Health Issues

The Centers for Medicare & Medicaid Services (CMS) has announced that its temporary program to cover GLP-1 drugs for obesity in Medicare, called the BALANCE model, will not launch as scheduled on January 1, 2027. Instead, CMS is extending the duration of a separate short-term program, called the Medicare GLP-1 Bridge, which was originally scheduled to run from July-December 2026 but will now run through the end of 2027. Under the Bridge program, eligible beneficiaries can get Medicare coverage of GLP-1s for obesity for a $50 copay.

Extending the short-term GLP-1 Bridge program is good news for eligible Medicare beneficiaries because it provides the certainty of obesity drug coverage at a $50 copay for a longer duration, but federal spending will also rise by some unknown amount since CMS hasn’t disclosed the projected cost. The cost to Medicare of covering obesity drugs under Part D has been estimated at between $25 billion and $35 billion over 10 years, which could have been a driving factor in the reluctance or unwillingness of major Part D plan sponsors to participate in the BALANCE model as it was originally designed.

While CMS sought robust participation of Part D plan sponsors in the BALANCE model, which was voluntary for plans, interest appears to have fallen short of the targeted level. Although GLP-1 drug manufacturers agreed to a $245 net price, a substantial discount off prevailing list prices, savings to plans from a lower price may have been insufficient to offset higher costs associated with an uptake in GLP-1 use for obesity treatment. Plans would also have been at some financial risk if their actual costs for covering GLP-1s were higher than they expected. Higher costs for Part D plans under the BALANCE model would have translated to higher federal spending and increased Part D premiums for enrollees, always a tough sell but especially so when the cost of health care, including prescription drugs, ranks as a top concern for many Americans.

Implementation of the BALANCE model in Medicare faces an uncertain future. CMS could opt to revise the financial incentives to make participation more appealing to Part D plan sponsors, such as by negotiating an even lower net price with manufacturers or taking other steps to shift financial risk associated with GLP-1 coverage away from plans. While CMS’s approach to Medicare obesity drug coverage after the short-term Bridge program ends is unknown, a financially sustainable solution for how to cover GLP-1 drugs for obesity remains elusive.

The Centers for Medicare & Medicaid Services (CMS) has announced that its temporary program to cover GLP-1 drugs for obesity in Medicare, called the BALANCE model, will not launch as scheduled on January 1, 2027. Instead, CMS is extending the duration of a separate short-term program, called the Medicare GLP-1 Bridge, which was originally scheduled to run from July-December 2026 but will now run through the end of 2027. Under the Bridge program, eligible beneficiaries can get Medicare coverage of GLP-1s for obesity for a $50 copay.

Extending the short-term GLP-1 Bridge program is good news for eligible Medicare beneficiaries because it provides the certainty of obesity drug coverage at a $50 copay for a longer duration, but federal spending will also rise by some unknown amount since CMS hasn’t disclosed the projected cost. The cost to Medicare of covering obesity drugs under Part D has been estimated at between $25 billion and $35 billion over 10 years, which could have been a driving factor in the reluctance or unwillingness of major Part D plan sponsors to participate in the BALANCE model as it was originally designed.

While CMS sought robust participation of Part D plan sponsors in the BALANCE model, which was voluntary for plans, interest appears to have fallen short of the targeted level. Although GLP-1 drug manufacturers agreed to a $245 net price, a substantial discount off prevailing list prices, savings to plans from a lower price may have been insufficient to offset higher costs associated with an uptake in GLP-1 use for obesity treatment. Plans would also have been at some financial risk if their actual costs for covering GLP-1s were higher than they expected. Higher costs for Part D plans under the BALANCE model would have translated to higher federal spending and increased Part D premiums for enrollees, always a tough sell but especially so when the cost of health care, including prescription drugs, ranks as a top concern for many Americans.

Implementation of the BALANCE model in Medicare faces an uncertain future. CMS could opt to revise the financial incentives to make participation more appealing to Part D plan sponsors, such as by negotiating an even lower net price with manufacturers or taking other steps to shift financial risk associated with GLP-1 coverage away from plans. While CMS’s approach to Medicare obesity drug coverage after the short-term Bridge program ends is unknown, a financially sustainable solution for how to cover GLP-1 drugs for obesity remains elusive.

The other day, I was asked for a one-pager on what’s wrong with the U.S. health system. “Just one page.” To my amazement, with our thousands of fact sheets and policy briefs and even our Health Policy 101, we didn’t have anything short or current, nor could I find one elsewhere to send along. The closest we came was this 2022 policy brief. So, while this isn’t my usual column about current issues, and it’s only about problems, not the reasons for them or solutions, it might be useful to some of you.

First, our health system is not affordable, either for people or for the country. About a quarter of the public struggle with their medical bills and the numbers rise sharply for people with chronic illnesses or major diseases who need a lot of care. About 100 million deal with medical debt. We spend almost twice per capita what other wealthy nations spend, putting pressure on other national priorities and for employers on wages.

Despite progress, we still have 27 million people who are uninsured, and according to projections from the Congressional Budget Office, cuts in the One Big Beautiful Bill will bring that total to about 40 million if the cuts aren’t reversed.

The system is beyond complex and challenging to navigate. The poster child of this is prior authorization review, which almost everyone hates. People tell us on surveys that it’s their single greatest problem getting care.

As is well known, although we spend much more than other wealthy nations, our health outcomes lag behind theirs in most cases. There are a lot of different ingredients in that stew, but our well-heeled health system has not lifted our health outcomes.

Trust in health professionals remains strong, but trust in critical agencies such as the Centers for Disease Control and Prevention and the Food and Drug Administration is at a low point. The agencies take it on the chin for different reasons from both Democrats and Republicans. If we have another COVID-like crisis, we’ll pay a big price for that; national emergencies, like wars, cannot be handled state by state.

If I were to nominate one more item for the list, it would be the “crisis” in primary care. In many parts of the country, it’s just not easily available, and in some, like the Silicon Valley where I live, much of it has been skimmed off to expensive concierge practices with long waiting lists.

Finally, the politics of health care are as broken as the system (and are a reason it is broken). For decades, Democrats and Republicans have not been able to agree on any major solutions to our health care problems and disagree sharply on the role of the federal government in health, forcing us to gravitate to smaller incremental changes where there might be some agreement. They also blow their importance out of proportion. I won’t name names in this short piece.

The result: we have neither a competitive health care system nor a regulated one—we have a fragmented, micromanaged health system that fails to control costs and makes both patients and health professionals more miserable than they should be.

Of course, if you have a problem requiring a world-renowned specialist or the very latest drug and can get to and afford her, him, or it, it can be the greatest health system in the world.

View all of Drew’s Beyond the Data Columns

As net health insurance premiums in the Marketplace have jumped by an average of nearly 60% nationally ^{due to the expiration of federal subsidy enhancements, many consumers have been reassessing what coverage they can afford – or whether they can afford coverage at all.}

One of the clearest signals of that growing anxiety isn’t coming just from enrollment data or policy analysis. It’s showing up in what people are searching for online, particularly when it comes to the cost of health insurance.

A healthinsurance.org analysis of more than five years of Google Trends data shows a sharp spike in affordability-related searches in 2025, followed by continued growth in early 2026. Searches related to the cost of health insurance, lower-cost coverage options, subsidies, and even the consequences of going without insurance surged as consumers grapple with rising costs.

Taken together, these trends suggest a meaningful shift in how consumers are approaching health coverage in today’s higher-cost environment.

See the findings below.

Why consumers’ interest in health insurance costs surged

During the open enrollment period for 2026 Marketplace health coverage, some clear trends emerged in conjunction with the expiration of federal premium subsidy enhancements: Fewer people enrolled, and more people selected Bronze plans, which have lower premiums but higher out-of-pocket costs. And even with those changes, average net (after-subsidy) premiums grew by 58%, going from $113/month in 2025 ^{to $178/month in 2026.}

So it’s not surprising that there has also been a significant increase in online search interest around health insurance costs and lower-premium coverage options in 2025 and 2026.

The cost of health insurance is causing consumer anxiety

In early 2026, search interest in “cost of health insurance” was more than double what it had been at the same time in 2025, and search interest in “health care subsidy” had nearly tripled. This isn’t surprising given the expiration of federal premium subsidy enhancements at the end of 2025, and the anxiety this may have caused for consumers.

If all Marketplace enrollees had renewed their 2025 plans for 2026, average net premiums were projected to increase by 114%. ^{This caused significant sticker shock when people got their renewal notices last fall. Instead of renewing, many consumers opted to downgrade to a plan with a lower premium or drop their coverage altogether, resulting in net premiums “only” increasing by 58%.}

The unfortunate reality is that most 2026 Marketplace enrollees were faced with higher premiums, higher out-of-pocket costs, or both. As a result, a recent KFF survey found that more than half of returning Marketplace enrollees are reducing their spending on food or basic household items so that they can afford their health insurance premiums and out-of-pocket costs.

But we know that 1.2 million fewer people enrolled in Marketplace plans for 2026. ^{Some of those people might have moved to other ACA-compliant coverage, such as an employer’s health plan. But some are likely uninsured altogether in 2026, while others might have opted for non-ACA-compliant insurance or even “coverage” that isn’t actually insurance, such as} health care sharing ministry plans or Farm Bureau plans.

Bronze plans became much more popular with Marketplace enrollees in 2026, growing from about 30% of enrollments in 2025 to about 40% of enrollments in 2026.

At the same time, Silver plan selections dropped significantly, going from 56% of enrollments in 2025 to 43% in 2026.

And while Gold plan selections increased slightly, from 13% of enrollments in 2025 to 17% in 2026, ^{it’s worth noting that in many cases this was still a coverage downgrade, if the person previously had a Silver plan with strong cost-sharing reductions.}

This is because for those with income that doesn’t exceed 200% of the federal poverty level, a Silver plan provides much more robust benefits than a Gold plan. But in many states, Gold plans have lower premiums than Silver plans.

This helps to explain why some enrollees switched from Silver plans to Gold plans (or Bronze plans) in an effort to reduce premiums, despite giving up cost-sharing reductions to do so: Across all Marketplace enrollees, 51% were receiving CSR benefits in 2025, and that dropped to 37% in 2026. ^{CSR benefits are only available on Silver plans, so consumers who are CSR-eligible are forfeiting that benefit if they select a non-Silver plan.}

Searches for ‘catastrophic health insurance’

Despite the fact that the Trump administration took steps to expand access to Catastrophic plans in the fall of 2025, Catastrophic plans accounted for just 0.3% of all Marketplace plan selections in 2026, up only slightly from about 0.2% in 2025. ^{Catastrophic plans aren’t available at all in 14 states, are only offered by some (but not all) Marketplace insurers in most other states, and can never be purchased with premium tax credits. So while they’re fully ACA-compliant, they still make up just a tiny sliver of Marketplace enrollment.}

But it’s also worth pointing out that while “Catastrophic health insurance” has a specific definition under the ACA, consumers were using this term to describe cheap “bare bones” coverage long before the ACA. Search interest in “catastrophic health insurance” grew considerably in 2025 and 2026, and although some people using this search phrase might be looking for ACA-compliant coverage, others might be looking for lower-cost plans that aren’t ACA-compliant.

Increasing interest in high-deductible health plans

Search interest related to high-deductible health plans has been steadily climbing in recent years, reaching new highs in 2025 and early 2026. As is the case with “catastrophic health insurance,” the term “high-deductible health plan” (HDHP) has a specific definition. ^{These plans are regulated by the IRS, and enrollees are allowed to make pre-tax contributions to a health savings account. But consumers who are doing online searches may or may not know that, and might simply be looking for lower-cost coverage.}

In 2026, for the first time, all Bronze and Catastrophic Marketplace plans are considered HDHPs, meaning enrollees in these plans can make HSA contributions. For enrollees who are willing and able to do so, this could have significant tax advantages, and could explain why some people opted to switch to these plans, despite the higher out-of-pocket costs.

But having access to an HSA doesn’t necessarily mean that a person will utilize that option. Opening an HSA and making contributions to it are optional. And while the majority of people enrolled in employer-sponsored HDHPs receive HSA contributions from their employer, ^{most people with HDHPs purchased in the individual market have to make their own HSA contributions.}

Although Marketplace plan selections during open enrollment dropped by about 1.2 million people in 2026 compared with the year before, that doesn’t account for people who might not have paid their initial premiums to effectuate their coverage. Nor does it account for people whose coverage was terminated at the end of a grace period due to non-payment of premiums.

A Wakely analysis that covered about 80% of the individual market found that 86% of the people who selected a plan during the open enrollment period for 2026 (including those whose coverage was auto-renewed) paid their January premium. The other 14% includes some people whose coverage didn’t get effectuated, and others who were in a grace period and may or may not have paid their past-due premiums by the end of that grace period.

But overall, the Wakely analysis projects that “average enrollment in the individual market could shrink 17% to 26% in 2026 compared to 2025 average enrollment.”

A KFF analysis of returning Marketplace enrollees found that nearly one in five reported being unsure they’ll be able to continue to pay their monthly premiums throughout 2026. ^{So it’s not surprising that online search interest in whether there’s a penalty for going without health insurance increased so much in 2025 and early 2026. Some people have already given up their coverage (plan selections during open enrollment dropped by about 1.2 million people compared with 2025), and others are unsure whether they’ll be able to maintain their coverage throughout 2026.}

Although the Wakely analysis gives some good clues about early effectuated enrollment, it will likely be at least mid-2026 before we have official nationwide numbers from CMS in terms of how many people had effectuated Marketplace coverage as of February 2026. The effectuated enrollment number is always lower than the number of plan selections made during open enrollment.

But the first effectuated enrollment report won’t reflect the number of policies that lapsed at the end of March when their three-month grace period ended. Nor will it reflect people who were able to make their initial premium payments but weren’t able to continue to make those payments later in the year.

So as insurers start to prepare rates and plans for next year, it remains to be seen how many people will have individual-market coverage as we head into 2027.

Note: There hasn’t been a federal penalty for being uninsured since 2018, but DC and four states do impose a penalty.

What to do if you’re struggling with health insurance costs

If health insurance feels unaffordable in 2026, you’re certainly not alone. Read more about what to do if you’re feeling premium sticker shock, and what you can do if you can’t afford health insurance and aren’t eligible for Medicaid.

Consumer search trends signal growing cost pressure in health insurance

Democrats are casting about for new health reform ideas in the hope that they can gain traction in the run-up to 2028 and be enacted afterward. Jonathan Cohn wrote artfully about it in the Bulwark, and as is always the case, it’s not possible to improve on Jonathan’s take. I am frequently asked now: “What are the new ideas?” There are lots of ideas. Recently, I wrote about one that would resonate with voters: getting rid of prior authorization review.

What I see is a conundrum facing those who are thinking about big new health policy ideas for a possible new political and policy world. The subject is near and dear to my heart because we have to be prepared to analyze, poll about, and report on whatever may come at KFF. 

It’s a conundrum for Democrats because only so much can be done at one time by one president, Congress, and secretary, and there are real tradeoffs to be considered. The voters’ priorities and the candidates’ needs are often not the experts’ priorities, and choices will need to be made between the ideas that will be popular and resonate with voters in campaigns and after elections, and those often more weedy and wonky things that are deemed important to do to lower spending or improve coverage, restore agencies, or grapple with AI. Funds will need to be divided between restoring huge cuts in coverage and public programs and doing new things in an environment where the deficit and debt have grown, and new funding will be tough to come by. The most important thing candidates need to do is not present plans, it’s to show voters they care.

There are at least three equally important big priorities Democrats will be thinking about that are in themselves challenging and, in a world of limited dollars and political capital, will be in tension. 

One is to rebuild Medicaid and the ACA and replace lost federal funding. It will take more than a trillion dollars in funding over 10 years to replace all of the lost funding. And since restoring funding is not a rallying cry for politicians, they will need to decide what cuts they want to replace and how to fashion funding replacement into popular ideas that can sell with voters. What would the Democratic plan look like in 2029 to provide enhanced tax credits? How will Democrats handle Medicaid work requirements? They are harmful and inefficient, but popular. Repeal them? Leave it up to states? Coverage for millions and more than 300 billion dollars in hard-to-replace Congressional Budget Office-scored savings will be at stake. What about the cuts to provider taxes and payment providers and states will be clamoring for? Coming up with a trillion dollars over 10 years is a steep hill to climb in the face of the deficit and debt, and it wouldn’t leave much else for new initiatives requiring more new spending, such as improving the traditional Medicare benefit by covering dental and vision services, as many Democrats want to do. 

There is also a massive task ahead to rebuild federal health agencies, which isn’t receiving enough attention yet, mostly because it’s early and it’s not a glamorous topic. Just to throw out a few related issues: Nobody thought the CDC was even close to perfect before (including every White House I ever knew); or thought the Surgeon General/Assistant Secretary for Health arrangement made perfect sense (at times in the past they were combined). The FDA has been a perennial lighting rod (especially out in Silicon Valley, where I live). CMS is divided by program (ACA, Medicaid, Medicare) and has a difficult time using its purchasing and policy power across programs, which (before the ACA) was the original vision behind the agency when it was formed. What should staffing levels be in HHS and each of its parts? Should their new missions be the same as their old ones? Where should they fall on health equity in the future?

It’s easier to tear agencies down than rebuild them and if these issues are left entirely to a new secretary without a head start, it will be at least two years into a new administration before there is a coherent plan and there is some risk not enough will actually happen. With current views of government as desultory as they are, however, it will take some creative messaging and packaging to make this essential job popular, much less something to campaign on, making it a task requiring careful thought and planning. 

Then there is the third priority—that it’s time to deal with underlying health care costs. It certainly is time, as spending is increasing more rapidly again, but it has been time for as long as I have been in health care and there is no evidence that new political will to seriously take on health care costs has suddenly materialized. The health care industry is concentrated, making efforts to promote competition difficult, if still necessary, and regulation to control costs in various ways has always met stiff resistance. That has left us with a hodge podge of strategies to change delivery and payment at the margin to promote “value,” with the Hail Mary, Medicare for All, still out there with very strong advocates and critics, and limited prospects in a polarized Congress and politically divided country. As I have written, every payer is on their own trying to reduce their own spending, with no national strategy or plan. Everyone knows we are not giving enough attention to our high health care prices and except for some scattered state initiatives, we’re doing little about it. 

To these three potentially competing priorities I would add a fourth: making the health system we have work better for patients frustrated by its complexity. This is the world of apps and AI (which can both simplify and complicate) and streamlining prior authorization review. Dr. Oz has talked a lot about this. There is discussion again among Democrats about a “patient’s bill of rights.” Assuming we don’t change the entire health system, complexity is almost as big of a problem as costs. 

As discussions unfold, history suggests a few lessons for idea generators to keep in mind: 

A trillion dollars is a lot. New funding will likely have to be split between restoring cuts and new priorities. And there is no question that the public’s priority is not underlying costs or payment reform or value, or AI, or many of the things that occupy the attention of experts: people simply want to be able to afford their health care coverage. Assuming new spending is paid for, how it’s paid for also matters, with cuts and offsets or new taxes creating new tradeoffs and rivals.

Experience also suggests a golden rule: “keep it tangible and simple.” But that’s not usually what the “idea machine” produces. Traditionally, ideas have been developed by groups of experts and stakeholders, often generating the classic 35-point plan that checks every stakeholder’s box but cannot easily be explained to voters and isn’t useful to candidates.

And again, reconstructing the agencies and along with them the national commitment to public health and science while working longer term on restoring trust is less flashy work that needs to be done.

Of course, 2028 is a long way off and there is also the possibility of a President Vance or a President Rubio. The agenda, and the ideas that may need to be generated and the work that needs to be done, may be wholly different.

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