Insights^

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.

On January 8, 2026, the House Energy and Commerce Health Subcommittee held a hearing to examine 10 bills related to Medicare services, including clinical lab services, home infusion, oxygen therapy, and more. Many committee members were eager to take the next steps in the legislative process.

OPENING STATEMENTS

• Subcommittee Chairman Morgan Griffith (R-VA-09)

• Ranking Member Frank Pallone (D-NJ-06)

WITNESS TESTIMONY

• Ms. Susan Van Meter, President, American Clinical Laboratory Association – Testimony

• Ms. Connie Sullivan, President and CEO, National Home Infusion Association – Testimony

• Mr. Thomas Ryan, President and CEO, American Association for Homecare – Testimony

• Mr. David Lipschutz, JD, Attorney and Co-Director of Law and Policy, Center for Medicare Advocacy – Testimony

MEMBER DISCUSSION

H.R.1703, Choices for Increased Mobility Act of 2025

This legislation would require the Centers for Medicare & Medicaid Services to establish specific Medicare billing codes for certain materials used in ultralightweight manual wheelchairs.

Rep. John Joyce (R-PA-13) asked Mr. Ryan to explain the benefits of lighter-weight wheelchairs for patients. Mr. Ryan answered that patients suffer additional wear and tear when ambulating using a wheelchair, and when patients can use a lighter wheelchair, they suffer less.

H.R.2005, DMEPOS Relief Act of 2025

This bill would extend the higher payment rate, known as the 75/25 blended rate, for durable medical equipment in nonrural or noncontiguous areas under Medicare.

Subcommittee Vice Chair Diana Harshbarger (R-TN-01) asked how reimbursement cuts undermine Medicare’s goal of keeping patients safely at home and avoiding extra costs. Mr. Ryan stated that the service model has changed drastically over the years, with patients receiving equipment later and increasing the need for more equipment repairs.

Rep. Mariannette Miller-Meeks (R-IA-01) voiced support for the bill and asked how current reimbursement rates are affecting access to care. Mr. Ryan stated that durable medical equipment companies are reducing their offerings and using personal savings to sustain their business.

H.R.2172, Preserving Patient Access to Home Infusion Act

This bill provides technical clarifications that remove the requirement that a nurse be physically present in a patient’s home for providers to be reimbursed for home infusion drugs.

Subcommittee Ranking Member Diana DeGette (D-CO-01) stated that she felt this bill is a commonsense expansion of the 21st Century Cures Act.

Subcommittee Vice Chair Harshbarger voiced support for the bill and asked about the current process for patients seeking home infusion therapy. Ms. Sullivan stated that it becomes very difficult and almost impossible for Medicare patients.

Rep. Raul Ruiz (D-CA-25) expressed his support for the bill, noting its positive impact on his constituents. Rep. Ruiz then asked Ms. Sullivan to expand on how the bill would make home infusion a more dependable option for patients. Ms. Sullivan shared that, currently, patients are often placed in a skilled facility, and the bill would remove the barriers, stress, and burden that families and patients experience, allowing them to receive treatment at home.

Rep. Buddy Carter (R-GA-01) asked how home infusion pharmacies aid patients in receiving proper treatment at home. Ms. Sullivan answered that currently, Medicare only pays for these services when they take place face-to-face. She said that the bill’s expanded scope would ensure that pharmacies’ oversight of the benefit is useful. Additionally, she said that the bill would provide continuous support for both patients and physicians, which prevents patients from returning to the emergency room. She also stressed that this bill is important because Medicare patients often do not have this benefit covered in the same way that individuals with private insurers do.

Rep. Nicholas Langworthy (R-NY-23) asked how the legislation would keep patients on track with their treatment plans. Ms. Sullivan shared that home infusion is extremely efficient for patients, as support comes from a local pharmacy without providers needing to travel to the home for treatment.

H.R.2477, Portable Ultrasound Reimbursement Equity Act of 2025

This bill provides a separate payment for the transportation and setup services of portable ultrasound equipment.

Rep. Lori Trahan (D-MA-03) asked how important timely care is for fragile patients and how this legislation can support timely care. Mr. Ryan shared that he felt care in the home was where money should be going, and travel time reimbursement is needed for access to care, especially for medically fragile patients.

H.R.2902, Supplemental Oxygen Access Reform (SOAR) Act of 2025

This bill establishes certain requirements for the payment and provision of supplemental oxygen and related services under Medicare.

Rep. Troy Balderson (R-OH-12) asked how the SOAR Act can help address current industry issues. Mr. Ryan shared that suppliers are not currently able to support liquid oxygen requirements, and the bill would move portable oxygen out of the competitive bidding process, which would help to push innovation and new technology back in the sector. Mr. Ryan continued that while it would only affect a small group of patients, it would allow them to have a much greater quality of life.

Rep. Dwight Evans (D-PA-03) emphasized the need for accessible liquid oxygen and asked how patients are affected by the lack of access. Mr. Ryan shared that the service model for respiratory therapy has changed, and patients are suffering from poor quality of care.

H.R.5243, to amend title XVIII of the Social Security Act to increase data transparency for supplemental benefits under Medicare Advantage

This bill would require companies that offer Medicare Advantage plans to submit enrollee-level data on supplemental benefits to the Department of Health and Human Services (HHS). The bill would mandate reporting on data such as eligibility for supplemental benefits, the types of benefit categories offered, and utilization and payments for supplemental benefits. HHS would also be required to publish annual data reports.

Rep. Troy Carter (D-LA-02) questioned how individuals perceive supplemental benefits. Mr. Lipschultz shared that companies encourage people to enroll in plans because of their supplemental benefits. However, Mr. Lipschultz argued these benefits are often difficult to access or understand, and this legislation would provide better data to educate people about Medicare Advantage options.

H.R. 5269, Reforming and Enhancing Sustainable Updates to Laboratory Testing Services (RESULTS) Act of 2025

This bill aims to improve Medicare reimbursements for clinical laboratory testing. The act aims to ensure a Medicare Clinical Laboratory Fee Schedule (CLFS) rate- setting process that is representative of commercial market rates, reduce the administrative data collection and reporting burden on clinical laboratories, and limit future annual payment cuts to 5%.

Subcommittee Chairman Griffith asked about the proposed 11% payment cut to the complete blood count (CBC) test and how patient access would be affected if action is not taken. Ms. Van Meter shared that a CBC is the most common test ordered by providers, and the cut could lead to negative downstream effects due to reduced compensation.

Vice Chair Harshbarger asked what Ms. Van Meter expects for the next data collection cycle. Ms. Van Meter stated that a major flaw in the current system is that data from 2019 must be reported. Additionally, the training on how to report this has not been shared, which will cause issues for many clinical laboratories.

Chairman Guthrie asked Ms. Van Meter to describe the current reporting process. Ms. Van Meter shared that the data that originally determined Medicare reimbursement rates were much higher than private insurance rates was flawed and that the RESULTS Act would ensure that CMS had widespread, accurate data to properly set reimbursement rates. When asked about using an independent claims database, Ms. Van Meter said the data would come directly from private health plans and be representative of the entire field, providing CMS with widely representative, statistically significant data. Chairman Guthrie then asked about the importance of clinical innovation and how it supports patient access to care. Ms. Van Meter stated that clinical innovation drives personalized medicine as diagnostics are extremely important to determine the correct treatment, and with the current unstable payment system, there is no capacity to have long-term research and development of innovation.

Rep. Gus Bilirakis (R-FL-12) shared that he was very supportive of the legislation and asked about the effects of the bill on patients with rare diseases. Ms. Van Meter shared that patients and providers need access to both routine and rare disease tests to create the best treatment plans and prevent unnecessary deaths. Tests for rare diseases such as rapid genomic sequencing can yield actionable results for patients and families but innovation in the sector will be curtailed by deep price reductions.

Rep. Joyce voiced his support for the RESULTS Act, sharing that he believes it will support patient access to lab services and that under-reimbursement for laboratory tests poses barriers for seniors. Rep. Joyce asked Ms. Van Meter to speak on the impact of price cuts on access to clinical laboratory tests for patients. Ms. Van Meter said that cuts will lead to longer turnaround times, smaller test offering lists, decreased viability of laboratories, and reduced innovation in the sector.

Rep. Balderson emphasized the importance of data collection and asked if there was a chance we would be returning to Medicare paying higher rates than other insurers. Ms. Van Meter shared that the Office of Inspector General (OIG) report mentioned in her testimony lacked the level of data needed to set payment rates. The RESULTS Act would allow CMS to use a more comprehensive set of data and set Medicare rates more accurately.

Rep. Thomas Kean (R-NJ-07) asked about the urgency of reforming the schedule. Ms. Van Meter stated the cuts will begin on tests that beneficiaries rely on as of January 31, 2026. Rep. Kean questioned how innovations in biomarker tests provide hope for patients and families. Ms. Van Meter shared that they are the foundation for precision medicine to ensure the best treatments for a patient’s specific condition, and the current Medicare fee schedule negatively affects innovation due in the long-term.

Rep. Langworthy asked what the unique challenges are for rural communities for clinical lab testing. Ms. Van Meter shared that the infrastructure in rural communities is not ideal and could be compromised due to payment cuts, leading to longer turnaround times for results and a lack of access to services.

Rep. Jay Obernolte (R-CA-23) asked about the use of Artificial Intelligence (AI) in the clinical lab industry and how best to leverage it. Ms. Van Meter shared that leveraging AI tools for genomics and large datasets for diagnostics is common and continues to expand.

H.R.6210, Senior Savings Protection Act

This bill reauthorizes outreach and assistance programs under the Medicare Improvements for Patients and Providers Act (MIPPA) by extending funding for 5 years at the current levels. MIPPA grants funding for community-based organizations that provide in-person counseling, education, eligibility screening, benefit explanation, application and enrollment assistance, and outreach to promote Medicare enrollment.

Rep. Bilirakis voiced his support for the bill.

Rep. Doris Matsui (D-CA-07) asked how low-income subsidies and other programs help seniors afford their health care and how funds are used to help beneficiaries. Mr. Lipschutz shared that these programs help to reduce costs as well as give seniors cost-sharing options for the entire year. The funding connects beneficiaries with local organizations that can help them meet their needs.

H.R.6361, Ban AI Denials in Medicare Act

This bill would prohibit the testing of the Wasteful and Inappropriate Service Reduction (WISeR) Model and prohibit the implementation of payment models testing prior authorization under traditional Medicare.

Rep. Kim Schrier (D-WA-08) shared that one of the most common complaints she has from constituents is the denial of care, especially for those enrolled in Medicare Advantage. She said she is supportive of the legislation due to the high rate of inappropriate denials of care.

Rep. Greg Landsman (D-OH-01) voiced his worries that the WISeR model would soon be expanded to other types of care and that providers would be incentivized not to provide care. He questioned the panel on their knowledge of how the model would approve or deny authorization. Mr. Lipschutz shared that the only information known about the model is that 3rd parties will be incentivized to deny care to patients.

Rep. Jake Auchincloss (D-MA-04) voiced his support for this legislation and said he was working on additional legislation to place guardrails on prior authorization. Rep. Auchincloss asked whether current AI models learn from their mistakes, and Mr. Lipschutz said no: the model will continually deny authorized AI models learn from their mistakes, and Mr. Lipschutz said no: the model will continually deny authorized care.

On December 17, 2025, the Joint Economic Committee held a hearing on realigning health care incentives to improve outcomes and reduce costs. The committee was very interested in the ideas shared by the witnesses and in working together to find long-term ways to reduce health care costs.

WITNESS TESTIMONY

• Mr. Brooks Tingle, CEO, John Hancock Financial – Testimony

• Dr. Ed Clarke, Vice President, Chief Medical Officer of the Insurance Division, Banner Health – Testimony

• Mr. Avik Roy, Co-Founder and Chairman, The Foundation for Research on Equal Opportunity – Testimony

• Mr. Matthew Fiedler, Senior Fellow, Brookings Institution Center on Health Policy – Testimony

MEMBER DISCUSSION

Vice Chairman Eric Schmitt (R-MO) began the discussion by asking how policymakers can address families applying for coverage without immigration status verification. Mr. Roy responded that verifying social security numbers could improve program integrity across both income and immigration status verification. He also suggested basing subsidies on the previous year’s tax returns instead of estimated future income. To address the issue of overutilization, Mr. Clarke recommended the Banner Model, which manages a population. Mr. Clarke argued that this incentivizes preventive care and primary care to reduce costs.

Ranking Member Maggie Hassan (D-NH) asked Mr. Tingle to speak to the positives of preventive and primary care, specifically for cost reduction. Mr. Tingle shared that prevention and early detection are key to success, but his company also believes it has a responsibility to ensure its customers have access to advancements in screening and technology so they can use the information to inform decision-making. Ranking Member Hassan then asked how increased access to enhanced Advance Premium Tax Credits (APTCs) in the ACA marketplace can lead to better preventive care. Mr. Fielder responded that if an individual is uninsured, they have reduced access to care, especially preventive care, which can lead to higher costs down the road.

Rep. Nicole Malliotakis (R-NY-11) questioned how to incentivize better, healthier decisions to lower premium costs. Mr. Roy responded that the ACA prevents charging different premiums based on health status, which he argued can make it difficult to incentivize health in the short term. He recommended adopting the Swiss model, where, among other differences, health insurance plans span multiple years and refunds can be issued for improved health status. When Rep. Malliotakis asked about how to reduce predatory pharmacy benefit manager (PBM) practices, Mr. Fiedler shared that it is difficult since there is very little competition for PBMs. Fixing that, he said, is the first step to addressing the issue.

Rep. Gwen Moore (D-WI-4) expressed her frustration that the Congressional Budget Office (CBO) does not score preventive care well, which can make it difficult to craft legislation for preventive care. She questioned whether the large increase in premium prices could be traced to the ACA, but Mr. Fiedler responded that ACA marketplace premiums are comparable to private insurance premiums. He also shared that health care as a share of US GDP has remained steady over the last decade.

Sen. Ashley Moody (R-FL) asked the panel whether there should be a health care fraud czar to oversee the numerous health programs, but Mr. Roy felt that improving program structure overall would be more effective at reducing fraud.

Rep. Don Beyer (D-VA-08) asked Mr. Fiedler how he should respond to hospital arguments against site-neutral payment. Mr. Fiedler responded that he did not think the services targeted for site-neutral payments are any more complex in hospital settings than in other care settings, which he said was the main argument hospitals use. Rep. Beyer then asked how the US can move away from the employer-based insurance system. Mr. Roy shared that the best approach would be to create an individual market with affordable plans offering high-quality care, which employers can then help fund.

Sen. Amy Klobuchar (D-MN) requested that Mr. Fiedler share how extending the enhanced APTCs could impact competition. Mr. Fidler shared that tax credits allow more individuals to purchase care, thereby expanding the market. As a result, he said, more insurers enter the ACA market, which increases competition. Sen. Klobuchar then asked Mr. Clarke to explain how quality, affordable coverage leads to more preventative care. Mr. Clarke responded that rewarding physicians for improved patient outcomes, which can only be achieved through health insurance coverage, creates better incentives for primary care physicians to engage in preventive patient care.

Chairman David Schweikert (R-AZ) was curious about what has been the biggest success in incentivizing behavior change. Mr. Tingle responded that the biggest surprise is that behavior change is achievable with the correct incentives and that small prices, such as a $5 gift card, have incentivized the behavior change. In discussing ways to reduce health spending with Chairman Schweikert, Mr. Roy pointed out that while prevention can reduce costs, it can also lead to higher expenditure. Mr. Clarke favored a capitation model, but Mr. Fiedler suggested that a complete capitation model might result in reduced health services.

On December 11, 2025, the Medicaid and CHIP Payment and Access Commission (MACPAC) met for their December meeting. The Commissioners examined strategies for implementing the community engagement requirements which were signed into law under the One Big Beautiful Bill Act.

CONSIDERATIONS FOR IMPLEMENTING COMMUNITY ENGAGEMENT REQUIREMENTS: FINDINGS FROM STAKEHOLDER INTERVIEWS

MACPAC staff began by reviewing the community engagement requirements and current clarifications before sharing their findings from stakeholder interviews. The interviews were conducted between June and August of 2025 and included stakeholders such as CMS officials, state Medicaid directors, representatives of national advocacy organizations, and think tank staff.

One of the largest concerns raised by interview participants was how states will access community engagement data. For example, while free data sources are available, they are often not updated in a timely manner or provide aggregated data, making it difficult for state Medicaid agencies to comply with verification requirements. Paid data sources can be timelier but are also expensive. For example, it was reported that North Carolina’s contract with Equifax for its data set doubled from 2022 to 2025. Stakeholders have requested that Centers for Medicare and Medicaid Services (CMS) provide guidance on free data sources or enter into agreements to reduce costs for paid data sources.

Another major concern raised by stakeholders is the cost of IT infrastructure changes. These infrastructure changes are needed to adequately meet reporting requirements but can cause administrative budgets to balloon. For instance, Georgia recently saw 90% of administrative spending go towards IT infrastructure upgrades.

During Commissioner discussion, there continued to be concerns raised about the cost and requirements of implementing new IT structures. One Commissioner verified that state funds were still being matched at a rate of 10 to 90 for IT upgrades. There was also concern about how to best report verification data, especially for populations that may not have access to technology or digital tools. One suggestion was to look for ways to track and manage data that does not put the impetus on the individual to prove their exemption status or continued eligibility.

The opportunities for managed care organizations were also discussed, with multiple Commissioners highlighting how they have previously been critical to successful engagement with their members. Commissioners discussed continuing to explore how other similar partners could increase engagement, especially in maintaining timely data and finding a framework for effective monitoring.

One Commissioner emphasized the importance of understanding and comparing infrastructure and policy decisions across states to gain a clearer picture of how each state is managing the rollout. The Commissioner noted that this would become more important if some states see enrollment numbers drop drastically, and that it is important to pause and intervene to prevent large population segments from losing their health care coverage.

The Chair concluded the session by suggesting that the Commission should reexamine some rules and regulations regarding managed care plans and their role in helping individuals remain eligible.

EXPERT PANEL ON IMPLEMENTING COMMUNITY ENGAGEMENT REQUIREMENTS

MACPAC invited Lindsay Browning, Deputy Executive Director of Programs, National Association of Medicaid Directors, and Caprice Knapp, Principal Deputy, Center for Medicaid and CHIP Services, to answer questions from MACPAC staff and Commissioners.

The panel opened with questions from MACPAC staff. The first topic focused on what Ms. Browning and Ms. Knapp were hearing from states, as well as the deeper policy questions states have been grappling with. Ms. Knapp answered that CMS is seeing a lot of alignment with the responses MACPAC staff have reported from stakeholders, with the greatest emphasis on timelines and IT infrastructure. Deeper policy questions have related to how best to convert the data states can access into acceptable formats and how to partner with the respective Departments of Education. She emphasized that questions can be sent to medicaidreforms@cms.hhs.gov. Ms. Browning also noted alignment with interviews conducted by MACPAC staff, in which states emphasized concerns about member engagement. She also said she has been receiving policy questions about differential impacts of the community work requirements between states and how states can best show a clear paper trail for future audits.

When asked about which areas state agencies are seeking additional federal guidance, Ms. Browning emphasized the need for states to receive early signals from CMS about future guidance. More clarity on where CMS will be specific or flexible with implementation requirements, what the minimum product looks like for IT solutions, and data reporting expectations were also of interest. Ms. Knapp did not provide a clear answer on what additional guidance states could expect from CMS before June 2026. She did highlight the monthly informational calls and all state calls that CMS intends to continue as good sources of information and early signaling.

Ms. Browning was also asked about what lessons from the recent unwinding of the Public Health Emergency (PHE) could be applied to the rollout of the community engagement requirements, Ms. Browning made it clear that while there are similarities, the new community engagement requirements are not an established body of policy that can be examined; instead, decisions are being made now and in the future. That said, she feels that the increased automation of eligibility policies and the advancement of community engagement structures in the unwinding were helpful. Ms. Knapp emphasized the importance of outreach and vendor and managed care plan engagement for being successful.

Answers to questions about monitoring implementation and data collection emphasized minimizing the burden on states by clarifying what needs to be reported and creating a list of a reasonable number of measures. Building on existing systems and adopting a collaborative approach with CMS were listed as strategies for long-term implementation success.

The floor was then opened for Commissioners to ask questions directly, starting with what states are seeing as initial priorities. Ms. Knapp shared that, in her experience, states are seeking guidance on the minimum viable product for data reporting and clarification on qualifying events and medical fragility exemptions. Ms. Browning reported that states are most concerned with verifying employment, income, and education, with discussions about expanding to the volunteering category to take place later.

A couple of Commissioners raised concerns about how CMS will evaluate whether states are prepared to roll out the new requirements. Ms. Knapp assured questioners that both IT and policy readiness review parameters are in place. CMS is also working with states that are choosing to start implementation early, allowing them to avoid disenrolling individuals through a hold-harmless period. CMS can also step in and put a state on pause if there are unexpected events, such as large numbers of disenrollments.

When asked how MACPAC can be helpful to states and CMS during the lead-up to January 2027, Ms. Browning emphasized recommendations on outcome measurement, specifically identifying a small set of meaningful measures to best monitor and track eligibility requirements. Other recommendations about member outreach were also suggested.

The cost of IT infrastructure procurement was also discussed, with Commissioners wondering how states can keep costs down. Ms. Knapp emphasized that Administrator Oz was meeting with vendors to figure out solutions to high procurement costs, especially for systems that multiple states would be interested in. Ms. Browning raised the need for continued evaluation of data source costs, specifically for states finding high-value data from lower-cost sources.

On December 10, 2025, the Senate Committee on Homeland Security Subcommittee on Investigations held a hearing on principles to fix healthcare. Democratic Senators focused on the need to extend the enhanced Advance Premium Tax Credits (APTCs) while Republicans were firm that the Affordable Care Act (ACA) needs a complete overhaul.

OPENING STATEMENTS

• Chairman Ron Johnson (R-WI)

WITNESS TESTIMONY

• Mr. Christopher Briggs, Obamacare Enrollee – Testimony
• Mr. Nick Stehle, Obamacare Enrollee – Testimony
• Mr. Joel White, President, Council for Affordable Health Coverage – Testimony
• Mr. Tarren Bragdon, President and Chief Executive Officer, Foundation for Government Accountability – Testimony
• Mr. Dan Jacobs, Small Business Owner and ACA Marketplace Enrollee – Testimony
• Mr. Aaron Lehman, Farmer and ACA Marketplace Enrollee – Testimony

MEMBER DISCUSSION

Sen. Rick Scott (R-FL) stated he understands how important it is for people to have access to health care they can afford, which is why he has introduced S.3264, a bill that would establish HSA-style accounts through which individuals could purchase health care. Mr. White was in support of the bill, indicating that it will help the small business market. Mr. Bragdon was also in support of the bill, stating, “putting money in patients’ pockets is transformative.”

Sen. Bernie Moreno (R-OH) stated that only a small percentage of Americans are affected by the expiration of APTCs, and therefore, said more work needs to be done to reduce costs for all Americans. Some ideas he shared were increased transparency in health care costs, the use of association health plans, and reforms of certain practices by pharmacy benefit managers (PBMs).

Sen. Elissa Slotkin (D-MI) shared that while the ACA is not perfect, it did provide affordable coverage for people with pre-existing conditions. She also said she is not willing to take away enhanced ATPCs while Congress considers other policies to improve the affordability of health care.

Ranking Member Richard Blumenthal (D-CT) asked Mr. Lehman to share his recent experience shopping for a health care plan. Mr. Lehman indicated that seeing the rise in premiums resulted in intense sticker shock, which has made him and other farmers he represents nervous about how they will afford coverage. Ranking Member Blumenthal asked Mr. Jacobs how not extending APTCs would affect his business. Mr. Jacobs expressed concern about how the rise in premiums will lead to less consumer spending, especially in the service industry, and he is expecting many small businesses to close as a result. Ranking Member Blumenthal indicated that he would like to tackle additional health care challenges, but APTC extension is on a tight timeline that needs to be addressed immediately.

Chairman Johnson was strongly opposed to extending APTCs, repeating that now the subsidies are returning to the rates that were originally set in the ACA. He is in support of returning to the high-risk pool model for individuals with pre-existing conditions, feeling that it provides a good option to receive health insurance. Chairman Johnson asked Mr. White about the rise in insurance company’s stock prices and how to drive down health care costs. Mr. White shared that the increase in the stock price was directly correlated with the increase in the premium price. Mr. White indicated that the only way to decrease costs was to bring consumerism back to health care. Mr. Bragdon also supported the statement, saying that without consumerism, there is no incentive to reduce costs.

Chairman Johnson asked Mr. Lehman and Mr. Jacobs what percentage of their income an individual pays for health insurance before a subsidy should begin to apply. Mr. Lehman did not have an exact figure in mind, and Mr. Jacobs responded that he “is not a policy maker” and is “a bad person to ask” because he “would rather pay more so people who make less can have better health care.”