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The idea of a snow day was always exciting as a kid: not going to school, playing in the snow, and getting a sugar rush from drinking hot chocolate. While Congress might wish for the childhood magic to return now that DC has been hit by a snow storm, it does not stop their growing to-do list for the week. So, let’s get into it. Welcome to the Week Ahead!
The Administration
President Trump plans to meet with health insurance executives on the heels of their recent questioning during two House committee hearings.
But what could President Trump actually have to say to them? We think it could go something like this: “Look, I like you people. I really do. You’re smart, you run big companies, very successful. But the system? The system is a mess. This is why I introduced my Great Healthcare Plan. We’re going to lower drug prices and insurance premiums, and you’re going to do it. We can help you but only if you help us, no excuses.”
No matter the verbiage the president uses, expect him to make a big deal of this meeting and highlight his plan to show that his administration is doing something to address affordability concerns.
It’s important to remember that in announcing the plan, President Trump called on Congress to enact his plan. So, it’s unclear what, if anything, the president plans on doing beyond pressuring Congress to put the principles in his plan into effect.
The Senate
The ball is now in the Senate’s court, after the House passed by a wide margin the minibus and the fiscal year 2026 (FY 26) Homeland Security funding bill last week to finish its work on the remaining FY26 funding bills. The minibus included over a dozen health care extenders (i.e., Medicare telehealth flexibilities, community health center funding) and 35 new health care policies (i.e., pharmacy benefit manager reform, Medicare coverage of multi-cancer early detection screening tests). There are a few procedural motions that need to happen before the Senate can vote on the bills to avoid a government shutdown on January 30.
Minority Leader Chuck Schumer (D-NY) said that Democrats will block the minibus if it includes funding for the Department of Homeland Security, after the second fatal ICE shooting in Minnesota. This creates a wrinkle that will need to be ironed out if the Senate wants to avoid a partial government shutdown.
So, what happened to those APTC conversations? With the funding bills taking up all the debate time, it seems that conversations about an APTC extension have been put on hold. With the end of January deadline from Leader John Thune (R-SD) fast approaching, the likelihood of an extension coming together is shrinking.
Health Care Hearings This Week
- January 28: Senate VA Committee hearing on modernizing the VA health care system
- January 29: Senate Aging Committee hearing on drug labeling
The House
With the House out of session, let’s reflect on the recent Energy and Commerce and Ways and Means Committee hearings with health insurance executives. While we saw passionate questioning from members on both sides of the aisle, there is more to come as Committee leaders have promised more hear care hearings hearings and future hearings with leaders from other areas of the health care sector. So, the question is: who’s next? hospital CEOs? pharma execs? If we were either, we would be look at our calendars and get ready to travel to DC.
But what actually happened at the hearings? Although there was plenty of partisan fighting at the hearings, there was also strong support on both sides to tackle issues related to prior authorization and anger over the high compensation packages for insurance CEOs. While this could be the spark needed for bipartisan action on health care, expect the harsh winds of partisanship (especially during an election year) to make getting a fire going very difficult.
There You Have It
We hope everyone has stayed safe and warm with the snow. What is your favorite snow day tradition? Let us know. Make it a great week!
On January 16, 2026, the Medicare Payment Advisory Commission (MedPAC) met to see presentations and discuss findings on the Medicare Advantage (MA) program and Dual-Eligible Special-Needs Plans (D-SNPs). The information from the presentations and discussion will be included in the March 2026 report to Congress.
THE MA PROGRAM: STATUS REPORT
MedPAC staff offered a comprehensive overview of the MA program. MedPAC staff shared that in 2025, MA plans enrolled 55% of eligible beneficiaries, with the beneficiaries having an average of 42 plans to choose from. They also predicted that MA rebates will reach a historic high in 2026, which they said could help in reducing cost sharing as well as providing beneficiaries supplemental benefits such as dental and vision services. MedPAC staff also noted that MA spending has been greater than traditional Medicare Fee-for-Service (FFS) spending, which may be attributed to upcoding. They also noted that the new V28 reduced coding-intensity model appears to help control MA costs while maintaining stable supplemental benefits and MA plan availability. It is expected that the V28 model will continue to reduce MA coding intensity effects in coming years.
The Chair opened Commissioner discussion by sharing that he thinks about MA plans as an indirect way to provide access to care. He differentiated this from more direct ways MedPAC examines, such as hospital payments and the post-acute care space.
Multiple Commissioners were interested in the excess administrative expenses expected with MA plans, seeking clarification on how administrative costs are accounted for in the medical-loss ratio and how savings can be passed on to beneficiaries.
There was also interest in the V28 service model due to its relative newness. MedPAC staff clarified that there are plans to compare the effects of the V24 model to the V28 model to see if there are code discrepancies between the models and that the V28 model uses Medicare FFS data to periodically update the model calibration. Some Commissioners raised concerns that the model is affecting MA plans that have not been found to be upcoding and wondered if there was a way to make plan-specific adjustments in those cases. MedPAC staff shared that such changes would need to be a change in policy, not just a change in the data model.
One Commissioner requested that in the future MedPAC take a closer look at other Medicare populations such as those with permanent disabilities, as much of the previous and current work focuses on the older adult population.
There were also broad concerns from the Commissioners about the profit margin of MA plans, especially when compounded with concerns about MA plans having a much higher spending amount per beneficiary than those enrolled in Medicare FFS. It was suggested that future work could provide a clear breakdown of how money flows through MA plans, as well as taking a closer look at the star rating system which some Commissioners believe is helping to accelerate payment rates. Receiving clearer data from reliable sources was highlighted as a need from staff and Commissioners. It was also suggested that the use of supplemental benefits and clear beneficiary-level data could be helpful to the Commission. Another thought was that the Commission needs to understand how supplemental benefits are used to market MA plans and how beneficiaries shop for plans.
The Commissioners shared a wide variety of ideas about how to transform the MA space to work better for beneficiaries. These included flexible spending accounts to allow supplemental benefits to be purchased directly, going back to encounter-based coding, revisiting out-of-pocket maximum policies to contain costs, and reconsidering whether the quality payment system should be budget-neutral. Another suggestion made was to streamline the plan choices and create better materials to explain the differences between types of care plans.
Overall, the Commissioners shared the sentiment that MA plans are somewhat overfunded, and that program changes are needed to ensure quality care is still delivered while costs are contained.
MANDATED REPORT: D-SNPS
MedPAC staff began the session with an overview of D-SNPs, sharing that nearly half of dually eligible beneficiaries are enrolled and use has tripled over the last decade. MedPAC staff shared how each type of D-SNP plan had various results on Healthcare Effectiveness Data and Information Set (HEDIS) quality measures, which can make it difficult to directly compare across plan types. It was also noted that look-alike plans offer an alternative to D-SNPs and Chronic Condition Special-Needs plans (C-SNPs) are becoming more popular in the market.
The Commissioners questioned how integration for D-SNPs can be best measured, but MedPAC staff shared that the plan providers are very aware of the quality incentives that relate to higher payments and will focus their efforts on those measures, which can make it difficult. One Commissioner shared that they were not surprised that there is no correlation between increased integration and broad quality measures, stating that integration is not the only or strongest way to create value for challenged populations.
Multiple Commissioners had questions about D-SNP marketability to beneficiaries and would like to see some qualitative data from plans and beneficiaries in the future. MedPAC staff shared that current reports indicate that care coordination benefits are hard to explain to beneficiaries so many beneficiaries still make their plan decisions on supplemental benefit access.
There was conversation about the ability to join C-SNPs in the middle of the year which MedPAC staff clarified was not a new policy. MedPAC staff also explained that the rationale is that they are specific, specialized plans for those with health needs and the policy is in place to provide beneficiaries access to specialized plans for those with health needs as soon as possible.
There was also worry that these plans help with the cherry-picking of beneficiaries, leaving other plans with lower patient populations resulting in fewer plan offerings.
The discussion ended with the Commissioners agreeing that the wide variety of plan options can make the process of picking one difficult to navigate, and some streamlining would be helpful. However, it was also agreed that this must be balanced with providing a variety of plan specifications so each beneficiary can find one that best suits their needs.
It looks like Congress continues to perfect the art of governing by deadline. With more than a dozen pieces of health care policy – often called health care extenders – expiring on January 30, 2026, House Appropriations Chair Tom Cole released bill text on January 20 for a minibus that includes these health polices and a whole lot more.
In this latest package, Congress is doing 3 things:
- They are extending the January 30 health care extenders, but not all for the same length of time
- They are authorizing new health programs but only temporarily – adding more health care extenders to the list
- They are also using this legislative vehicle for major policy reforms on pharmacy benefit managers (PBM) and organ drug exclusivity.
Health Care Policy Extensions by Date
So, let’s look at what health care policies Congress is extending. We list them by date of extension.
September 30, 2026
Tennessee disproportionate share hospital payments
December 31, 2026
Community health centers
National Health Services Corps
Temporary Assistance for Needy Families program
Public health emergency and national health security programs
No Surprises Act implementation and funding
Special diabetes programs
Personal responsibility education
Family-to-family health information centers
Medicare dependent hospitals
Low-volume hospital payment adjustment
Work geographic practice cost index floor
Medicare Part D coverage of certain authorized oral antiviral drugs
September 30, 2027
Medicare quality measurement support
December 31, 2027
Telehealth flexibilities
Medicare outreach and enrollment support
January 1, 2028
Ground ambulance add-on payments
September 30, 2028
Medicaid disproportionate share hospital payment cut delay
September 30, 2029
Teaching health center graduate medical education
September 30, 2030
Hospital at home waiver
March 1, 2033
Medicare sequestration begins
September 30, 2035
Adjustment to Medicare hospice aggregate cap (was already extended through September 30, 2033)
New Health Care Policy
Now, let’s look at 35 new health care policies Congress is authorizing.
Medicaid
- Streamlined enrollment process for eligible out of State providers – effective date is 3 years after enactment
- Removing certain age restrictions on Medicaid eligibility for working adults with disabilities – enactment after January 1, 2028
- Medicaid State plan requirement for determining residency and coverage for military families – effective beginning January 1, 2030
- State studies and HHS report on costs of providing maternity, labor, and delivery services – no later than 30 months after enactment and every 5 years thereafter for States; no later than 3 years after enactment and every 6 months thereafter for HHS
Medicare
- PBM reform
- Extending Medicare’s Advanced Alternative Payment Model incentive payments and maintain adequate qualifying thresholds
- Extending use of funds for Medicare hospice surveys through December 31, 2026
- Telehealth for in-home cardiopulmonary rehabilitation from January 31, 2026 – January 1, 2028
- Expanding definition of “aberrant billing patterns” for durable medical equipment – starting January 1, 2029
- HHS Inspector General report on clinical diagnostic lab tests at high risk for fraud – due no later than January 1, 2028
- Update guidance from HHS on telehealth for individuals with limited English proficiency – no later than 1 year after enactment
- Inclusion of virtual diabetes prevention program suppliers in the Medicare Diabetes Prevention Expanded Model from January 1, 2026 – December 31, 2029
- Outreach and education on medication-induced movement disorders – no later than January 1, 2028
- GAO report on wearable medical devices – within 18 months of enactment
- Adjustments to Medicare part D cost-sharing reductions for low-income individuals – starting in plan year 2028
- Strengthening Medicare Advantage provider directory accuracy requirements – starting in play year 2028
- Strengthening Medicare Advantage provider directory accuracy requirements – by plan year 2028
- Medicare coverage of multi-cancer early detection screening tests – beginning January 1, 2029
- Medicare coverage of external infusion pumps and non-self-administrable home infusion drugs – beginning the first calendar quarter that starts at least 1 year after enactment
- Any willing pharmacy requirement – starting plan year 2029
- Requiring a separate identification number and an attestation for each off-campus outpatient department of a provider – starting January 1, 2028
- Revising phase-in of Medicare clinical laboratory test payment changes
Public Health
- Funding adjustments for the World Trade Center program
- Maternal mortality best practices
- Organ Procurement and Transplantation Network reforms
- Federal living organ donor reimbursement program reforms
- Federal Program for Pediatric Studies of Drugs through Fiscal Year 2028
- Federal sickle cell disease program expansion through Fiscal Year 2030
- Lifespan Respite Care Program through Fiscal Year 2030
- PREEMIE network reauthorization through Fiscal Year 2030
- Dr. Lorna Breen health care provider protection extension through Fiscal Year 2030
Food and Drug Administration
- Changes application of orphan drug exclusivity to only the specific FDA-approved indication
- Expansion of pediatric cancer drug development
- Extension of rare pediatric disease priority review vouchers to September 30, 2029
- Establishment of Abraham Accords Office within FDA
Yes, that’s 35 new policies Congress is authorizing in this bill.
Congress keeps jamming authorizing policy into appropriations bills, using must-pass funding vehicles to avoid resolving whether certain Medicare, Medicaid, and Food and Drug Administration programs should be modified, terminated, or permanently authorized. Why does Congress keep doing this? That’s a whole thing, and clearly a topic to delve into another day.
What Now?
Including health care extenders in this appropriations minibus is welcome news for health care providers who rely on these programs. However, this bill still needs to get through both houses of Congress and signed by the President before it can get into law. We’ve seen Congress appear to be close to a deal before on health care extenders only to trip at the last minute (i.e. the deal that came together and failed in December 2024).
Regardless of the outcome of this package, keep this list of health policies handy. Our analysis will either become a list of new health extender deadlines – or – it will provide a roadmap of bipartisan, bicameral support for the next health care legislative package.
As we approach the one-year anniversary of President Trump taking office for the second time, we have just as many questions about what the next 3 years will look like as we did on day one. President Trump has already achieved one of his personal goals – a Nobel Peace prize – when Venezuelan opposition leader Maria Corina Machado gifted her Peace Prize medal during a White House visit. What else could President Trump check off from his bucket list? Let’s find out –welcome to the Week Ahead!
The Administration
President Trump released his Great Healthcare Plan which calls for lowering prescription drug prices and insurance premiums, and increasing transparency in health care costs and insurance benefits. The lack of details in the fact sheet creates more questions than it answers, but it’s clear the plan targets pharmacy benefit managers (PBMs) and health insurance companies, calling out those entities for deceptive practices and for accepting subsidies that the administration argues raise the cost of health insurance. Pharmaceutical companies are also under a microscope, with calls to codify most-favored-nation (MFN) pricing agreements and increase access to over-the-counter drugs. Many of the specific proposals in the plan, such as codifying MFN deals and PBM reform will require Congress to act. As we’ve seen, getting this Congress to act on health care is not easy, but getting the White House involvement is a necessary first step to unify the Republican majorities in both chambers.
The White House has promoted Farnoosh Faezi-Marian to Chief of the Health and Human Services (HHS) Branch at Office of Management and Budget (OMB). Faezi-Marian previously serviced as a Program Examiner at OMB, where she worked on budget development and execution for the Administration for Strategic Preparedness and Response. The promotion now has her leading the OMB office that is responsible for examining budget requests and making funding recommendations for HHS agencies so she will be an important voice in developing the President’s upcoming budget request to Congress for HHS.
The Senate
The Senate has left town without reaching an agreement on an extension of the enhanced advance premium tax credits (APTCs). The Open Enrollment period has already closed for most states, but a handful have deadlines to sign up for coverage through the end of January, which provides external pressure to reach an agreement. Senate Majority Leader Thune (R-SD) also previously told Punchbowl News that a deal would need to come together by the end of January, creating internal political pressure to move things along. Sen. Susan Collins (R-ME) who has been involved with negotiations on a bipartisan agreement has said negotiations will continue over the recess, but Leader Thune has cast doubt on the talks saying, “it doesn’t look like they’re close.”
The House
With the House scheduled to be out of session next week, it’s crunch time to pass the six remaining appropriations bills to avoid at least a partial government shutdown on January 30. Although reports indicate neither side wants another shutdown, the remaining bills are some of the trickiest. These include Labor-HHS, Defense, and Homeland Security. The House has been working to pass appropriations bills in the form of minibus packages, and we expect that to continue. However, the controversy over ICE involved shootings in Minneapolis has made many believe that Homeland Security funding may need to be passed through a continuing resolution (CR).
Adding to the frenzy, over a dozen health care extenders, including telehealth flexibilities, community health center funding, and more, are set to expire at the end of the month. These have often been tied to government funding bills, but the possibility of a minibus for most and a CR for the Homeland Security bill raises questions as to whether the House has the stomach to authorize a longer-term extension for health care extenders or if they will keep kicking the can down the road. Extending funding for a year or two could provide stability for crucial health programs but would require more discussion than a shorter-term funding decision.
The House Budget Committee is holding a hearing on Health Care Costs that will feature witnesses from the Foundation for Research on Equal Opportunity and the Council for Affordable Health Coverage, both of whom might as well have offices in the Capitol Building for how often they’ve appeared in the last 4 months. But while there has been a lot of testimony, we have not seen any legislation as a result.
Other Health Care Hearings This Week
- January 22: House Energy and Commerce Health Subcommittee hearing on health insurance affordability
- January 22: House Ways and Means Committee hearing with health insurance CEOs
There You Have It
With the NFL and College football playoffs happening, we’re seeing the season end for teams week after week. Are you prepared for the post-football seasonal depression? Let us know. Make it a great week!
