Insights

On January 29, 2026, the Medicaid and CHIP Payment and Access Commission (MACPAC) met for its January meeting. The Commissioners heard a presentation from MACPAC staff on considerations for implementing community engagement requirements passed in the 2025 reconciliation legislation, before discussing the draft principles and policy recommendation to be included in their June report to Congress. The Commissioners were supportive of the draft principles but had suggestions for improving the draft policy recommendation.

The session began with MACPAC staff providing an overview of the community engagement requirements. MACPAC staff presented 4 draft principles from research with stakeholders: The Centers for Medicare and Medicaid Services (CMS) should provide timely federal guidance and technical assistance to states, CMS and states should ensure that eligible individuals can gain and maintain coverage, CMS and states should prioritize efficiency when procuring, updating, and operating state information technology (IT) systems, and CMS and states should use timely monitoring and evaluation data to inform policy and operations. MACPAC staff then presented a policy recommendation on monitoring and evaluating community engagement requirements in Medicaid, which reads “The Secretary of the U.S. Department of Health and Human Services (HHS) should direct the CMS to develop a transparent plan for monitoring and evaluating community engagement requirements in Medicaid that provides insight into how such policies affect eligibility and enrollment, health status, employment, and the attainment of other identified policy goals. CMS should identify new metrics for state reporting, as needed, and build upon existing data collection activities to minimize administrative burden. Additionally, CMS should ensure the timely publication of monitoring and evaluation results to inform policy and operational decision making.”

All Commissioners agreed with the presented principles, feeling that they properly addressed implementation concerns. For the first principle, one Commissioner suggested adding an implementation readiness checklist developed by CMS to assist states in their internal evaluation of readiness by the end of 2026.

Commissioners raised more concerns about the policy recommendation. A couple of Commissioners felt MACPAC should recommend statutory changes for monitoring and evaluation instead of the proposed recommendation for HHS to direct CMS. Multiple Commissioners expressed support for including language about assessing the costs and benefits of implementation on the Medicaid population. Some possible measures raised include time spent on requirement appeals, time spent uninsured, and the rate of increased work experiences. In response, a few Commissioners pointed out that while these measures are helpful data points, collection may be difficult as CMS does not currently have a way to measure them. Some Commissioners requested that more specific language than “health status” be included in the policy recommendation, feeling that it was too broad a category. MACPAC staff requested that Commissioners share their thoughts on what specifics to include.

A few other suggestions were raised by Commissioners. One Commissioner wanted more language encouraging automated processes to help beneficiaries demonstrate community engagement and to evaluate alternatives to wet signature requirements on paperwork, due to concerns that they create an undue burden. Another Commissioner suggested that CMS solicit a request for proposals (RFP) for research and evaluation of the impacts of community engagement requirements. Lastly, a Commissioner indicated a need to better understand the beneficiary population that will still receive benefits, citing concerns that they will be higher risk and have greater health needs, which might result in the policy not producing the expected cost savings.

On January 22, 2026, the House Energy and Commerce Health Subcommittee and the House Ways and Means Committee held hearings to investigate commercial health insurance costs. There was bipartisan agreement in both hearings that U.S. health care spending is high and that the rate of return for the American people is far short than what it should be. The insurance companies CEOs tended to agree but also cited growing health care demand and the rising cost of health care services as reasons for increased health insurance costs. There were also concerns raised by members on both sides of the aisle about consolidation and integration as well as concerns about improper denials of care. However, members on both Committees divided along familiar lines about the impact of the Affordable Care Act (ACA) and the enhanced advance premium tax credits (APTCs) on health care affordability. The leadership of both Committees have said today’s hearings are just the first step into looking into concerns about rising health care costs.

OPENING STATEMENTS

• House Energy and Commerce Health Subcommittee Chairman Morgan Griffith (R-VA-09)
• House Energy and Commerce Health Subcommittee Ranking Member Diana DeGette (D-CO-01)
• House Energy and Commerce Chairman Brett Guthrie (R-KY-02)
• House Energy and Commerce Ranking Member Frank Pallone (D-NJ-06)
• House Ways and Means Committee Chairman Jason Smith (R-MO-8)
• House Ways and Means Committee Ranking Member Richard Neal (D-MA-1)

WITNESS TESTIMONY

• Mr. Stephen Hemsley, CEO, UnitedHealth Group – Testimony
• Mr. David Joyner, Chairman and CEO, CVS Health – Testimony
• Ms. Gail Boudreaux, President and CEO, Elevance Health – Testimony
• Mr. David Cordani, President, CEO, and Chairman of the Board, The Cigna Group – Testimony
• Mr. Paul Markovich, President and CEO, Ascendiun – Testimony
• Ms. Ellen Allen, Executive Director, West Virginians for Affordable Health Care (Energy and Commerce Health Subcommittee Witness) – Testimony
• Ms. ReShonda Young, Resident of Waterloo, IA, and Owner, TnK Health and Nutrition (Ways and Means Committee Witness) – Testimony

MEMBER DISCUSSION

ACA and Enhanced APTCs

Republicans argued that the ACA did not make health care more affordable and that APTCs papered over the rising cost of health care and have driven fraud and improper enrollment in the marketplace. Democrats countered that the ACA, while not perfect, has helped millions get health insurance coverage and accused Republicans of using the hearing to distract from the fact that they allowed the enhanced APTCs to expire. Regarding fraud, Rep. Lloyd Doggett (D-TX-35) criticized Republicans who have cited a Government Accountability Office (GAO) report on the risk of fraud associated with the enhanced APTCs, saying that fraud was committed by insurance brokers, not enrollees. Rep. Adrian Smith (R-NE-03) later noted that both fraud and improper enrollment associated with enhanced APTCs need to be dealt with.

Vertical Integration and Consolidation

One of the most common topics brought up by the committee members was consolidation and vertical integration. Rep. Diana Harshbarger (R-TN-01) raised concerns about companies steering patients to their own clinics to increase profits, but Mr. Hemsley and Mr. Joyner both shared that their companies see integration as a way to provide better value and consumer experience while addressing the challenges of health care fragmentation. Rep. John Joyce (R-PA-13) asked the panelists if highly consolidated markets make it harder to contract competitive rates with insurance companies, which all panelists agreed. Rep. Lori Trahan (D-MA-03) questioned why consumers should believe that consolidation lowers costs, to which none of the panelists had an answer. Rep. Trahan continued, sharing that research has shown that consolidation raises prices.

During the House Ways and Means hearing, Chairman Jason Smith (R-MO-8) kicked off his questioning by asking insurance company CEOs to raise their hands in response to questions about employing providers, owning pharmacies, and owning pharmacy benefit managers (PBMs). When many of them raised their hands, Chairman Smith noted his concerns about how integration and consolidation have not led to reduced premiums. Other members of the Committee, on both sides of the aisle expressed similar concerns.

HSAs

Energy and Commerce Committee Ranking Member Pallone (D-NJ-6) asked Ms. Allen if a health savings account (HSAs) containing a few thousand dollars would be more helpful than an extension of APTCs. Ms. Allen replied that a few thousand dollars would only amount to 1 month of premiums, making it much less helpful for affordability. Rep. Lizzie Fletcher (D-TX-07) asked the panel if HSAs could be used to pay premiums, to which all panelists responded no. Rep. Kat Cammack (R-FL-03) suggested passing legislation to allow premiums to be paid with HSA funds. Rep. Cliff Bentz (R-OR-02) highlighted that HSAs would allow patients to earn interest on the money instead of health insurance companies earning interest on premium subsidies.

Pharmaceutical Industry and PBMs

Multiple members raised concerns about the pharmaceutical industry and the need for PBM reform. Rep. Erin Houchin (R-IN-09) wanted the panel to clarify how PBMs and group purchasing organizations (GPOs) can be so profitable if they claim to pass savings onto patients, but no panelist answered. Rep. Mariannette Miller-Meeks (R-IA-01) was interested in why many GPOs are headquartered internationally and suggested the committee look at future legislation to address it. Rep. Jake Auchincloss (D-MA-04) questioned the reasoning for UnitedHealth Group to have both a PBM and a GPO but Mr. Hemsley did not provide a clear answer. Rep. Auchincloss requested that the committee investigate how PBMs and GPOs function.

Prior Authorization and Claim Denial

Many committee members questioned the high rates of claim denials for UnitedHealth Group. Rep. Debbie Dingell (D-MI-06) and Rep. Nanette Diaz Barragan (D-CA-44) requested that Mr. Hemsley explain why analysis indicates that UnitedHealth Group denies 33% of claims, which is the highest rate in the United States. Mr. Hemsley responded that internal reports indicated only 2% of claims are denied. Rep. Kim Schrier (D-WA-08) asked why Medicare Advantage plans will often deny or delay paying claims for services already rendered that have been deemed necessary by medical professionals. Mr. Hemsley stated that patients should receive care that medical professionals feel is appropriate. Rep. Robin Kelly (D-IL-02) was interested in knowing if UnitedHealth Group uses AI to deny claims, but Mr. Hemsley assured the members that AI is only used for administrative purposes such as gathering documents.

During the Ways and Means Committee hearing, members on both sides of the aisle also brought up concerns about improper prior authorization. Members such as Reps. Mike Thompson (D-CA-4) and Greg Murphy (R-NC) expressed frustrations about patients being improperly denied care. Rep. Murphy even went so far as to say that if he had his way he would make all of them nonprofit because in his view, insurance companies put made profit over patients. Rep. Thompson asked a similar question about the use of AI for prior authorization as Rep. Robin Kelly did during the Energy and Commerce hearing and got similar answers. He said something needed to be done, because all he hears from doctors in is district is about improper denials. Rep. Mike Kelly (R-PA-16) mentioned his Improving Seniors’ Timely Access to Care Act. Rep. Linda Sánchez (D-CA-38) said she believes insurers should be penalized for denials if they are overturned. Rep. Jimmy Panetta (D-CA-19) asked if the insurance CEOs would support legislation such as his Requiring Enhanced and Accurate Lists (REAL) Health Providers Act, which would require insurance companies to update their network directories annually. The CEOs all said they are committed to working on the issue of network accuracy. Approaching things from a different angle, Rep. Terri Sewell (D-AL-7) expressed concerns about the impact of claims denials on rural providers.

Other Medicare Advantage Concerns

During the Ways and Means Committee hearing, members on both sides of the aisle also brought up other concerns related to Medicare Advantage beyond just improper denials. Rep. Doggett brought up his concerns that insurance companies are getting paid for providing care to Veterans on Medicare Advantage plans when the Department of Veterans Affairs (VA) already pays for that care. Rep. Doggett mentioned legislation to address that, and Rep. Thompson also expressed support for that bill. Rep. David Schweikert (R-AZ-1) expressed concerns about the Medicare Payment Advisory Committee (MedPAC) findings that Medicare Advantage costs more than traditional Medicare, and he asked the CEOs about how to get Medicare Advantage back to being a system that would incentivize better outcomes and lower costs. Mr. Hemsley took issue with MedPAC’s estimates but said he would be happy to work to improve Medicare Advantage.

Health Affordability Improvements

When asked by Rep. John James (R-MI-10) if they felt health care is affordable, none of the panelists agreed. Rep. Nick Langworthy (R-NY-23) asked what steps each company was taking to lower premiums for their members. Mr. Hemsley shared that UnitedHealth Group is focused on managing costs, providing better care coordination, and using a value-based care reimbursement model. Mr. Joyner said that CVS remains committed to improving the health status of population they serve, which they do through prevention, access to low-cost therapies and reimbursing on an outcomes-based model. Ms. Bourdeaux shared that Elevance Health is improving their prior authorization process to reduce complexity, is committed to reducing fraud, waste, and abuse, and is reimbursing for value and outcomes.

Other Topics

• Rep. Vern Buchanan (R-FL-16) expressed his support for preventive health care (including the need to ensure access to healthy food).

• Rep. Doggett asked the Committee’s leadership to ask Centers for Medicare and Medicaid Services (CMS) Administrator Dr. Oz to testify about the Trump administration’s decision to reinstate certain insurance brokers who had committed fraudulent activity.

• Several members, on both sides of the aisle, expressed concerns that insurance company stocks and executive compensation have risen, even though access to affordable care and health care outcomes have not improved.

• Rep. Murphy expressed frustration that in his view, insurers are fraudulently keeping money that should be due to providers under the No Surprises Act.

• Reps. Judy Chu (D-CA-32) and Brad Schneider (D-IL-10) expressed concerns about the impact of decisions by Health and Human Services (HHS) about vaccine recommendations for children on vaccine access. All the insurance company CEOs said they were not planning on making changes to their coverage policies for vaccines.

• Several members of Congress expressed concerns about the impact of health insurance costs on rural communities. In response to a question from Rep. Michelle Fischbach (R-MN-7), Mr. Hemsley said challenges in access to care in rural communities lead to higher insurance costs.

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.