Home Blog Page 5

Recent Trends in Medicaid Outpatient Prescription Drugs and Spending

healthissuesadmin
-
0
Recent Trends in Medicaid Outpatient Prescription Drugs and Spending



rewrite this content and keep HTML tags

In recent years, Medicaid spending on prescription drugs has grown, in part due to the emergence of new, high-cost drugs, including GLP-1s and cell and gene therapies that treat, and sometimes cure, rare diseases. There have been several recent Trump administration prescription drug initiatives (Box 1), including new payment models, that could help combat rising costs for state Medicaid programs, though questions remain about the implementation and impact of the deals. While lower prices for state Medicaid programs through the new models could result in reduced Medicaid prescription drug spending and potentially expanded coverage of certain drugs, the extent of the savings and how states or manufacturers will respond remain unclear. In most cases, Medicaid programs already pay lower prices, net of rebates, than other payers.

Medicaid enrollees are typically protected from high out-of-pocket costs for prescription drugs, meaning the recent federal prescription drug deals will not impact costs for people with Medicaid. However, the 2025 reconciliation law, signed by President Trump on July 4, 2025, is expected to result in significant Medicaid funding cuts and coverage losses. The loss of Medicaid coverage altogether could make it more difficult and costly for families to access the prescription drugs they need. While TrumpRx (see Box 1) offers discounts for uninsured or other cash-paying patients, the costs would likely still be prohibitive for low-income people with Medicaid or people who have recently lost Medicaid coverage.

This issue brief describes recent trends in the number of Medicaid outpatient prescriptions and the spending on those drugs and examines the implications of recent federal actions on future trends. Key findings include:

Net spending on Medicaid prescription drugs after rebates is estimated to have grown substantially in recent years, increasing from $31 billion in FY 2019 to $46 billion in FY 2024 (or 46%). Both net spending per prescription and net spending per enrollee also grew over the period, increasing by 42% (from $43 in FY 2019 to $61 in FY 2024) and 25% (from $481 in FY 2019 to $603 in FY 2024), respectively.

Rebates reduce Medicaid spending on prescription drugs by over half, with state supplemental rebates making up an increasing share of all rebates.

While net spending increased substantially, the number of prescriptions paid for by Medicaid only grew slightly in recent years, increasing from 734 million in FY 2019 to 751 million in FY 2024 (or 2%). At the same time, the number of Medicaid prescriptions per enrollee declined by 12% (from 11.2 in FY 2019 to 9.9 in FY 2024).

Looking ahead, more recent quarterly data show the number of Medicaid prescriptions and Medicaid enrollment declining while gross Medicaid spending remains elevated.

Box 1: Recent Federal Medicaid Prescription Drug Initiatives

“Most-favored nation” (MFN) drug pricing: Following an Executive Order in May 2025 and letters to major pharmaceutical companies in July 2025, the Trump administration announced reaching agreements with several drug manufacturers to provide MFN prescription drug pricing in Medicaid, introduce new medications at MFN prices, and sell certain products directly through TrumpRx. The manufacturers also committed to increasing their investment in U.S. manufacturing in return for a 3-year reprieve from tariffs. These MFN agreements are based on the premise that the U.S. shouldn’t pay higher prices for prescription drugs than the prices paid in other comparable nations. Details of these agreements remain confidential, leaving the full scope of the deals largely unknown. Medicaid drug prices, net of rebates, are already typically lower than for other payers in the U.S. However, there is no public information on the extent of rebates for specific drugs, so no way to compare net prices in Medicaid to those in other countries.

New CMS Innovation Center (CMMI) models: In addition to implementing the Cell and Gene Therapy (CGT) Access Model created under the Biden administration, the Trump administration has announced two new Medicaid drug pricing models. The recently announced MFN drug prices will be made available to state Medicaid programs through the GENEROUS (GENErating cost Reductions fOr U.S. Medicaid) Model, a drug payment model through which CMS will negotiate supplemental drug rebates based on prices paid in other countries. The model is voluntary for states and manufacturers and launched in January 2026. The Trump administration also announced the BALANCE (Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth) Model, another model that intends to expand access to obesity drugs in Medicaid and Medicare by negotiating lower GLP-1 prices with manufacturers through supplemental rebates. This model is also voluntary for states and manufacturers and will launch as early as May 2026. Under both models, CMS will negotiate standardized coverage criteria in addition to supplemental rebates, and manufacturers will provide additional lifestyle supports through the BALANCE model.

President Trump’s “Great Healthcare Plan”: In his “Great Healthcare Plan,” President Trump has proposed to “codify” the administration’s MFN drug pricing deals that have been agreed to by drug companies in recent months. However, at this time very little is known publicly about the agreements, making it difficult to understand what it would mean to “codify” these deals.

TrumpRx: The administration also set up a website, TrumpRx.gov, which the public can use to search for discounted prices on brand-name medications when paying without using insurance. Through the TrumpRx website patients cannot purchase medications directly but instead, for the majority of the website’s drugs, can print drug manufacturer coupons that can be used at retail pharmacies at the time of purchase. The website launched in early February 2026, offering discounts on over 40 mostly brand name medications.

What are recent trends in Medicaid prescription drug spending?

Net spending (spending after rebates) on Medicaid prescription drugs is estimated to have grown substantially in recent years, increasing from $31 billion in FY 2019 to $46 billion in FY 2024, a 46% increase (Figure 1). However, from FY 2023 to FY 2024 alone, gross spending remained relatively steady and rebates grew, resulting in net spending decreasing by 10%. Net spending per prescription grew by 42% over the period (from $43 in FY 2019 to $61 in FY 2024) (data not shown), and net spending per enrollee grew by 25% over the period (from $481 in FY 2019 to $603 in FY 2024). There are a number of factors that contribute to changes in drug spending including changes in enrollment and utilization patterns, policy changes, changes in existing drug prices, and the number and price of new drugs coming to market. Analysis has shown that recent growth in Medicaid drug spending is being increasingly driven by spending on high-cost specialty drugs, including new cell and gene therapies that treat, and sometimes cure, rare diseases and other high-cost specialty drugs like those for cancer treatment. Other drugs such as GLP-1s, which are both costly and widely utilized, also further contribute to spending increases. In addition, while there has been a substantial increase in net prescription drug spending over the period, the increase in net spending on prescription drugs is in line with increases in total Medicaid spending, which grew by 52% over the period based on KFF analysis of CMS-64 financial management reports. Overall, prescription drug spending accounted for 6% of all Medicaid spending in 2024 and has remained relatively stable between 5% and 7% of all Medicaid spending over the last two decades.

Rebates reduce Medicaid spending on prescription drugs by over half, with state supplemental rebates making up an increasing share of all rebates (Figure 2). Rebates reduced gross Medicaid spending on prescription drugs by 53% on average over the period; the share of gross spending rebates accounted for declined slightly from 54% in FY 2019 to 51% in FY 2023 before increasing to 56% in FY 2024 (Figure 1). State supplemental rebates account for an increasingly larger share of all Medicaid drug rebates (Figure 2). In addition to federal statutory rebates, most states negotiate directly with manufacturers for supplemental rebates, and recent data signal states may be expanding the scope of their negotiations to combat rising drug spending. The recently announced federal models (Box 1) plan to provide lower drug prices by negotiating supplemental rebates on top of statutory rebates, though it is not clear how most-favored nation (MFN) prices under the model compared to net prices states may have already negotiated through supplemental rebate agreements. A number of factors are likely contributing to the overall uptick in rebates for FY 2024 including increasing state supplemental rebates as well as the lifting of the rebate cap beginning January 1, 2024.

What are recent trends in the number of Medicaid prescriptions?

While net spending increased substantially, the number of prescriptions paid for by Medicaid only increased slightly from 734 million in FY 2019 to 751 million in FY 2024, a 2% increase (Figure 3). The number of Medicaid prescriptions declined in FY 2020 before steadily rising and peaking in FY 2023 and then beginning to decline again in FY 2024. The number of Medicaid prescriptions per enrollee declined by 12% over the period, falling from 11.2 in FY 2019 to 9.2 in FY 2023 before increasing to 9.9 in FY 2024. Following the initial onset of the COVID-19 pandemic, increases in Medicaid enrollment due to the continuous enrollment provision likely contributed to modest increases in prescriptions overall but declines in prescriptions per enrollee through FY 2023. Other factors, including increases in the number of days supplied per prescription, may have also played a role (this analysis does not account for days supply, see Methods). For FY 2024, Medicaid enrollment declines during the unwinding of the continuous enrollment provision as well as higher health care needs among enrollees post-unwinding are likely resulting in a decrease in the number of prescriptions but increase in prescriptions per enrollee.

What are early indicators of future Medicaid prescription drug trends?

Quarterly data through most of FY 2025 show the number of Medicaid prescriptions and Medicaid enrollment continue to decline, while gross Medicaid spending remains elevated (Figure 4). Recent trends in the number of prescriptions paid for by Medicaid appear to roughly mirror trends in Medicaid enrollment, with both the quarterly number of Medicaid outpatient prescriptions and average quarterly Medicaid enrollment peaking in 2023, due to the pandemic-era continuous enrollment provision. After, during the unwinding of the provision, both enrollment and the number of prescriptions began to fall. As more provisions in the 2025 reconciliation law are implemented and individuals begin to lose coverage, Medicaid enrollment and the number of prescriptions may continue to decline. Quarterly gross spending has remained elevated despite declines in Medicaid enrollment and in the number of prescriptions. It remains unclear if recent increases in rebates will continue — blunting the increase in gross spending — or how federal changes in the 2025 reconciliation law and recent federal prescription drug initiatives (Box 1) may impact future gross and net spending trends.

Figure 4

Methods

Number of Prescriptions and Gross Spending Data: This analysis uses 2018 through 2025 State Drug Utilization Data (SDUD) (downloaded in January 2026) converted to federal fiscal years (FY). The SDUD is publicly available data provided as part of the Medicaid Drug Rebate Program (MDRP), and provides information on the number of prescriptions, Medicaid spending before rebates, and cost-sharing for rebate-eligible Medicaid outpatient drugs by national drug code (NDC), quarter, managed care or fee-for-service, and state. It also provides this data summarized for the whole country. The data do not include information on the number of days supplied in each prescription. CMS has suppressed SDUD cells with fewer than 11 prescriptions, citing the Federal Privacy Act and the HIPAA Privacy Rule. This analysis used the national totals data because less data is suppressed at the national versus state level.

Rebate Data: This analysis uses CMS-64 Financial Management Reports (FMR) for FY 2019 through FY 2024 (downloaded in August 2025). These reports include total Medicaid expenditures broken out by various service categories, and this analysis pulls out the drug rebate line items. The rebate data used includes statutory rebates, state supplemental rebates, rebates under the ACA offset, rebates from VBAs, and rebates for opioid use disorder medication assisted treatment. To estimate net Medicaid spending on prescription drugs each fiscal year in figure 1, the rebates collected in the CMS-64 were subtracted from the gross spending totals from the SDUD. State supplemental rebates in figure 2 include all “state sidebar” drug rebates in CMS-64 and rebates collected under value-based arrangements; all other rebates are categorized as federally required rebates. Supplemental rebate agreements negotiated between Medicaid managed care plans and manufacturers are not included.

Limitations: There are a number of limitations to the estimates of Medicaid prescriptions and spending found in this analysis, including:

This analysis examines the number of Medicaid prescriptions in the data and does not adjust for days supplied by each prescription. An increase in prescription lengths, especially during the pandemic, could contribute to fewer prescriptions.

The SDUD are updated quarterly; a new quarter of data is typically released, and the prior five years of data are also updated. This means prescription and gross spending totals can vary depending on when the data is downloaded, and totals may not match other outside sources or prior KFF analysis for this reason.

The spending collected on the CMS-64 and reported in the FMR data uses a cash-basis of accounting, meaning expenditures are based on the date of payment not necessarily when the service occurred. In practice, states have two years following the date a service was rendered to report their spending. There may be timing differences causing misalignment between the prescriptions paid for by Medicaid in the SDUD and the rebates reported in the CMS-64.

Drugs not dispensed by a pharmacy but received in other settings, including physician-administered drugs, can be eligible for rebates under the MDRP if they meet the definition of a “covered outpatient drug,” generally meaning a prescription drug that is FDA approved from a rebating manufacturer and identified separately on a claim for payment. This analysis includes any rebate eligible drugs, though billing practices may vary by state.

Spending data is not adjusted for inflation.



Source link

How Does Health Spending in the U.S. Compare to Other Countries?

healthissuesadmin
-
0
How Does Health Spending in the U.S. Compare to Other Countries?



rewrite this content and keep HTML tags

Relative to the size of its economy, the U.S. spends a greater amount on health care than other high-income nations. And while the U.S. has long had higher than average health spending, recent years have seen higher spending growth in peer nations. This chart collection compares health care spending in the U.S. and other OECD countries that are similarly large and wealthy, using data from the OECD Health Statistics database for peer countries, and from the 2024 National Health Expenditure Data for the U.S.

The analysis is available through the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.



Source link

How Does Cost Affect Access to Health Care?

healthissuesadmin
-
0
How Does Cost Affect Access to Health Care?



rewrite this content and keep HTML tags

This analysis explores trends in how the cost of health care affects access to care in the U.S. using National Health Interview Survey (NHIS) data through 2024.

In 2024, about 1 in 6 adults (17%) reported delaying or not getting healthcare due to cost, including those who delayed or did not get medical or mental health care and those who rationed prescription drugs due to cost. Uninsured adults and adults who are in worse health are twice as likely to report that they or a family member had difficulty paying medical bills.

The analysis is available through the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.



Source link

Bronze health plan popularity surges in Marketplaces

healthissuesadmin
-
0
Bronze health plan popularity surges in Marketplaces



rewrite this content and keep HTML tags

As consumers face decreased access to Marketplace health insurance subsidies for 2026 plans – and higher net premiums for consumers who continue to be subsidy-eligible – one clear buying trend has emerged: a migration of buyers to Bronze-level health plans.

While details about the plans that people selected for 2026 are not yet available in most states, several state-run Marketplaces have published this information in early 2026. Data from those state-run exchanges shows a significant number of enrollees have downgraded their coverage, opting for a Bronze plan instead of a Gold or Silver plan.

What’s happening with Marketplace health plan enrollments?

Enrollment in Marketplace health plans declined in 2026 after four consecutive years of record-high enrollment. This was not surprising, given the sharp increase in net premiums for 2026 due to the expiration of federal subsidy enhancements at the end of 2025.

We don’t yet have Marketplace metal-level plan selection data for the states that use HealthCare.gov, but about half of the state-run Marketplaces have shared information about the metal levels that people selected during open enrollment. In most cases, Bronze plan selections increased significantly. (There were a couple of exceptions, which we’ll discuss in a moment.)

Why might consumers be downgrading to Bronze plans?

Lower premiums

Although all Marketplace plans cover the ACA’s essential health benefits, Bronze plans have higher deductibles and out-of-pocket limits than Silver or Gold plans. As a result, Bronze plans have lower monthly premiums.

So when consumers were faced with average net premiums that more than doubled for 2026, it’s understandable that people may have selected a different plan with a lower premium, in an effort to keep their monthly premium costs affordable.

Access to HSA contributions

The fact that Bronze plans are newly HSA-eligible may also have been a factor in some enrollees’ decisions to downgrade to a Bronze plan. As of 2026, all Bronze (and Catastrophic) Marketplace plans are HSA-eligible, meaning that people who enroll in these plans have the option to contribute pre-tax money to a health savings account (HSA).

Learn more about health savings accounts and the tax advantages they offer.

Contributions to an HSA will reduce the ACA-specific modified adjusted gross income (MAGI) that’s used to determine Marketplace subsidy eligibility. So selecting an HSA-eligible plan and making HSA contributions is a way for people to increase their subsidy amount (due to their reduced MAGI) or potentially qualify for subsidies if the HSA contribution brings their MAGI down below 400% of the federal poverty level (FPL).

This became more important in 2026, due to the return of the “subsidy cliff.” Enrollees with household income above 400% of FPL have to pay full-price for their coverage in 2026, so opting for a Bronze plan and contributing to an HSA may have been a choice that allowed some enrollees to continue to qualify for a subsidy.

Which state-run Marketplaces have reported an increase in Bronze plan selections?

Of the state-run Marketplaces that have published 2026 enrollment metrics thus far, all but two have reported an increase in the percentage of enrollees selecting Bronze plans:

  • California: Of enrollees in 2025 plans, 130,000 enrollees switched to Bronze plans for 2026. And among new enrollees, more than a third selected Bronze plans, compared with fewer than a quarter last year.
  • Idaho: Nearly 60% of enrollees picked Bronze plans, while enrollment in Silver and Gold plans declined compared to 2025 enrollment.
  • Maine: Nearly 60% of enrollees picked Bronze plans – up from 46% in 2025. (The percentage of enrollees in Bronze plans had been quite steady from 2022 through 2025.)
  • Maryland: The exchange reported that 5,743 people switched from 2025 Gold plans to Bronze plans for 2026.
  • New Jersey: Among people who actively selected a plan (not counting auto-renewals), 31% chose a Bronze plan, up from 16% the year before.
  • Pennsylvania: Bronze plan selections were 30% higher than they were the year before.
  • Rhode Island: As of mid-January 2026, about 38% of new enrollees had picked a Bronze plan, up from about 15% in previous years. There was also a trend of existing enrollees switching to Bronze plans at that point.
  • Vermont: Almost twice as many people newly selected a Bronze plan for 2026, compared with 2025. And more than 60% of the new Bronze enrollees had previously been enrolled in Gold plans.
  • Virginia: Bronze plan selections increased, although not as significantly as they did in most of the other states listed above. For 2026 coverage, 42% of enrollees selected Bronze plans, up from 38% in 2025.

Four of those nine states (California, Maryland, New Jersey, and Vermont) offer state-funded subsidies in addition to federal subsidies, in an effort to make Marketplace coverage more affordable. But despite this additional assistance, a significant number of enrollees still downgraded their coverage for 2026.

Which state-run Marketplaces reported a reduction in Bronze plan selections?

Two state-run Marketplaces have reported a decrease in Bronze plan selections for 2026. In both cases, the state had taken action to make more robust coverage more affordable for residents:

New Mexico

Very few Marketplace enrollees in New Mexico have Bronze plans. Enrollment in Bronze plans dropped slightly – from 3.4% in 2025 to 3.1% in 2026.

New Mexico offers additional state-funded subsidies that result in robust “Turquoise” plans being available to enrollees with household incomes up to 400% of the federal poverty level. These are by far the most popular plans in the New Mexico Marketplace, selected by nearly eight out of ten enrollees buying 2026 plans.

New Mexico is also the only state that used state funding to fully backfill the reduction in federal premium subsidies for 2026. So while consumers in many states responded to higher net premiums (stemming from the expiration of the federal subsidy enhancements) by downgrading their coverage to a plan with a lower premium, there was no need for New Mexico residents to do that.

Washington

About 87,000 Washington Marketplace enrollees selected Bronze plans for 2026, versus about 96,000 who had picked Bronze plans for 2025. (In both cases, this was roughly three out of ten enrollees, since total enrollment declined for 2026.)

But Gold plan selections increased significantly in Washington, increasing from 18% of plan selections in 2025 to 53% in 2026.

This migration to Gold plans happened because Washington adopted premium alignment for 2026, requiring insurers to add a 43% load to the premiums for Silver plans. This is because most Silver plans actually have benefits that are similar to those of Platinum plans, as a result of cost-sharing reductions (CSR).

Because Silver plans became more expensive, premium subsidies also increased, as subsidy amounts are based on the cost of a Silver plan. These larger subsidies made Gold plans more affordable, leading to a substantial increase in Gold plan selections for 2026.

What does a shift to Bronze plans mean for consumers?

Bronze plans have average deductibles of nearly $7,500 in 2026, which is more than double the overall weighted average deductible across all Marketplace plans. Plan designs vary considerably, but some Bronze plans count all non-preventive care toward the deductible (and deductibles can be as high as $10,600 in 2026, depending on how the plan is designed).

So consumers who select Bronze plans will generally have deductibles that are quite a bit higher than the average Marketplace plan deductible. Their total out-of-pocket exposure is often as high as the allowable maximum, which is $10,600 for a single individual in 2026. And depending on how the plan is designed, it might pay very little until the enrollee has met the deductible.

This means Bronze plan enrollees should be prepared for the possibility of having to pay several thousand dollars in out-of-pocket costs if they end up needing medical care during the year.

Unfortunately, a person who downgraded to a Bronze plan because of premium affordability might struggle to come up with the money to pay their deductible. Or they might avoid getting necessary medical care because of the cost.

Options for Bronze plan buyers facing higher out-of-pocket costs

If you’re enrolled in a Bronze plan and worried about higher out-of-pocket costs, there are several tips to keep in mind:

  • Comparison shop for your care whenever possible. Although your health plan might have a wide range of in-network hospitals, medical offices, and pharmacies, that doesn’t mean your out-of-pocket costs will be the same at all of them. If you need a prescription, you can check with various in-network pharmacies (including mail-order options) to see if there are price differences. The same is true for other medical care, and there are transparency tools that can help you determine what your costs will be.
  • Discuss your financial situation with your medical providers. You may find that they can offer a payment plan that fits within your budget.
  • If at all possible, consider opening and funding an HSA. All Bronze plans are HSA-eligible as of 2026. The money you contribute to an HSA is pre-tax. And if you need to use it to pay your deductible or other medical expenses, it will continue to be tax-free when you make the withdrawal. If you don’t end up needing to use the money in your HSA, it will remain in the account in future years until if and when you need it.
  • If your income isn’t more than 200% of the federal poverty level, you might be eligible for reduced out-of-pocket costs if you use a federally qualified health center (FQHC) that’s in your plan’s provider network. Depending on your income, these clinics can reduce the amount that you’d otherwise have to pay out-of-pocket under the terms of your health plan.
  • Consider supplemental coverage, such as a critical illness policy or an accident insurance policy, that could reimburse some of your out-of-pocket costs if you were to face unexpected medical costs for a covered illness or injury.
  • Some people with high-deductible health insurance choose to enroll in a local doctor’s direct primary care (DPC) membership program, to have unlimited access to various primary care services. And as of 2026, having a DPC membership no longer prohibits a person from making HSA contributions if they also have an HSA-eligible health plan, as long as the DPC membership meets certain parameters.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written hundreds of opinions and educational pieces about the Affordable Care Act for healthinsurance.org.



Source link

What Medicare’s Temporary Program Covering GLP-1s for Obesity Means for Beneficiaries

healthissuesadmin
-
0
What Medicare’s Temporary Program Covering GLP-1s for Obesity Means for Beneficiaries



rewrite this content and keep HTML tags

The Centers for Medicare & Medicaid Services (CMS) has released a memo fleshing out the design of a short-term program providing Medicare coverage of GLP-1s for obesity in 2026 ahead of a multi-year demonstration program beginning in 2027. Medicare is statutorily prohibited from covering drugs used for weight loss, and these demonstration programs are designed to fill that gap.

Under the short-term program, called the “Medicare GLP-1 Bridge,” Medicare will cover GLP-1s approved for weight reduction – Wegovy and Zepbound – for eligible beneficiaries enrolled in Medicare Part D for a $50 copayment. Eligibility is based on BMI of 35 or more alone, or 27 or more plus other clinical criteria. Although beneficiaries must be enrolled in Part D to participate, the short-term program will operate outside the Part D benefit for its duration from July 1 to December 31, 2026. Instead, providers will submit GLP-1 prescriptions and prior authorization requests to a central processer managed by CMS.

CMS’s efforts to provide Medicare coverage of GLP-1s for obesity could offer substantial benefits to millions of Medicare beneficiaries, given the high demand for these medications. The number of beneficiaries eligible for the Medicare GLP-1 Bridge is unknown, but a previous KFF analysis estimated that close to 14 million Medicare beneficiaries had a diagnosis of overweight or obesity in 2020 (BMI of 25-29.9 and 30 or more, respectively), though applying the specific criteria that determine eligibility for the Medicare GLP-1 Bridge would reduce that number.

There are potential drawbacks to the short-term program, however. Because it will operate outside the Part D benefit, the $50 copayment won’t count towards the Part D deductible or the $2,100 out-of-pocket spending cap. Part D enrollees using a GLP-1 for type 2 diabetes, sleep apnea, or other Medicare-covered uses will continue accessing the drug through their Part D plan and paying their plan’s cost-sharing requirement, even if it’s more than the $50 copayment for GLP-1s for obesity under the Medicare GLP-1 Bridge. And low-income Medicare beneficiaries who qualify for reduced cost sharing through the Part D Low-Income Subsidy can’t use those subsidies for GLP-1 prescriptions filled under the short-term program. For low- and modest-income individuals, the $50 copayment could be a barrier to participation.

Another potential issue is that beneficiaries who participate in the short-term program will need to be enrolled in a Part D plan that participates in the longer-term demonstration, called the BALANCE Model, to continue accessing Medicare coverage of GLP-1s for obesity starting in 2027. CMS is aiming for robust Part D plan participation in the BALANCE model, which is voluntary for plans, but this is still uncertain. Transitioning Medicare coverage of GLP-1s for obesity from the mandatory Medicare GLP-1 Bridge to the voluntary BALANCE model sets up the possibility that beneficiaries with coverage under the short-term program may need to switch Part D plans during the 2027 open enrollment period, with potential cost and coverage implications for other medications they use.



Source link

Medicaid Workers and Job-Based Insurance: Who Is Offered, Eligible, and Enrolled?

healthissuesadmin
-
0
Medicaid Workers and Job-Based Insurance: Who Is Offered, Eligible, and Enrolled?



rewrite this content and keep HTML tags

Passage of the 2025 reconciliation law, also known as the “One Big, Beautiful Bill,” in July 2025 and the inclusion of new work requirements for certain Medicaid enrollees in the law focused attention on the work status of adults enrolled in the program as well as their access to job-based insurance. Most adults who will be subject to the new Medicaid work requirements are already working. These adult workers rely on Medicaid because most work in jobs that do not offer health coverage or are not eligible for the offered coverage. While employer-sponsored insurance is the main source of coverage for working-age adults in the United States, access to job-based coverage is more limited for low-wage workers, those who work in certain industries, part-time workers, and those who work at smaller firms. Many employers— small and large— report that Medicaid provides important access to health care to their employees.

New work requirements are unlikely to increase employment (as most Medicaid adults are working or face barriers to work). Given the limited offers and eligibility for job-based coverage for low-wage workers, the new requirements are also not likely to substantially reduce reliance on Medicaid as a source of coverage for those workers. However, these requirements will likely reduce Medicaid enrollment because even some enrollees who are working will be unable to verify their work status.

Using data from the 2025 Current Population Survey Annual Social and Economic Supplement (CPS ASEC), this analysis examines the availability of job-based insurance in 2024 for adult Medicaid workers ages 19 to 64 and explores the reasons why Medicaid adults who are working are not eligible for employer coverage, and if eligible, why they do not take up the offer. The analysis excludes Medicaid adults who are self-employed, are also enrolled in Medicare, receive disability-related payments from Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) and focuses on states that have adopted the Medicaid expansion and Wisconsin, which has adopted a partial expansion. Medicaid adults enrolled through the expansion, or partial expansion in Wisconsin, will be subject to the new work requirements. Georgia is excluded from the analysis because enrollment in the Pathways to Coverage Program is too small to be captured in the data. This analysis does not attempt to identify adults who would be subject to work requirements. It covers a broader group of Medicaid enrollees, including adults with dependent children, some of whom may be exempt.

Most Medicaid adult workers work for an employer that does not offer job-based insurance or are not eligible if their employer offers coverage. For workers to enroll in job-based insurance, they need to work for an employer that offers coverage and be eligible to enroll in that coverage. Nearly two-thirds (65%) of Medicaid adult workers in expansion states and Wisconsin either work for an employer that does not offer health coverage (52%) or are not eligible for coverage that is offered by their employer (13%) (Figure 1). In contrast, about one in five (21%) adult workers who are not covered by Medicaid in the same states are not offered (16%) or eligible (5%) for coverage offered by their employer.

About a quarter (26%) of adult Medicaid workers decline coverage when they are eligible compared to 17% of adult workers not covered by Medicaid. Many adult workers who are eligible for job-based insurance do not take up the offer because the coverage is unaffordable (Appendix Table 1). For adult Medicaid workers who did not enroll in job-based coverage, Medicaid likely provides coverage that is more affordable, and in some cases, more comprehensive than the health insurance available through their employer.

About one in ten (9%) adult Medicaid workers take up coverage offered by their employer and are covered by both Medicaid and the employer plan. In these cases, Medicaid provides wrap-around coverage, covering premiums and cost sharing, as well as providing coverage for benefits not included in the employer plan.

Even when adult Medicaid workers in low-wage jobs have access to job-based insurance, the employee share of the costs can be unaffordable. Workers in firms with many lower-wage workers (where at least 35% earn $37,000 or less annually) have higher average contribution rates toward their premium for family and single coverage compared to workers at firms with fewer low-wage workers (31% vs 26% for family coverage and 19% vs 16% for single coverage). These higher contributions likely mean low-income families with job-based coverage spend a greater share of their income on health costs overall (premium contributions and out-of-pocket expenses) than those with higher incomes, which may contribute to decisions not to enroll in the offered coverage.

Most Medicaid Adults Work for an Employer That Does Not Offer Job-Based Insurance or Are Not Eligible if Their Employer Offers Coverage

Medicaid adults who work part time are less likely to be eligible for job-based insurance than those who work full time. About one-third (32%) of adult Medicaid workers work part time, and among these part-time workers, one in five (21%) are eligible for coverage from their employer compared to 42% of those who work full time (Figure 2). Under the Affordable Care Act’s shared responsibility mandate, employers with at least 50 full-time equivalent employees are required to provide minimum essential coverage to employees, but that requirement only extends to employees who work an average of at least 30 hours per week. As a result, among firms that offer health benefits, relatively few offer benefits to part-time workers.

Medicaid Adults Who Work Part Time Are Less Likely to be Eligible For Job-Based Insurance Than Full-Time Workers

Eligibility for job-based insurance among adult Medicaid workers varies by industry. The share of adult Medicaid workers eligible for job-based insurance varies from 56% in the mining industry to 20% in the agricultural and forestry industry (Figure 3). Medicaid adults working in educational and health services industry represent nearly a quarter (23%) of adult Medicaid workers and 41% are eligible for job-based insurance. On the other hand, about one in six (16%) adult Medicaid workers have jobs in the leisure and hospitality industry where only 22% are eligible for employer-based insurance.

Eligibility for Job-Based Insurance Among Adult Medicaid Workers Varies by Industry

Among adult Medicaid workers who are offered insurance by their employer, most are not eligible because they do not work enough hours. About one in eight (13%) adult Medicaid workers work for an employer that offers health insurance but are not eligible (Figure 1). Nearly seven in ten (69%) of these workers reported they were not eligible because they did not work enough hours per week or weeks per year to qualify (Figure 4). About one in ten (13%) Medicaid workers were not eligible because they had not worked for the employer long enough, and another 5% said they were not eligible because contract and temporary employers were not allowed in the employer’s health plan.

Among Adult Medicaid Workers Who Are Offered Insurance by Their Employer, Most Are Not Eligible Because They Do Not Work Enough Hours

Reasons for Not Taking Up Job-Based Coverage Among Adult Workers Covered By Medicaid and Those Not Covered by Medicaid



Source link

How Do Health Expenditures Vary Across the Population?

healthissuesadmin
-
0
How Do Health Expenditures Vary Across the Population?



rewrite this content and keep HTML tags

In a given year, a small portion of the population is responsible for a very large percentage of total health spending. This collection of charts explores the variation in health spending across the population through an analysis of 2023 Medical Expenditure Panel Survey (MEPS) data. The analysis finds that five percent of the population accounted for nearly half of all health spending, spending an average of $72,918 annually in 2023. People with health spending in the top one percent spent an average of $150,467 per year.

The analysis also examines spending variation by age, gender, race, insurance coverage status and presence of certain health conditions. Adults who have been diagnosed with a serious or chronic disease have significantly higher out-of-pocket spending.

The chart collection is part of the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.



Source link

Your guide to early retirement health insurance options

healthissuesadmin
-
0
Your guide to early retirement health insurance options



rewrite this content and keep HTML tags

If you’re retiring before age 65 and your employer doesn’t offer retiree health benefits, you’ll need a plan for your health coverage until you become eligible for Medicare at 65. Let’s take a look at your early retirement health insurance options and what you need to know about each one.

Can early retirees get health insurance through the ACA Marketplace?

Yes. The ACA Marketplace / exchange can be a great option for early retirees to find coverage. ACA-compliant coverage is guaranteed-issue regardless of medical history, and if you lose access to your employer’s health plan when you retire, the loss of coverage will trigger a special enrollment period for individual-market coverage.

Depending on your household income, you might be eligible for premium tax credits (subsidies) that cover some or all of the premiums for a Marketplace plan.

Here’s what you need to know about Marketplace health coverage for early retirees:

  • Premiums do not vary based on gender or medical history, but they do vary based on age. In most states, a 52-year-old will have a premium that’s roughly double the premium for a 21-year-old, and a 64-year-old’s premium will be three times as high as a 21-year-old’s.
  • If you qualify for a premium subsidy, the subsidy is based on your premium for the second-lowest-cost Silver plan (benchmark plan). So the premium subsidy is also larger for older enrollees, as it’s based on a larger benchmark plan premium.
  • To qualify for a premium subsidy, you must have a household income in the subsidy-eligible range, as described below. Here’s how household income is calculated under the ACA.
  • Marketplace subsidy eligibility is based on your total household income for the full year, even if that income isn’t evenly spread across the year.

How can early retirees find out if they’re eligible for Marketplace subsidies?

Let’s take a closer look at how Marketplace subsidy eligibility works for early retirees, since the subsidies can make a big difference in terms of how affordable a Marketplace plan will be.

The subsidy-eligible income range depends on where you live and how many people are in your household. On the lower end of the income spectrum, your household income must be at least 100% of the federal poverty level (FPL) to qualify for subsidies, but in most states, it actually needs to be above 138% of FPL because Medicaid is available below that level.

On the upper end of the income spectrum, you wouldn’t be eligible for federal premium subsidies if your household income exceeds 400% of FPL. (State-funded subsidies are available to enrollees with household incomes above 400% of FPL in Connecticut, New Jersey, and New Mexico.)

Here are the income ranges that make a single Marketplace enrollee eligible for federal premium subsidies in 2026 (using the 2025 federal poverty guidelines). (The income limits are higher if your household includes additional people.)

  • In Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming (states that have not expanded Medicaid under the ACA), your income must be between $15,650 and $62,600.
  • In Hawaii, your income must be between $24,827 and $71,960.
  • In Alaska, your income must be between $26,980 and $78,200.
  • In the rest of the country, your income must be between $21,598 and $62,600.

Your household income used to calculate subsidy eligibility includes total earnings from employment, capital gains, investment income, a pension, rental income, and Social Security. (Retirement benefits can begin as early as age 62.)

But if, for example, you’re planning to live off of savings and the income (dividends, interest, capital gains, etc.) from those savings isn’t enough to put you in the subsidy-eligible range, you would not be eligible for Marketplace subsidies.

On the other end of the spectrum, if your income will decline significantly when you retire, your pre-retirement income from earlier in the year could make you ineligible for subsidies for the remainder of that year, depending on how much you earned.

For example, consider a person who earns $100,000 per year (about $8,333 per month), who is planning to retire at the end of August. By that point in the year, they will have earned nearly $67,000. Unless they’re in Alaska or Hawaii, that means they will be ineligible for Marketplace subsidies for the whole year – even if they don’t earn anything at all for the final four months of the year.

You may want to have a discussion with a financial advisor before you retire, to ensure that you have a plan in place for managing your income in retirement if you’re hoping to qualify for Marketplace subsidies. And when determining the timing of your retirement, be sure you understand what your total household income will be during the year you retire – including money you earned before your retirement date and any severance pay you might receive – as well as future years.

Just for perspective in terms of how much difference a subsidy can make, here are 2026 Marketplace premiums for a single 60-year-old in Mobile, Alabama, which is fairly mid-range in terms of premium costs:

  • Household income of $60,000: Lowest-cost Bronze plan is $0/month (because the household receives a subsidy of $827 per month).
  • Household income of $63,000: Lowest-cost Bronze plan is $827/month (because the household is ineligible for subsidies, due to the “subsidy cliff”).

Note: You can reduce your ACA-specific household income by contributing to a health savings account (HSA) if you select an HSA-eligible health plan. And if you continue to have earned income during retirement (from a part-time job, self-employment, consulting, etc.), you can contribute to a pre-tax retirement account, which will also lower your household income under ACA rules.

Use a subsidy calculator to see if your retirement income makes you subsidy-eligible.

Can early retirees get Medicaid if they’re in an expansion state?

In 40 states and Washington, DC, Medicaid eligibility has been expanded under the ACA. This means that adults under age 65 are eligible for Medicaid if their household income doesn’t exceed 138% of FPL.

If you’re under 65, your eligibility for Medicaid in an expansion state is based solely on your income, so assets aren’t taken into consideration. (Individuals age 65 and older face both income limits and asset limits when applying for Medicaid.)

And unlike eligibility for Marketplace subsidies, your Medicaid eligibility can be determined based on annual income or current monthly income. This can make Medicaid coverage possible even if the person had a higher income earlier in the year.

But there are a couple of important points to understand about using expanded Medicaid as your early retiree health coverage:

Medicaid expansion states will soon have a work requirement

Starting in 2027, Medicaid expansion enrollees will face a work requirement, due to federal legislation enacted in 2025. Unless they qualify for an exemption, Medicaid expansion enrollees will be required to spend at least 80 hours per month participating in “community engagement” activities.

These “community engagement” activities can include employment, community service, education, or a combination these activities. Enrollees will be required to provide proof of these activities to their state Medicaid agency in order to keep coverage in force.

Some early retirees who plan to volunteer extensively or return to school or hold a part-time job (that doesn’t push their income out of the Medicaid-eligible range) will continue to be eligible for Medicaid expansion coverage in those states that expanded Medicaid. But those who do not plan to have at least 80 hours per month of community engagement are unlikely to be eligible for Medicaid in 2027 and future years.

Medicaid estate recovery

Under federal rules, states are required to use estate recovery (recouping funds after a Medicaid beneficiary has died) for Medicaid-funded long-term care that was provided after a person was 55 years old. But states also have the option to use estate recovery to recoup any Medicaid expenses that were incurred after a person was 55 years old, so states vary in their approach to this.

If you’re planning to use Medicaid as your early retiree coverage, make sure you understand how your state handles estate recovery, so that there are no eventual surprises for your heirs. (Here’s Medicaid contact information for each state.)

Is COBRA or state continuation a good option for early retirees?

When you retire, you may have access to COBRA or state continuation (“mini COBRA,” which is offered in many states to people whose employers weren’t large enough to be subject to COBRA). These federal and state provisions allow early retirees to continue their employer-sponsored coverage temporarily. Here’s what you need to know about this option:

  • If your employer’s health plan is subject to COBRA and you retire, COBRA allows you to continue your existing coverage for up to 18 months.
  • If your employer’s health plan is subject to state continuation, the length of time you can keep your plan will depend on the rules in your state.
  • You’ll be responsible for the full premium cost (including the portion your employer was paying), plus an administrative fee. For COBRA, the fee is 2% of the premiums. For mini-COBRA, the fee varies by state.

COBRA can be a good solution if you’ll be eligible for Medicare within 18 months of retirement, as it means you won’t have to switch to new  coverage for the gap between your retirement date and the start of your  Medicare coverage. But it’s a good idea to compare Marketplace plans to your COBRA offer to see which makes more sense for your circumstances, as each option has pros and cons.

You can use COBRA even if you still have several years before you’ll be eligible for Medicare. Just know that once you exhaust your COBRA benefit, you’ll need to pick a new plan at that point, to cover the rest of your early retirement years.

Early retirement health insurance through a spouse’s coverage

If you’re retiring early but your spouse is still working, you may both have access to your spouse’s employer-sponsored health plan. There is no federal law requiring group health plans to offer coverage to spouses, but almost all of them do.

If your spouse is enrolled in their employer’s plan and you’re enrolled in your own employer’s plan, your loss of coverage will trigger a special enrollment period that will allow you to be added to your spouse’s plan (assuming the plan is offered to employees’ spouses).

If you and your spouse are both covered under your plan, the loss of coverage when you retire will trigger a special enrollment period that will allow both of you to enroll in your spouse’s plan (assuming your spouse is an eligible employee and the plan allows employees’ spouses to enroll).

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written hundreds of opinions and educational pieces about the Affordable Care Act for healthinsurance.org.

 



Source link

Constrained Budgets Lead States to Restrict HIV Drug Access Through Ryan White

healthissuesadmin
-
0
Constrained Budgets Lead States to Restrict HIV Drug Access Through Ryan White



rewrite this content and keep HTML tags

States are facing constrained budgets, putting pressure on HIV care and prevention programs, including the Ryan White HIV/AIDS Program. Ryan White, the nation’s HIV safety-net, is funded each year through discretionary federal appropriations, state dollars, and other sources. However, funding does not necessarily match the number of people who need support or the cost of services.

The largest component of Ryan White provides grants to states, including for their AIDS Drug Assistance Programs (ADAPs), which provide HIV treatment and insurance assistance for people with HIV. In the past, ADAPs have used waiting lists and other cost-containment measures when programs could not meet the needs of all those eligible, and in the early 2000s, waiting lists were common. Significant waiting lists were last cleared with an influx of emergency federal funding in 2013 and then were used occasionally for a few years. They have not been used for over a decade and, to date, have not returned. However, several states facing budget pressures have recently moved to institute other cost-containment measures, including restricting eligibility and scope of services, and some are considering waiting lists for the future.  This represents the first time such broad cost-containment measures have been taken since the waitlist era.

Ultimately, such changes could result in people with HIV losing access to care and treatment, which could worsen health outcomes (increasing morbidity and mortality) and leading to new HIV infections (four in ten new HIV transmissions are associated with someone who is aware of their HIV status but not in care).

State ADAPs Respond to Strain by Limiting Enrollment and Services Offered

Florida recently annoucned changes to its ADAP, which would dramatically limit eligibility and scope of assistance. Specifically, the state plans to reduce income1 eligibility for the program from 400% of the federal poverty level (FPL) to 130% FPL (for an individual, which is the equivalent of eligibility decreasing from a maximum income of $63,840 to $20,748 annually).

Additionally, the state plans to remove Biktarvy from its formulary. Biktarvy is the most widely prescribed antiretroviral (ARV) medication nationally (accounting for 52% of the U.S. ARV market) and the only single tablet regimen (STR) included among the national HIV treatment guidelines list of recommended initial treatment regimens. Some studies have shown that STRs improve adherence by reducing pill burden.

The state also plans to roll back its insurance assistance program. ADAPs can help cover insurance costs in addition to directly purchasing medications. Ending insurance assistance poses unique challenges, as insurance coverage allows individuals to meet both HIV-related and other health care needs and helps protect clients in the face of unexpected medical costs (e.g. through out-of-pocket maximums).2 With expiration of enhanced Affordable Care Act premium tax credits, out-of-pocket premiums for people in ACA plans are increasing substantially this year.

The changes in Florida have received significant push back from advocates, patients, and providers, and the state was sued for proceeding with these changes without formal rule making. (The state then issued a proposed rule which it followed with emergency rulemaking. Litigation continues seeking to block implementation).

Florida, however, is not alone. New data from the National Association of State and Territorial AIDS Directors (NASTAD) indicate that 23 states (including Washinton, D.C.) have implemented or are considering ADAP cost-containment measures.3 Eighteen (18) ADAPs, including Florida‘s, have already made or are making changes and five additional states report that they are considering introducing such measures in the future. Further, 12 of the 19 states already implementing cost-containment measures are considering additional changes for the future.

For example, in addition to Florida, Pennsylvania, Kansas, Delaware, and Rhode Island have also reduced income eligibility for their programs (though to a lesser degree). Other changes states are exploring or implementing include reducing formularies (though, so far, none as consequential as removing Biktarvy), reducing funding for medical and support services, making recertification more stringent (which can create churn and lead to program disenrollment), implementing annual client spending caps, and restricting or ending health insurance assistance.

At Least 19 ADAPs Have Taken Cost-Containment Actions, 5 More Are Considering Future Action

To date, no state has implemented a waiting list, a measure widely seen as a last resort. However, Arkansas, Louisiana, and New Jersey report considering implementing one as a future cost-containment measure.

Multiple Factors Are Exerting Budget Pressures on ADAP

There are a range of factors affecting ADAP budgets. These include, but are not limited to, the following:

Federal ADAP Funding Not Keeping Pace With Inflation

Since 1996, Congress has allocated (or “earmarked”) a set amount of funding for ADAPs during the annual appropriations process. After modest funding levels in the late 1990s, followed by significant growth in the early 2000s, ADAP inflation-adjusted appropriations have declined by 31% since 2005.4 The decline is largely attributable to more than a decade of flat funding in nominal dollars. When adjusted to 1996 dollars, the FY25 appropriation ($438.8 million) has similar purchasing power as the program’s FY1999 funding level ($434.0 million).5 In other words, in the last 20 years, ADAP funding has not kept pace with inflation, even before accounting for enrollment growth and increased costs (discussed below).

ADAP Earmark in Nominal Dollars and Adjusted for Inflation (1996 dollars)

In the NASTAD report ADAPs identified growing client enrollment, growing drug costs, and rising insurance costs as the top three drivers of budget concerns. These concerns are explored further below:

Increased Client Enrollment

While modern era federal ADAP funding has not kept pace with inflation, the number of ADAP clients served has increased significantly. The number of clients served increased by 56% from 2007 (the first year with available data for the full year) to 2024 (the most recent year with available data), rising from 165,3826 to 257,644 clients served. Adjusted for inflation, appropriations per client served dropped from about $3,600 in 2007 to approximately $1,700 in 2024. Additionally, the national HIV treatment guidelines have evolved to recommend HIV treatment at the time of diagnosis -as opposed to starting at signs of disease progression- which has led to more people with HIV having an indication for treatment.

Rising HIV Drug Costs

Another factor impeding the reach of ADAP dollars is the increasing cost of drugs for HIV treatment. A recent analysis found that the average wholesale price (AWP) of recommended initial antiretroviral regimes in 2012 ranged from an AWP of $24,970 to $35,160, increasing to $36,080 to $48,000 in 2018. Costs have generally increased since then. Data in the treatment guidelines show that the AWP for Biktarvy (again the number one treatment regimen for people with HIV and only STR recommended by the treatment guidelines start list) was $61,000 in 2025. The 2025 AWP for other recommended (two-pill) regimens ranged from $34,320 to $65,196. While ADAPs do not pay the full AWP because they have access to price discounts through the 340B drug pricing program and supplemental manufacturer rebates, increasing drug prices may still affect them; it is a main concern cited by ADAPs regarding cost challenges. Additionally, ADAPs ability to generate rebates (which make up a growing share of their budgets) through Medicare have diminished due to programmatic changes, including adoption of the out-of-pocket cap in Part D – by introducing the cap, ADAPs and other 340B entities, have less opportunity to generate rebates on claims because they make fewer cost-sharing payments.

Increased Insurance Premium Costs and Expiration of Enhanced Tax Credits

As mentioned above, ADAPs can also purchase health insurance for eligible clients. However, the cost of individual market coverage is on the rise, with the expiration of the enhanced premium tax credits being a particular driver and premium increases also playing a role.

ACA premium tax credits help make marketplace plans more affordable for people with low to moderate incomes. They were first enhanced as part of the American Rescue Plan Act in 2021 and extended by Congress through 2025, but have since expired due to the lack of a bipartisan Congressional agreement to continue them. The enhanced tax credits had improved insurance affordability for ADAPs purchasing coverage on behalf of clients, including for those previously eligible for the less generous ACA subsidies and, newly, for those with incomes over 400% FPL, a group for whom premium costs were limited to 8.5% of income. Without the enhanced credit those 100-400% FPL revert to the original, less generous, ACA tax credits and those over 400% FPL have lost financial assistance altogether. For enrollees keeping the same plan, expiration of the enhanced premium tax credits is estimated to more than double what subsidized enrollees previously paid annually for premiums—a 114% increase from an average of $888 in 2025 to $1,904 in 2026.

Additionally, after holding relatively steady since 2020, premiums increased steeply between 2025 and 2026, with the average premium cost for benchmark plans increasing by 26%7, with significant variation across states. Some southern states with high HIV prevalence saw especially large average increases (e.g. 33% in Florida and 35% in Texas). These premium increases occurred for a range of reasons including, but not limited to, higher health care costs, use of expensive GLP-1 drugs, the threat of tariffs, and the expiration of the enhanced premium tax credits. While the vast-majority of ADAP clients have modest incomes, these costs will be borne out most acutely for the 7% of clients served by insurance purchasing who have incomes over 400% FPL, a group who lost the enhanced tax credits that previously capped premium costs as a share of their income. ADAPs covering individuals in this higher income group face a two-fold setback – loss of enhanced tax credits and no protections against rising premiums. 

Additionally, individuals who lose ADAP insurance coverage due to cost-containment measures may find financing coverage independently more challenging due to reduced tax credit generosity and increases in premiums.

Looking Ahead

While ADAPs have sought to leverage additional state funds, drug rebates, and capture limited emergency and supplemental funding, these efforts have not remedied budget shortfalls, leading many to institute cost-containment measures. ADAPs may increasingly face budget pressures that could lead to additional such measures in the future. This could leave growing numbers of people with HIV ineligible for safety-net services, particularly if states further lower income eligibility limits or institute waiting lists. The expiration of enhanced tax credits amplifies these challenges, both increasing costs for programs and leaving those who are ineligible for ADAPs with fewer affordable alternatives. Limiting access to Ryan White services will in turn affect the ability of people with HIV to stay engaged in HIV treatment, a cornerstone of national efforts to address the HIV epidemic.

Endnotes



Source link

The Midterms Lurk Behind Every Health Policy Move Now

healthissuesadmin
-
0
The Midterms Lurk Behind Every Health Policy Move Now



rewrite this content and keep HTML tags

Look for the midterms to play a role in every health policy decision until November, as both Republicans and Democrats maneuver for advantage with voters. That’s the case with two recent Trump administration moves to strengthen the hand of Republicans in the midterm elections. Democrats start out with a significant advantage on health in the midterms, but rather than cut and run to other issues, Trump wants Republicans to try to erode that advantage where they can.

One example is the shake-up at Health and Human Services, surrounding Secretary Robert F. Kennedy, Jr. with a new cadre of advisers, deposing others and installing the Director of the National Institutes of Health as Acting Director of the Centers for Disease Control & Prevention at the same time. This augments a controversial secretary with administration appointees placed there to deliver on policies the administration wants Republicans to trumpet, such as their initiatives to lower drug costs, including “most favored nation” (MFN) drug pricing and Trump Rx. Keeping the secretary in place rather than replacing him also appeases Make America Healthy Again (MAHA) supporters in the Republican base and may appeal to other voters who support MAHA ideas.

Four in 10 adults say they are MAHA supporters—the amorphous cause RFK Jr. champions—including 22% of Democrats and 38% of Independents. We don’t know if many of them will vote in the midterms for that reason, but some may if they feel strongly about MAHA-related issues or a candidate who champions them. Make America Great Again (MAGA), Independent and Democratic MAHA adherents almost certainly have different elements of MAHA-ism they care about, from vaccines to healthier food to environmental chemicals, to general distrust of government—and not all of these issues will be in play in the midterm races they vote in. Anti-vax views can be strongly held but notably, 31% of MAHA adherents disapprove of RFK Jr.’s handling of vaccines. The secretary sometimes takes heat from the more extreme MAHA groups for not going far enough, but overall, he holds down a lot of the MAHA flank for Trump and Republicans while the newly installed advisors pursue policy deliverables.  

Four in Ten Adults Say They Support the Make America Healthy Again (MAHA) Movement, With Support Closely Tied to Republicans and MAGA Republicans

Saying the quiet part about underlying political strategy out loud as he often does, Trump recently linked the drug cost policies he wants to advance directly to the midterms, calling on Republican candidates to emphasize efforts to bring down drug costs as a midterm campaign message. It’s an effort to play offense and blunt attacks from Democrats focusing on affordability and rising premiums, especially in the Affordable Care Act (ACA) Marketplaces. Politically, the goal for Trump and Republicans is not to “win” the health care issue but to erode the Democratic advantage on it by talking a lot about drug costs and villainizing drug companies. (Lately, adding insurance companies to the mix of villains as well.) Of course, Democrats also have advanced drug cost policies they can talk about if they choose to fight on that terrain rather than health care affordability generally.

Overall, as the chart shows, Democrats still have a sizable advantage on health heading into the midterm campaigns, including a modest one on drug costs despite the administration’s initiatives. Their primary strategy is to link health care costs to the public’s broader concerns about affordability at a time when paying for health care has emerged as voters’ top economic worry. 

Among Voters, Democrats Have an Edge Over Republicans on Most Health Issues

It remains to be seen if Republican candidates in close races will want to go head-to-head with Democrats on health care, despite Trump’s urging them to do so. They may feel they have other cards to play, and some will not want to highlight decisions they made to cut Medicaid and double people’s ACA premium payments in a general election.

Policies have declared and undeclared purposes. We analyze the pros and cons of policies like Trump Rx or MFN when the primary purpose of the policy is to signal to voters that “I care about your drug costs” and “I am doing something about it.” The political strategy behind them is usually undeclared but almost everything in health policy between now and November will be substantially about the midterms. 

View all of Drew’s Beyond the Data Columns



Source link

1...456...28Page 5 of 28
© Newspaper WordPress Theme by TagDiv