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WSJ Finds Excess Rx Refills At Medicare Plans Via Mail Order Many argue The Wall Street Journal has it out for health plans as it has had many hard-hitting investigations of fraud and bad practices over the past year or so. Some parts of the industry have accused the Journal of being wrong or behind the times, but the newspaper seems to constantly find scandal afoot, especially among the big national plans. Some of its findings, which are hard to question, have led to ongoing investigations by federal regulators and Capitol Hill. The Journal’s latest expose finds that mail order pharmacies – again the biggest owned by the big national healthcare players — regularly overfill Medicare prescriptions. The Journal finds that excessive filling is a common practice at mail order firms. Too-frequent refills by all U.S. pharmacies cost Medicare and patients $3 billion between 2021 and 2023 says the Journal.

Johnson Under Fire From Moderates On Healthcare As Congress returns this week, House Speaker Mike Johnson, R-LA, is facing a backlash from moderates in his already divisive caucus with a razor-thin majority. Moderates are upset that Johnson refused to hold a vote on Exchange subsidy extensions. After that, four members sided with Democrats on a discharge petition to force a vote in January. These moderates are committed to reaching a compromise with the Senate to extend the subsidies in some form. #exchanges #healthcare #coverage #congress #gop #speakerjohnson https://thehill.com/homenews/house/5667397-mike-johnson-house-republican-moderates/?tbref=hp AHIP Goes On Offensive Against Cost Blame AHIP, the health plan lobby, is continuing its media campaign to note that plans are not responsible for huge surges in costs and premiums. It notes that plans made just 0.8% in 2024 and the industry’s profits are now regulated by various rules and laws. However, vertically integrated healthcare behemoths, which own insurers, typically do

Congress Comes Back To Exchange Saga Congress is slated to reopen next week and will return to the Exchange subsidy controversy. Some lawmakers say that arriving at a potential compromise on extending enhanced subsidies is about 50-50 right now. A vote will be held in the House on a Democratic bill to extend the subsidies with no changes for three years. At least four Republicans are expected to support the measure, which would mean the bill likely passes. The same extension was voted down in the Senate (it did not reach 60 votes), but the bill could be used for a compromise measure, which then would go back to the House. GOP leaders in each house, though, are expected to put roadblocks up to final passage. With the reduction in subsidies and major increases in premiums, between 2.2 million and 7.3 million people may decide against renewing their insurance because

Drug Prices To Climb 3 Axis Advisors reports that the costs of at least 350 drugs in the U.S. are expected to rise in 2026. And as it notes, some of the firms boosting prices are the same that just agreed to reduce prices with President Trump. The firm also finds that a higher number of drugs will see price increases next year compared with last year, when more than 250 drugs were increased. The median price hike is about 4%. #drugpricing #branddrugmakers https://thehill.com/policy/healthcare/5668053-us-drug-prices-rise-2026 With Friends Like These … In 2025, health plans likely bought into the phrase “with friends like these, who needs enemies.” The year saw Republicans very much turning on the health insurer industry. Under fire on healthcare from Democrats, Republicans such as Donald Trump and House Speaker Mike Johnson, R-LA, lashed out at the greediness of insurers to deflect the criticism and problems with the Affordable

States Seek To Mitigate Impact Of Expiring Subsidy Enhancements A handful of states have taken action to mitigate the impact of expiring subsidy enhancements in the Exchanges. The states include New Mexico, California, Maryland, Colorado, Connecticut, Arkansas, Texas, and Wyoming. Most states passed appropriations to replace some of the federal subsidy losses, while others passed premium realignment laws. #exchanges #coverage #healthcare https://www.beckerspayer.com/payer/aca/how-states-are-responding-to-expiring-aca-subsidies/ At Least 16 Health Systems Drop MA At least 16 health systems are dropping Medicare Advantage (MA) plans in 2026. Some big-name systems are included, and many are targeting big MA plans. #hospitals #healthplans #medicareadvantage https://www.beckershospitalreview.com/finance/16-health-systems-dropping-medicare-advantage-plans-2026 OIG Calls Out Payments For Deceased Enrollees The Health and Human Services’ Office of Inspector General (HHS OIG) says that state Medicaid agencies have made an estimated $289 million in improper capitation payments to managed care organizations on behalf of deceased enrollees since 2016. This comes from a series of audits. The

Major Drug Policy Developments Major drug policy developments this week. First, the hospital lobby scored a major victory when a court ordered the new 340B rebate pilot paused. The Trump administration is seeking to experiment with rebates as opposed to upfront discounts to curb the growth in the discount drug program. The administration rightfully alleges that the program is unaccountable and does not meet the original safety net purpose. The judge ordered a preliminary injunction against the “hastily assembled” pilot set to kick off on Jan. 1 on the basis it “likely” violates the Administrative Procedure Act’s (APA’s) arbitrary and capricious standard.  The judge noted Congress did authorize the federal government to create a rebate model, but regulators had not followed the APA’s requirements in doing so. Second, Rep. Anna Paulina Luna, R-FL, says she is hopeful Congress will codify President Trump’s executive order on capping prescription drug prices next

Exchange Subsidy Deal 50-50 Some lawmakers are saying that there may be a 50-50 shot at obtaining an agreement to extend enhanced Exchange premium subsidies in January. But there are major obstacles. GOP leaders in each house are tending to gravitate toward the larger conservative side of their caucuses, which is dead set against an extension. Minority Leader Chuck Schumer, D-NY, wants either a clean extension or to hang the issue around the GOP’s neck in midterms. Sen. Bill Cassidy is advocating the possibility of extending subsidies as well as seeding health savings accounts (HSAs) for some and giving Americans the ability to decide one way or another. Another leading compromise would extend for two years with some reining in of the generosity of the enhancements. The bill could come to life in this way. Four GOP lawmakers in the House signed on to a Democratic discharge petition which will