies prove the reduction in Exchange enrollment in 2026 was the result of fraud control efforts enacted during the last few years. It said the sharp rise in premiums was not the cause. Policy experts dispute this and argue that tougher enrollment processes and enhanced premium subsidy expiration led to a surge in premiums and enrollment declines. Enrollment in Exchange plans fell by nearly 3 million nationwide this year to about 19.2 million. The Trump administration says 2.9 million people were removed through fraud initiatives. More are expected to cancel coverage throughout the year due to premium affordability issues. I have a blog running Thursday on this topic. Stay tuned. But a hint on where I stand – the truth is always somewhere in the middle. #exchange #enrollment #coverage https://www.fiercehealthcare.com/regulatory/kennedy-oz-contend-fraud-crackdown-not-skyrocketing-prices-led-millions-leave-obamacare Molina’s Exchange Plight Molina Healthcare

Many Plans Still Showing Losses Despite a reasonable recovery among the national health players in Q2 2026, HealthScape Advisors, part of Chartis, says health plans remain under significant financial pressure. Its annual look at health plans’ financial performance finds that plans posting an operating loss increased over the past several years. In 2023, 54% of health plans reported an operating loss, and that grew to 70% in 2024. And in 2025, that rose again to 73%. HealthScape says operating losses are concentrated among regional plans and Blues plans, with 72% of regional insurers and 83% of Blues reporting one in 2025. Fourteen percent of national payers reported an operating loss in 2023 and 2024, but the rate jumped to 43% in 2025. Read my blog last week on the national players here: https://www.healthcarelabyrinth.com/are-insurers-turning-the-financial-corner-yes-but-there-is-more-work-to-be-done/ #healthplans #margins https://www.fiercehealthcare.com/payers/number-health-plans-reporting-operating-losses-growing-report KFF Shows How Hospitals Drive Price Growth Healthcare policy group KFF covered the pernicious

340B Bill Would Hinder Administration’s Reforms Another bill with bipartisan Senate support has been introduced to stop the administration from extending a rebate pilot it plans to launch that would convert 340B upfront discounts to retrospective rebates.  The bill would establish an independent, third-party data clearinghouse to address Big Pharma’s concerns that discounts are being diverted and duplicated by qualifying hospitals and other participants. The entity would coordinate 340B transaction data between parties and oversee any issues. #340b #drugpricing #branddrugmakers #hospitals https://www.fiercehealthcare.com/regulatory/new-bipartisan-340b-reform-bill-curbs-hhs-rebate-pilot Rural Funding Stalled And Has Onerous Oversight Rural hospitals complain that $50B in aid for rural healthcare is being stalled and subjected to onerous paperwork and regulatory oversight. Hospitals want the Centers for Medicare and Medicaid Services to create more flexibility around deadlines and funding caps. (Article may require a subscription) #ruralhealthcare #obbba #hospitals https://www.modernhealthcare.com/providers/mh-cms-rural-health-transformation-program-red-tape Wakely Dives Deep Into Exchange Financial Turmoil A great white paper from Wakely

Oscar, Clover Have Good Financial Results Exchange-dominant Oscar Health reported strong Q2 results, with a profit of $362 million compared with a loss of $228.4 million a year ago. The company saw record profitability in 1H 2026, generating $1.1 billion in earnings from operations and $1 billion in net income. Clover Health’s Medicare Advantage (MA) membership grew 48% year-over-year in Q2 to 157,309 members. The company posted $153 million in profit, up 54% from Q2 2025, and revenue of $743 million, up 56% from Q2 2025. It was also buoyed by its Star lawsuit win. Additional article: https://www.fiercehealthcare.com/finance/oscar-health-boosts-2026-earnings-outlook-after-record-profitability-during-first-half-year #healthplans #margin https://www.fiercehealthcare.com/finance/clover-health-reaffirms-ai-commitments-discusses-star-rating-amid-strong-q2-performance Fitch Says Hospital May Peak Ratings advisory Fitch says nonprofit hospitals have broadly maintained their steady operating performance improvements, but that 2026 could be a peak because of crushing policy changes that will remove revenue from providers.  #obbba #medicaid #hospitals https://www.fiercehealthcare.com/providers/fitch-2025-likely-brief-operational-peak-nonprofit-hospitals-ahead-obbba-changes Small Group Costs To Spiral Preliminary rates from