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December 19, 2025

Trump Moves Ball On Drug Prices President Donald Trump registered more wins on drug price reform. The White House announced that nine additional pharmaceutical companies have agreed to follow a most-favored-nation (MFN) drug pricing policy, with some of the companies throwing in several months’ worth of emergency drug supplies. As with other drug firms, the drug companies will lower the Medicaid prices for drugs that are more expensive than they’re sold in other countries, although prices are already deeply discounted through federal and state rebate programs. The firms will also deeply discount cash-pay customers’ drugs via the TrumpRx website. The deals also guarantee MFN prices on all new innovative medicines the nine companies bring to market. Trump has now reached deals with 14 of the 17 drug makers to which he sent letters in July demanding that they lower prices. At the same time, the Centers for Medicare and Medicaid Services

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December 18, 2025

Exchange Saga Top House Democrats on Thursday called on House Speaker Mike Johnson, R-LA, to hold an immediate vote under the discharge process on extending the enhanced Exchange premium subsidies so they do not expire at the end of the year. Johnson is unlikely to do this due to objections from conservative caucus members. The House adjourns tomorrow for rest of the calendar year. A discharge petition for a bill to extend the subsidies received 218 signatures, including four moderate GOP lawmakers who snubbed the Speaker after he broke promise to run an amendment on the subsidy extension. These members are now working with moderates in the Senate to vote on a consensus bill in January. #exchanges #coverage #healthcare https://thehill.com/homenews/house/5654903-jeffries-democrats-johnson-obamacare-subsidies/?tbref=hp More Charged For Fraud in MN The Department of Justice (DOJ) charged more individuals as part of a huge Medicaid fraud scandal in Minnesota. In part the scandal focuses on

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December Medicare Advantage Enrollment Growth

A quick blog to tell you about enrollment growth in Medicare Advantage (MA) in December 2025. The results show some interesting trends as we go into 2026. Many have predicted that MA enrollment could contract in 2026. I have said on a number of occasions that I doubted we would see that and instead see enrollment that is relatively flat or extremely small in terms of growth. I surmised that while most national plans want to see their enrollment contract by millions, I suspect regional plans will take on the challenge of enrolling robustly despite some financial risks. While it is too early to tell what will happen, we can read some tea leaves in the December data. What do the latest statistics show? Growth from January 2024 to February 2025 was 4.39% or 1.468 million. (I used February 2025 because of issues with the January 2025 statistics.) Enrollment in

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December 17, 2025

Houses Passes GOP Healthcare Reform Bill The House passed its healthcare reform today with no vote or provisions to extend the enhanced Exchange premium subsidies. The vote was 216-211, with one Republican defecting. By and large, the bill does little to solve the affordability problem: The vote comes after Speaker Mike Johnson, R-LA, broke his promise to hold a vote on a subsidy amendment. Johnson broke his word after conservatives objected. The GOP leadership blames the backtrack on no plan from moderates to pay for the major cost of the extension. But the caucus recently passed the One Big Beautiful Bill Act (OBBBA) without major offsets, increasing budget deficits by $4.1 trillion with interest over 10 years. And conservatives on the Rules Committee turned down moderate amendments and simply did not want to allow a subsidy vote. Given the duplicity of the speaker, GOP Reps. Rob Bresnahan (Pa.), Brian Fitzpatrick

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December 16, 2025

Speaker Rebuffs Moderates On Exchange Extension Vote In a rebuff to moderates in his caucus, House Speaker Mike Johnson, R-LA, said he won’t call a vote to extend the Exchange enhanced subsidies. Moderates are livid that the speaker has broken his promise to hold a vote. Johnson says the party’s leadership was unable to reach an agreement with moderates on offsetting cuts to the pricey extension. But moderates did submit multiple amendments to the Rules Committee to pay for part of the extension. Conservatives refused to vote to support the vote on the amendment. Moderates likely still vote for the main House reform bill to be voted on. But some media say some GOP moderates have not ruled out signing onto a Democratic-led discharge petition to force a vote on a three-year extension. But other media report that this is unlikely. Four GOPers would be needed to hit 218 to

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December 15, 2025

No Smooth Sailing: Agreement To Run Exchange Amendment Hits Rocks An agreement between moderate Republicans and the House GOP leadership to allow a vote on an amendment to extend the expiring Exchange is in doubt as the two sides squabble over whether any extension will be paid for by spending offsets. The amendment would extend the enhanced subsidies for two years but add certain eligibility reforms. But the House leadership is demanding spending offsets due to conservative objections. A full subsidy extension would cost about $35 billion a year. Conservatives could derail the amendment in the Rules Committee even before it gets to the floor. GOP moderates could vote against the bill as a whole and sink it as Democrats will not support it. As an alternative, the GOP moderates could team up with Democrats to force a vote via one of several discharge petitions, which need 218 signatures to

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This Year’s Open Enrollment Stories Tell You Just How Unaffordable Things Really Are

Each year during open enrollment I get calls from family, friends, and even referrals from outsiders to help solve some of their perplexing insurance woes. I have tried to limit my so-called portfolio of free clients, but the caseload continues to be robust given the crushing affordability crisis. Here are a few of the cases I supported this year. At the end, I wil sum up and give you a feel for what changes need to be made to ensure all Americans gain affordable healthcare. 30-year-old graduate student with no employer sponsored coverage – good outcome individually but shows the huge inequity of the coverage gap as well as rising unaffordability This person was on an Exchange Platinum plan in 2025 because of previous complex surgery and required follow-ups. As a student, the person was unsubsidized in the Exchanges for years because Florida did not expand Medicaid. No Exchange subsidies

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December 12, 2025

House GOP To Allow Vote On Exchanges But By Amending Major Reform Bill Two major decisions from GOP leaders in the House today. First, it will allow a vote on an Obamacare extension to appease several dozen vulnerable Republicans in swing districts. Second, but this will come via an amendment on a broad reform bill from Republicans focused on more conservative reforms. The main bill will feature the following reforms. Exchange cost-sharing subsidies would be funded to lower Silver premiums. This has positive and negative effects depending on subsidy status and income. Greater self-insurance provisions would be included, along with pressing for cheaper plan designs. Some pharmacy benefits manager reforms would be included. Even if the amendment passed, the bill would ultimately not pass in all chambers because it would be viewed as a poison pill by Democrats, especially in the Senate. Democrats are attempting to force a separate vote

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December 11, 2025

Dueling Healthcare Plans Fail In Senate As expected, both the Democratic and GOP healthcare bills failed to get the 60 votes needed to pass in the Senate today. Democrats’ clean three-year extension of enhanced Exchange premium subsidies failed 51-48. Four Republicans, including Sens. Susan Collins, R-Maine, and Lisa Murkowski, R-Alaska, voted with Democrats. The GOP proposal from Republican Sens. Bill Cassidy, R-LA, and Mike Crapo, R-ID, also failed by a 51-48 vote. Meanwhile, a growing number of centrist Democrats are joining forces with Republicans on bipartisan bills combining a shorter subsidy extension with policy reforms that could attract enough votes over time to past both chambers.  Additional articles: https://www.fiercehealthcare.com/regulatory/dueling-democrat-republican-aca-subsidy-plans-fail-senate and https://www.beckerspayer.com/payer/aca/competing-bills-tackling-aca-subsidies-fail-in-senate/ and https://thehill.com/homenews/senate/5644661-republican-senators-democratic-obamacare-bill/ and https://thehill.com/homenews/house/5643381-obamacare-aca-subsidies-democrats-division/?tbref=hp (Some articles may require a subscription.) #exchanges #healthcare #coverage https://www.modernhealthcare.com/politics-regulation/mh-senate-healthcare-vote-aca-subsidies Highmark and BCBS KC To Affiliate As regional blues struggle to compete in a more competitive environment, Highmark and Blue Cross and Blue Shield Kansas

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Medicare Advantage Developments For 2026

MA in store for a challenging year There have been significant developments on the Medicare Advantage (MA) front of late. Here is a recap of some big developments going into the new year. 2026 program audit protocols  On November 20, the Centers for Medicare and Medicaid Services (CMS) issued its annual program audit memo to describe changes. While in the past few years little changed, there were some major developments this year. Let’s briefly describe them: CMS will continue using the existing 2025 Final Audit Protocols for the Medicare Part C and Part D Program Audits and Industry-Wide Part C Timeliness Monitoring Project (CMS-10717) to conduct 2026 program audits. But CMS did announce a great many process changes: CMS also updated on the 2026 schedule: MA changes going into 2026 MA is contracting again, but there are some interesting trends. Star performance and changes When Star Year (SY) 2026 ratings

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