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PwC Highlights AI-Driven Change In Healthcare A blockbuster report from management consultant PwC predicts that $1 trillion of national healthcare spending could go to digital-first, personalized medical care. PwC also says healthcare is in the process of a monumental shift to artificial-intelligence-driven, consumer-centric healthcare services, which could mean simplified care models emerge that lower costs and increase quality. PwC notes that healthcare spending is expected to grow to $8.6 trillion by 2035, hitting 20% of gross domestic product. And this means health plan and provider executives must rethink care delivery. In terms of payers, PwC notes that medical cost trends are nearing double digits and that payers will be expected to deliver far more with far less. It says AI and other technologies can help build capabilities to deliver medical value and actively manage population risk within the plan and with provider partners. It says payers will increasingly serve as

Government Funding Bill Fails A government shutdown is coming closer to reality. A stop gap funding measure through November 21 passed the House on a vote of 217-212 but failed to achieve 60 votes in the Senate. Almost all Democrats and two Republicans voted together and the bill failed in the upper chamber by a vote of 44-48. Democratic Sen. John Fetterman, PA, voted with most Republicans in favor, while GOP Sens. Lisa Murkowski, AK, and Dr. Rand Paul, KY, voted with Democrats. The House is expected to be out until two days before funding expires but may now have to come back early. The measure included many critical healthcare funding and policy extensions. Additional articles: https://www.modernhealthcare.com/politics-regulation/telehealth-medicaid-dsh-stopgap-funding-bill/ and https://thehill.com/homenews/senate/5512606-government-shutdown-senate-funding-bill/ (Some articles may require a subscription.) #governmentshutdown #congress #ffy2026 #healthcare https://www.fiercehealthcare.com/regulatory/republicans-unveil-7-week-stopgap-hospital-funding-telehealth-extensions-no-aca-premiums Studies Project Impact On Hospitals From One Big Beautiful Bill Two new studies outline the financial fallout expected for hospitals

Provider Directory Rule For Medicare Advantage Medicare Advantage (MA) insurers will be required to submit provider directories to the Centers for Medicare and Medicaid Services (CMS) next year under a final rule issued Thursday. The provider information will be added to the Medicare Plan Finder. CMS will issue an operational guide to outline how to prepare and submit the directory. MA plans will have to submit their network lists by Jan. 1 and then once a year. Updates must be made every 30 days to reflect changes in provider participation. Insurers will not have to attest that they meet network adequacy standards. (Article may require a subscription.) #medicareadvantage #providers #cms https://www.modernhealthcare.com/politics-regulation/mh-medicare-advantage-plans-provider-directories-2026 CBO Again Projects Coverage Losses The Congressional Budget Office (CBO) issued a new assessment of the Exchange premium subsidy enhancements extension. It found making the enhancements permanent would cost $350 billion over ten years (added to the deficit) and boost

Stars Drama Begins Early The Centers for Medicare and Medicaid Services (CMS) will release SY 2026 results in October but appears to have botched part of the rollout. In Plan Preview 2, the agency provided insurers with a private preview of their individual ratings but may have accidentally disclosed every company’s preliminary ratings in the file. It is unknown if every plan got the ultimate sneak peek or not. CMS promptly pulled the electronic data, told plans to delete any download, and reuploaded just what it should have for each plan. It also has instructed plans not to make Stars public before October’s announcement after some did so. This led to some plans seeing increases in stock, while others who did not comment saw their stocks fall. (Article may require a subscription.) #stars #quality #medicareadvantage https://www.modernhealthcare.com/insurance/mh-unitedhealth-humana-centene-aetna-medicare-advantage-stars Optum Increases Comp For Independent Pharmacies Optum Rx, one of the big 3 pharmacy

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.