What’s Happening on the Hill🔍 Bring Out the Fraud SquadHouse Republicans are turning up the heat on ACA marketplace integrity, subpoenaing eight major insurers (CVS, Elevance, Centene, Oscar, Kaiser Permanente, Health Care Service Corporation, Blue Shield of California, and GuideWell) for documents about their fraud prevention measures. The move escalates a December inquiry that followed a GAO report showing federal auditors successfully obtained subsidized coverage for fictitious applicants, highlighting $21 billion in unreconciled tax credits. With enhanced subsidies expired and fraud concerns dominating Republican talking points, Judiciary Chair Jim Jordan is eyeing potential legislative reforms to the Administrative Procedure Act, which a federal judge cited when blocking Trump's marketplace integrity rules last summer. 🏥 CMS Promises, Broken.CMS dealt a crushing blow to rural primary care by canceling the Making Care Primary program just one year into what was supposed to be a 10-year commitment. Nearly 700 practices across eight states, with North Carolina leading at 23 clinics, lost promised funding as part of DOGE's efficiency cuts, saving taxpayers $750 million according to CMS. The Mountain Community Health Partnership had been counting on up to $10 million over the decade to hire staff, build specialist connections, and fund patient transport. The replacement LEAD program will route money through organizations and companies rather than directly to primary care providers, adding bureaucratic layers that Dr. William Hathaway of Mountain Area Health Education Center calls costly and counterproductive. "How is our organization supposed to plan for the future when the future can just go away so quickly?" he asked. More from CMS: Administrator Mehmet Oz is reshaping the ACA marketplace for 2027, proposing sweeping changes that expand access to catastrophic plans with $10,600+ deductibles while eliminating standardized plan designs. The rule would allow anyone over 30 who doesn't qualify for premium tax credits to get catastrophic coverage and let insurers offer multi-year terms up to 10 years. It's a calculated response to enrollment dropping to 23 million after enhanced subsidies expired: if comprehensive coverage is politically unattainable, make bare-bones coverage more accessible. The regulation also tightens enrollment verification and continues restricting special enrollment periods for low-income applicants, citing Republican fraud concerns. Consumer groups warn the changes prioritize coverage numbers over meaningful financial protection. 💊 Finally…Reform Finally PassesAfter years of talk, Congress delivered. The Consolidated Appropriations Act of 2026 includes landmark PBM reforms requiring 100% rebate pass-through to employers, detailed semiannual reporting on drug spending and spread pricing, and restrictions on compensation structures starting in 2028. The package mandates "any willing pharmacy" network participation and gives CMS authority to define "reasonable and relevant" contract terms with formal dispute resolution. Employers cheered the transparency while independent pharmacies celebrated protection from predatory contracting. The Pharmaceutical Care Management Association's response was notably bitter, calling it "the culmination of a years-long effort by drugmakers to convince Congress that discounts are in fact bad." But the victory comes with limits—it doesn't ban spread pricing outright and applies primarily to Medicare Part D, leaving commercial market reforms for future battles.
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