Trump administration pressed on details of drug price deals

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https://www.axios.com/2026/02/03/trump-drug-price-deals-pfizer-eli-lilly

The Trump administration is facing new pressure to disclose details about its confidential pricing agreements with big drug companies and whether they meaningfully lower costs for patients.

Why it matters: 

President Trump has touted the “most favored nation” drug pricing deals as one of his signature accomplishments, but most of the details have been kept under wraps, including how the new prices are calculated.

Driving the news: 

The advocacy group Public Citizen filed a Freedom of Information Act suit last week, seeking the text of the deals the administration struck with Eli Lilly and Pfizer.

  • Those and other agreements were touted in high-profile Oval Office ceremonies as a step toward lowering U.S. drug prices and aligning them with what’s paid in other developed countries.
  • The deals have been described in broad terms, but questions remain about basic matters like what exactly the companies agreed to.
  • The administration is “shaking hands with pharma CEOs and telling us they fixed drug pricing and then not disclosing any text,” said Peter Maybarduk, access to medicines director at Public Citizen. “It makes it hard to believe, makes it hard to understand, makes it hard to assess.”

Congressional Democrats also wrote to Pfizer, Eli Lilly, AstraZeneca and Novo Nordisk in December asking for details of their respective agreements.

  • The letter to Pfizer said the company and the administration seem to be “attempting to shield themselves from oversight, accountability, and specifics that could inform consumers about whether this agreement will save money.”
  • An administration official said: “Because the drug pricing agreements contain confidential, proprietary and commercially sensitive information, they will not be released publicly.”
  • None of the four companies provided more details when asked about the agreements. A Novo Nordisk spokesperson said “this agreement will bring semaglutide medicines to more American patients at a lower cost,” referring to the active ingredient in its blockbuster weight-loss drugs.

Between the lines: 

The deals would for the most part not lower existing drug prices for a huge segment of the public that gets coverage through Medicare or workplace insurance.

  • Instead, the most-favored nation prices would apply to Medicaid. One unanswered question is how much lower would those prices be, since drugmakers already are required to have low prices for Medicaid.
  • The deals also anticipate most-favored nation prices for newly launched drugs in future years. But it’s not fully clear how that would work, since drugs are usually launched in the United States first and there wouldn’t yet be prices abroad to use as a comparison.
  • There would also be discounted drugs sold through the government’s direct-to-consumer website TrumpRx. But the portal is built around cash purchases, which many cannot afford.

The big picture: 

Trump has railed against what he calls “global freeloading” and ending the way the U.S. pays more for drugs than other developed countries. But policy experts have questioned whether manufacturers will only meet him halfway, raising prices abroad without cutting them in the U.S.

  • “You can kind of see why the pharmaceutical industry wouldn’t be so opposed if what they end up getting is maybe a slightly lower price in the U.S. and higher prices in other countries,” said Juliette Cubanski, deputy director of the Program on Medicare Policy at KFF.
  • The Trump administration has also proposed new payment models to incorporate most-favored nation pricing into Medicare, which would lead to savings.
  • But the changes are tests that would only apply in certain geographic areas, and analysts say they would not have a drastic impact on Medicare spending.

The bottom line: 

Maybarduk, of Public Citizen, acknowledged that the goals of the drug pricing efforts are laudable, even if the practical effects remain unclear.

  • “The thing that we agree with here, of course, is that Americans pay too much for drugs, and we pay more than other countries for drugs.”

What is “Medically Necessary”?

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https://healthcareuncovered.substack.com/p/what-is-medically-necessary?utm_source=post-email-title&publication_id=255152&post_id=185846351&utm_campaign=email-post-title&isFreemail=true&r=59t65&triedRedirect=true&utm_medium=email

How Big Health Insurers hijacked a medical term and built a denial machine around it.

We hear the term “medically necessary” used every day by insurance companies as a reason to deny or delay health care. While doctors were hard at work treating patients, insurers quietly co-opted the term, and that’s causing serious problems now.

If you ask most doctors to define ‘medically necessary,’ you’ll get some version of: “The test, therapy, drug or procedure that will do the best job of treating my patient.” It’s that simple: whatever is best for my patient.

If you ask an insurer, you may get some legal definition about care “provided for the cure or relief of a health condition, illness, injury or disease (looks good so far, but wait there’s more!), and is not for experimental, investigational or cosmetic purposes and is necessary for and appropriate to the….” The problem begins with the meaning of “necessary and appropriate.”

The terms ‘necessary’ and ‘appropriate’ are left to interpretation. My doctor may feel that a certain test or medication is necessary and appropriate, but someone else may disagree. So how do insurers resolve that disagreement? This is where things go off the rails.

They resolve it by having a medical director they employ review what my doctor wants for me – and that medical director becomes the sole arbiter of what care I can have that will be covered by my health plan. That medical director can sign off on a denial of a claim or a request, and many times they justify that denial by saying the treatment isn’t medically necessary – for reasons that are entirely defined by the health plan.

It seems a clear conflict of interest when an anonymous medical director – possibly lacking in both expertise and experience – rejects a course of treatment laid out by a physician specializing in that disease or condition who has a history with that particular patient. But it happens all the time.

These medical directors work for the company that is denying the claim or request. They have been granted stock and stock options in that company. Their bonus is tied to the financial performance of the company. To say they are impartial and doing what is best for the patient is laughable at best.

Frequently, these medical directors are reviewing requests in areas outside their specialty. In addition, they make these determinations without ever seeing the patient, or reviewing the medical records, studies or lab results that led the treating physician to make the recommendation in the first place. An investigation by ProPublica found that Cigna medical directors were signing off on denials once every 1.2 seconds. This isn’t clinical review; this is profit enhancement.

This brings us to another problem: “coverage policies.” Insurance corporations have created a whole library of coverage policies, and they differ from health plan to health plan. If you’ve never read one of these coverage policies let me save you some time and trouble. Get up now and place your head between the door and the door jam. Now slam the door. You just achieved the headache and confusion that reading a long coverage policy would give you in a fraction of the time. You’re welcome.

Even if you read the policy and think it’s got you covered, you still aren’t home free. A medical director can overrule the policy and still deny the care. Also, that coverage policy may be different for each health plan, and they change from time to time. I am struck by this basic question: Why should the care you receive depend on the insurance card in your wallet and not your clinical situation? The answer, of course, is because that’s how the insurance companies want it.

So, what do we do about this? Let me give you two relatively easy solutions.

First, follow a coverage policy.

If only there was a group of doctors that represented every specialty, we could get them to meet and determine universal coverage policies that could be mandated for all health insurance, both government and commercial. Wouldn’t that be nice? Doctors could then provide good care to patients without having to figure out a library of different coverage policies. Wait, a group like that does exist. It’s called the RUC.

The RUC (Relative Value Scale Update Committee) is an American Medical Association specialty panel, a volunteer group of 32 physicians and over 300 physician advisors who represent every medical specialty. The committee evaluates thousands of individual services across the medical spectrum. Why don’t we ask them to develop a universal set of clinical coverage policies?

Second, fix the denial system. Pass a law that says whenever an insurer denies payment or a request for care, that denial must be signed by a medical doctor, and signing that denial qualifies as “the practice of medicine.” This would make those denials and the doctor who signed off on them subject to all the responsibilities and accountabilities required to practice medicine.

This includes:

  • having an active license in the state where the patient is seeking care; practicing within your specialty;
  • documenting your decision-making in the patient’s medical record, including the information you reviewed to come to your decision; and
  • being liable for malpractice if your decision causes harm to the patient and is not clinically justified.

Let’s assume we had this in place right now and applied it to a real-world situation: the GLP-1 coverage debate. When these glucagon-like peptide-1 drugs for diabetes and weight loss came to market they would have gone before the RUC for a clinical coverage policy. Let’s say the RUC determines that the drugs should be covered for individuals with a BMI over 30 who have tried and failed other diet programs, or for people with a BMI between 25 and 30 who have significant cardiac risk or are diabetic.

Now we have a universal coverage guideline. The doctors prescribing the drug have a very clear understanding of who will be covered and when, and it would apply to all patients regardless of which insurance company they had. As long as the prescribing physician stays inside the guidelines, no denials would be expected.

Let’s take an example from the flip side. A doctor wants to prescribe an expensive chemotherapy regimen to an elderly patient with cancer. The insurer could have that request reviewed and possibly denied by a medical director. However, that medical director would need to be an oncologist with a valid license in the state where the patient is getting treatment. If that oncologist reviews the patient information, denies the chemotherapy for valid clinical reasons, and documents those reasons in the patient’s chart, then the insurer can deny the request.

These two changes would eliminate so many problems, improve the lives of doctors, improve the lives of patients, and reduce administrative costs.

So why hasn’t this been done already? Well the one thing these changes would not do is increase the stock prices of insurance companies.

To put it more succinctly, it’s profits over patients. That’s why.

Senate Judiciary: UnitedHealth Turned Medicare Advantage Risk Adjustment Into a Profit Engine

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https://healthcareuncovered.substack.com/p/senate-judiciary-unitedhealth-turned?utm_source=post-email-title&publication_id=255152&post_id=186238639&utm_campaign=email-post-title&isFreemail=true&r=59t65&triedRedirect=true&utm_medium=email

A new report from the Republican-led Senate Judiciary Committee describes how UnitedHealth Group has turned a safeguard for sick patients in the Medicare Advantage program into a profit-making strategy.

The report, How UnitedHealth Group Puts the Risk in Medicare Advantage Risk Adjustment, details how Medicare Advantage (MA) payments (seemingly designed to compensate health insurers more for enrolling patients with greater health needs) have increasingly rewarded insurers with the resources, data and scale to capture and maximize diagnosis codes. According to the committee, UnitedHealth Group has leveraged its size, vertical integration and advanced data and AI capabilities to consistently stay ahead of efforts by the Centers for Medicare & Medicaid Services to curb excess payments tied to coding intensity.

Read the U.S. Senate Judiciary Committee’s How UnitedHealth Group Puts the Risk in Medicare Advantage Risk Adjustment here.

After reviewing more than 50,000 pages of internal UnitedHealth documents, Judiciary Committee investigators found that the company built a vast diagnosis-capture infrastructure that includes in-home health risk assessments, secondary chart reviews, “pay-for-coding” arrangements with providers, and tightly controlled clinical workflows within UnitedHealth-aligned medical practices. These efforts, the report states, go well beyond neutral documentation and instead amount to an aggressive strategy to maximize risk scores and, by extension, federal payments.

The committee, chaired by Sen. Chuck Grassley, (R-Iowa), warns that even when CMS attempts to rein in abuse (such as excluding more than 2,000 diagnosis codes from the risk-adjustment model) UnitedHealth appears uniquely positioned to identify new, untapped diagnoses among the thousands that remain. Because UnitedHealth also sells its diagnostic criteria, coding tools and workforce to rival insurers, its strategies can quickly spread across the entire Medicare Advantage market.

The report concludes with this:

While Senator Grassley’s staff will continue to evaluate the information produced by UHG, this initial review has revealed how UHG has been able to profit from the way that CMS risk adjusts payments to MAOs. The investigation has also shown that risk adjustment in MA has become a business in itself—by no means should this be the case. MAOs should receive payments that are commensurate to the complexity and acuity of the Medicare beneficiaries that they insure, not their knowledge of coding rules and their ability to find new ways to expand inclusion criteria for diagnoses. Taxpayers and patients deserve accurate and clear-cut risk adjustment policies and processes.

But what makes these findings especially notable is who commissioned the investigation in the first place. Grassley was one of the original architects and longtime champions of Medicare Advantage when it was enacted back in 2003. In recent years, he now warns that the program’s “promise of efficiency and choice” has been undermined by vertical consolidation, blinded oversight and systemic risk-code gaming.

In past inquiries — spurred by reporting from outlets like The Wall Street Journal and findings from the Health & Human Services’ Office of Inspector General — he has demanded answers from UnitedHealth over the use of in-home assessments and chart reviews that allegedly drove billions of dollars in additional payments to the company.

Continuing the bipartisan scrutiny of MA insurers, CMS recently released its proposed payment rates for MA plans in 2027. Notably, CMS is proposing to exclude diagnosis codes added to a patient’s chart during chart reviews by AI or insurers from their risk score; something many reform advocates and I have long supported. These changes and this investigation are important steps in reining in the abuses by MA insurers and reason for hope we are on the right track.

If The House Votes for Senate-Approved Spending Package, PBM Reform Becomes Law

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https://healthcareuncovered.substack.com/p/if-the-house-votes-for-senate-approved?utm_source=post-email-title&publication_id=255152&post_id=186639784&utm_campaign=email-post-title&isFreemail=true&r=59t65&triedRedirect=true&utm_medium=email

As early as today, the House of Representatives is expected to vote on a government funding package (approved by the U.S. Senate last Friday) that includes long-sought reforms to pharmacy benefit managers (PBM) – pharmaceutical middlemen, the biggest of which are owned by just three health insurance conglomerates – that sit between patients and their prescriptions.

None of this happened over night. PBM reform – even in the health care advocacy world – has only recently become a bi-partisan, winning issue. PBMs were largely only known to pharmacists, other middlemen, health-policy wonks and the small but mighty circle of advocates who understood how they squeeze patients and independent pharmacies and funnel profits back to Big Insurance. PBMs began life as intermediaries meant to negotiate lower drug prices on behalf of consumers, but over time their role changed as they huge profit centers for insurers like UnitedHealth, Cigna and Aetna merged with or created their own PBMs – which now control more than 80% of the PBM business in the country.

This monopolistic-evolution captured the attention of policymakers and watchdogs after HEALTH CARE un-covered and reform advocates began to raise the alarm about PBM abuses and profiteering.

The need for PBM reform was one of the reasons I started the Lower Out-of-Pockets (LOOP NOW) Coalition, in 2021. Over the years, the LOOP NOW Coalition, along with its 100 partner organizations, have worked to educate lawmakers about how PBMs restrict access to life-saving medications and contribute to the U.S. medical debt crisis. The coalition has endorsed legislation to ban several PBM business practices, like spread pricing, and to force PBMs to be far more transparent, especially in their dealings with employers that offer health benefits to their workers. Our work also led to an invitation for me to testify at a meeting of the Department of Labor’s Advisory Council on Employee Welfare and Pension Benefit Plans (the ERISA Advisory Council) and to meet with the Federal Trade Commission regarding the vertical integration of big insurers and the need for PBM (and Medicare Advantage) reform.

Through the work of advocates on the ground, things began to shift. What was once a side quest among health-policy activists became something real in Washington because the issue is easy to understand: PBMs have become unneeded profit centers insurers erected between patients and the medicines their doctors say they need.

We came close to reining in the PBM industry in late 2024 when reforms were included in House Speaker Mike Johnson’s first spending package, but they were scrapped after Elon Musk complained about the size and scope of the legislation.. His Tweets prompted GOP leadership to strip out the PBM provisions, even though they had broad bipartisan support in Congress and were backed by many consumer advocates and independent pharmacists. But now, it seems like the PBM language in the current spending package is more locked in. Here’s what the bill will do:

  • Change how PBMs get paid in Medicare Part D by moving them away from percentage-based payments tied to high drug list prices and toward flat, transparent service fees — so PBMs no longer profit more when drug prices are higher.
  • Require CMS to define and enforce contract terms between PBMs and Medicare Part D plans, giving the agency real authority to police abusive or one-sided arrangements.
  • Increase transparency by allowing CMS to track how PBMs pay pharmacies and which pharmacies are included (or excluded) from PBM networks, so regulators can finally see payment patterns and network practices across the system.
  • Lock into law existing protections requiring plan sponsors and PBMs to contract with any pharmacy that agrees to their standard terms — as long as those terms are reasonable and relevant — instead of quietly steering business to preferred or affiliated pharmacies.

These are important reforms, although more are needed. We’ll keep you posted on PBM-related efforts not only on Capitol Hill but also at the Department of Labor and in the states.

CMS’ 2024 Health Spending Report: Key Insights

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CMS’ 2024 Health Spending Report: Key Insights

As media attention focused on Minneapolis, Greenland and Venezuela last week, the Center for Medicaid and Medicare Services (CMS) released its 2024 Health Expenditures report Thursday: the headline was “Health care spending in the US reached $5.3 trillion and increased 7.2% in 2024, similar to growth of 7.4% in 2023, as increased demand for health care influenced this two-year trend. “

Less media attention was given two Labor Department reports released the Tuesday before:

  • Prices: The consumer-price index (CPI) for December came in somewhat higher than expected with an increase of 0.3% and 2.7% over the past 12 months. Overall inflation isn’t rising, but it also isn’t coming down.
  • Wages: The Labor Department reported average hourly earnings after inflation in the last year rose 0.7% during the first five months of this year, but real hourly earnings have declined 0.2% since May. They’re stuck.

Prices are increasing but wages for most hourly workers aren’t keeping pace. That’s why affordability is the top concern for voters.

Meanwhile, the health economy continues to grow—no surprise.  It’s a concern to voters only to the extent it’s impacting their ability to pay their household bills. They don’t care or comprehend a health economy that’s complex and global; they care about their out-of-pocket obligations and surprise bills that could wipe them out.

As Michael Chernow, MedPAC chair and respected Harvard Health Policy professor wrote:

“The headline number, 7.2% growth in 2024, is concerning but hardly a surprise. It follows 7.4% growth in 2023. This rate of NHE growth is not sustainable. It exceeds general inflation and growth in the gross domestic product (GDP), pushing the share if GDP devoted to health care spending to 18%  in 2024; the share of GDP devoted to health care is projected to rise to 20.3% by 2033. In fact, these figures may be an underestimate of the fiscal burden of the health care system because spending on some things, such as employer administrative costs, are not captured… Given all the attention to prices and insurer profits, it is important to note that those factors are not the main drivers of spending growth—this time, it’s not the prices, stupid. There was virtually no excess medical inflation (medical inflation above general inflation) for 2023 or 2024. In fact, prices for retail drugs (net of rebates) rose at a rate below inflation. There will certainly be cases of rising prices driving spending, but on average, price growth is not the problem. This does not mean high-priced products and services are not an important component of spending growth, but instead it implies that their contribution to spending growth on average stems from their greater use, not rising prices. The main driver of spending growth is greater volume and intensity of care…”

My take:

Since 2000 to 2024, total healthcare spending in the U.S. has been volatile:

  • 2000–2007: High growth, typically 6–8% per year (driven by rising utilization and prices).
  • 2008–2013: Growth slowed to 3–4% during and after the Great Recession.
  • 2014–2016: Growth ticked up to 4.5–5.8% with ACA coverage expansion.
  • 2017–2019: Moderation around 4.5%.
  • 2020: COVID‑19 shock—growth slowed to ~2% due to deferred care.
  • 2021: Rebound to ~4%.
  • 2022: 4.8%, close to pre‑pandemic norms.
  • 2023: 7.4%, fastest since 1991–92.
  • 2024: 7.2%, reaching $5.3 trillion (18% of GDP)

Between 2000 and 2024, total health spending in the U.S. increased $3.9 trillion (279%) while the U.S. population grew by 58 million (20.4%). 2025 spending is expected to follow suit. The underlying reason for the disconnect between health spending and population growth is more complicated than placing blame on any one sector or trend: it’s true in the U.S. and every other developed system in the world. Healthcare is expensive and it’s costing more.

This is good news if you’ve made smart bets as an investor in the health industry but it’s problematic for just about everyone else including many in the industry who’ve benefited from its aversion to spending controls and cost cutting.

The current environment for the healthcare economy is increasingly hostile to the status quo. Voters think the system is wasteful, needlessly complicated and profitable. Lawmakers think it’s no man’s land for substantive change, defaulting to price transparency, increased competition and state regulation in response. Private employers, who’ve bear the brunt of the system’s ineffectiveness, are timid and reformers are impractical about the role of private capital in the health economy’s financing.

The healthcare economy will be an issue in Campaign 2026 not because aggregate spending increased 7-8% in 2025 per CMS, but because it’s no longer justifiable to a majority of Americans for whom it’s simply not affordable. Regrettably, as noted in Corporate Board Member’s director surveys, only one in five healthcare Boards is doing scenario planning with this possibility in mind.

Paul

P.S. The President released his Great Healthcare Plan last Thursday featuring his familiar themes—price transparency for hospitals and insurers, most favored pricing and elimination of PBMs to reduce prescription drug costs—along with health savings accounts for consumers in lieu of insurance subsidies. The 2-page White House release provided no additional details.

The health care hiring boom is losing steam

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https://www.axios.com/2026/01/26/health-care-hiring-boom-job-growth-stalls?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiosvitals&stream=top

The health care job growth that’s powered the labor market since the COVID pandemic is stalling out.

Why it matters: 

Republican cuts to federal health programs, AI automation and rising costs are making health systems and other employers level off hiring — including for jobs requiring a professional license like nurses or physical therapists.

  • The results could widen gaps in care and exacerbate health disparities.

By the numbers: 

Health care employment drove most of the month-by-month job growth last year, increasing by an average of 34,000 jobs per month, according to the Bureau of Labor Statistics.

  • But that’s less than health care’s monthly average increase of 56,000 roles in 2024.

Health care hiring has essentially returned to a pre-pandemic pattern of slower growth after a post-COVID surge driven by returning patients and hospitals replacing burned-out workers, said Neale Mahoney, an economics professor at Stanford.

  • “It was only a question of when … and we’re starting to see it now,” Mahoney said.

Federal policy changes could further chill hiring.

  • Hospitals face financial pressure from the nearly $1 trillion cut to federal Medicaid spending in the GOP budget law. That’s combined with rising costs from treating more uninsured patients and other factors.
  • New caps on federal student loan borrowing could also push students away from clinical careers, many of which require pricey advanced degrees.
  • It wouldn’t be a surprise if a rise in deportations — combined with fewer foreign-born health workers opting to come to the U.S. on visas — dried up the pipeline of available help, especially in segments like home care.

Case in point: 

Alameda Health System, a safety-net provider based in Oakland, California, announced last month that it’s laying off 247 employees, including clinicians.

  • Administrators cited the system’s precarious finances: It expects to lose $100 million annually by 2030 as a result of the Medicaid cuts, per CBS San Fransisco.

AI automation is also pushing some providers to cut administrative staff.

  • Revere Health, the largest physician-owned health system in Utah, announced in September that it will lay off 177 employees, citing a partnership with a company that automates claims processing.
  • Clinical jobs in health care are more insulated from automation, and AI may actually help extend the clinical workforce where shortages exist.
  • Still, some clinicians are concerned. Almost 15,000 nurses in New York City went on strike this month, demanding new safeguards around AI use in hospitals, among other things.

What they’re saying: 

This past year represented “a repositioning of the labor market,” said Rick Gundling, chief mission impact officer at the Healthcare Financial Management Association.

  • Health systems are doing more targeted hiring, he said. They might look to downsize in revenue management but increase their clinical staff.

The intrigue: 

Demand for care is still high. The “silver tsunami” of aging Baby Boomers may keep jobs plentiful, said Laura Ullrich, director of economic research in North America at the Indeed Hiring Lab.

  • The U.S. is projected to be short some 100,000 health care workers by 2028, after all.
  • The question is whether the sector will remain near full employment, or whether circumstances will drive another surge.
  • “My opinion as an economist is that the tailwinds are stronger than the headwinds in health care,” she said.

UnitedHealth Group Throws a Hail Mary Before CEO Testifies

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https://healthcareuncovered.substack.com/p/unitedhealth-group-throws-a-hail?utm_source=post-email-title&publication_id=255152&post_id=185346893&utm_campaign=email-post-title&isFreemail=true&r=59t65&triedRedirect=true&utm_medium=email

And the questions I’d ask UnitedHealth Group’s CEO about his company’s ACA pledge.

When I first saw the headline that UnitedHealth Group would “return Obamacare profits to customers in 2026,” my immediate reaction was: Oh good grief.

The timing is just too perfect.

UnitedHealth’s pledge was tucked neatly into prepared testimony from CEO Stephen Hemsley, just hours before he (and four other Big Insurance CEOs) are to be hauled into Congress to testify before two House hearings on health care affordability.

“A text message conversation between my colleague, Joey Rettino, and me.

Today, the CEOs will be asked to explain why Americans are paying through the nose for coverage and still getting denied care, trapped in narrow networks and buried under medical debt. As of late, Republican lawmakers — and President Trump himself — have discovered religion on the issue, publicly fuming about high premiums and insurer abuses.

If you’re feeling a little misty-eyed about this sudden burst of corporate altruism, let me save you the trouble. This isn’t a moral awakening. It’s a PR maneuver and narrative control being implemented in real time.

Hail Mary

It’s the corporate version of a quarterback, down by four points, seconds left on the clock, closing his eyes and launching the ball fifty yards downfield, hoping something — anything — miraculous happens before the time runs out. UnitedHealth’s pledge is just a long, desperate PR pass into the end zone, praying lawmakers and reporters will focus on the gesture instead of the business model that allows them to gobble up those dollars in the first place.

It’s worth noting that UnitedHealthcare, while the largest insurer in the country with 50 million health plan enrollees, is actually a relatively small player in the ACA marketplace — about 1 million customers in 2026, compared with roughly 6 million for Centene, according to Politico. This is not UnitedHealth sacrificing a part of its core profit engine. (It doesn’t even disclose how much it makes on its ACA business, but I can assure you it’s a very small part of the more than $30 billion in annual profits it’s been making in recent years.) This is a carefully calibrated concession of a slice of this conglomerate’s business that won’t jeopardize its Wall Street standing, which is what Hemsley cares about most.

Read Stephen Hemsley’s prepared testimony here.

As I wrote yesterday, I spent years inside the insurance industry, helping executives shape their public image and get ahead of bad headlines. I know this playbook by heart. When scrutiny spikes, you roll out a “good guy” story. You announce a consumer-friendly initiative and you flood the zone with talking points. You give lawmakers anything they can point to as evidence of “progress,” so the temperature in the room drops just a few degrees. It’s all an optics game, and if I was in my old job I’d probably get a bonus for thinking of a stunt like this.

Reputational damage control

When Hemsley and his Big Insurance buddies sit before Congress, don’t be surprised if he pivots quickly from this show of supposed humility to pointing fingers at everyone else for driving up costs – including hospitals, doctors, drug companies and whoever else. How do I know this? Hemsley said as much in his prepared testimony. His fellow CEOs sang from the exact same hymnbook, written by the best flacks money can buy.

So no, I’m not impressed by UnitedHealth Group’s gesture. And neither should lawmakers.

If UnitedHealth and its peers were serious about affordability, they wouldn’t be waiting until the night before a congressional grilling to dangle a symbolic rebate. They would be opening their books and explaining their pricing algorithms. They’d come clean about how much of our premium dollar goes to care and how much goes to executive compensation, stock buybacks and acquisitions that tighten their grip on the health care system.

This isn’t a gift. It’s a distraction.

And like most Hail Marys, it doesn’t work if you’re already down a whole lot of points. I hope the lawmakers at today’s hearing remember the score.

In light of UnitedHealth Group’s latest move, see below for some questions that I would ask Hemsley if I were in Congress:

  • ACA plan and pledge specifics
    • How many people are enrolled in your ACA marketplace plans, and how much total profit are you committing to rebate to them?
    • What were your profits from ACA marketplace plans in recent years?
    • Will you commit to disclosing ACA-specific enrollment and profit figures when you announce 2025 earnings next Tuesday? And how many people dropped coverage after the enhanced ACA subsidies were not renewed?
    • By how much, on average, did you raise ACA premiums because Congress did not renew those subsidies?
  • Public money vs. private plans
    • Between 2020–2024, your filings show about $140 billion in operating profits and roughly $894 billion in revenue from Medicare and Medicaid versus $321 billion from commercial plans. Do you agree that about 74% of your revenue now comes from taxpayers and seniors?
    • Given that you have about twice as many people in commercial plans as in Medicare/Medicaid, do you agree the government is paying you far more per enrollee than private customers are?
  • Accountability going forward
    • Will you commit to disclosing ACA-specific enrollment and profit figures when you announce 2025 earnings next Tuesday?
    • Will you commit not to raise premiums or fees in your other lines of business to offset the ACA rebates?
    • Will you commit to providing the transparency and granularity needed for the public to verify that this rebate pledge is real and not a PR maneuver?

Why So Many Young Families Are Stuck Renting, Delaying Kids — and Getting a Cat Instead

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Rising health care costs are quietly reshaping family life and pushing homeownership, parenthood and financial stability further out of reach for millions of Americans.

The youngest of Millennials will hit 30 years old this year. For them and their older Millennial-counterparts, this is supposed to be the stage of life where people buy homes, have kids and settle into the textbook version of stability. But the reality for far too many Americans is something entirely different. It means delaying marriage, delaying children, delaying homeownership — and adopting pets to save them from college tuitions and pediatric specialists.

It’s not because an entire generation is collectively bucking the way “adulthood” used to be. It’s because the math doesn’t work anymore – and health insurance costs are a huge part of why.

Health care is eating the family budget

According to a new analysis from the Center for Economic and Policy Research (CEPR), the typical working family spent $3,960 on health care in 2024, including premiums and out-of-pocket costs. That’s the median… meaning half of families paid more.

Another striking finding from CEPR is that one in ten working families paid more than $14,800 in a single year on health care expenses. And for many low-income and rural households, health care consumed more than 10% of their entire income.

When the average Millennial earns about $47,034 a year, even the “average” health insurance spending now represents a meaningful slice of take-home pay before rent, student loans or the price of simply existing are even deducted. That threshold forces real tradeoffs: rent or deductible? Daycare or co-pays? Savings or prescriptions?

For young families trying to get started, that tradeoff answers itself.

Families with children spend significantly more on both health insurance and health care than those without. Working families with at least one child spent a median $5,150 per year.

Add that to childcare costs and it becomes clearer why many Millennials are putting off parenthood — or skipping it altogether. Hence the cat that doesn’t need braces or an albuterol prescription.

Health costs and home ownership

Diapers aside, medical bills also directly collide with the ability to own a home.

A recent study published in JAMA Network Open found that adults carrying medical debt were significantly more likely to experience housing instability such as trouble paying rent and mortgage, or evictions and foreclosures. As KFF researchers found, more than 100 million Americans have medical debt, and the vast majority of them have health insurance. It just isn’t adequate coverage because of ever-growing cost-sharing requirements.

That matters enormously for young families and would-be homeowners. Medical debt lowers credit scores, drains savings needed for down payments and makes lenders more hesitant. It’s hard to compete in today’s housing market when your emergency fund got wiped out by an MRI. Or your credit score took a hit because you found a lump.

This is not about lifestyle choices

In part because of these costs, the traditional milestones that once built financial security now often increase financial risk. Health insurance and health care costs are rising faster than inflation and faster than they did for previous generations. That’s why more and more insured families are delaying prescriptions and skipping care because of cost.

These uniquely American costs bleed into career moves, relationships, everything.

Millennials aren’t afraid of commitment. They’re afraid of math that doesn’t add up in large part because of a health care system that continues to be an ever-growing weight that is capable of wiping out savings and reshaping family decisions.

It’s easy to frame these trends as cultural shifts or personal preferences, but the data helps fill in the blanks. It’s not just Millannials facing these issues. Gen Xers and even Baby Boomers (some of whom still have a few years until they cross the Medicare and Social Security finish line) are dealing with budget-eating health care costs and medical debt, too.

When nearly half of adults say they couldn’t afford an unexpected $500 medical bill, it’s not surprising that people hesitate before taking on a 30-year mortgage or the lifelong responsibility of raising a child (or taking that trip to celebrate their retirement for that matter.)

For now, all that can be said is that Millennials’ cats are doing fine. They are benefiting heavily from the status quo. Maybe they have something to do with all of this.

Insurers face new GOP pressure on affordability

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https://www.axios.com/2026/01/22/health-insurance-gop-republicans-affordability?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiosvitals&stream=top

Health insurers are feeling political heat as Republicans try to shape the affordability narrative and counter Democratic messaging on health care costs.

Why it matters: 

President Trump and his allies have been increasingly assailing health plans over costs while seeking to deflect blame for blocking enhanced Affordable Care Act subsidies that help people afford premiums.

  • But the administration and Congress have less leverage than they have with drugmakers, and would have to address underlying drivers of health costs to really do something about premiums.

Driving the news: 

House Republicans have called CEOs of five of the largest health insurance companies in back-to-back hearings on Thursday, where they will be pressed on costs of coverage.

  • Executives from UnitedHealth, CVS, Elevance, Cigna and Ascendiun will appear before the House Energy and Commerce and Ways and Means committees.
  • Energy and Commerce Chair Brett Guthrie (R-Ky.) said on Wednesday the companies cover over half of the insured lives in the U.S., “so everybody’s being affected by the high cost of health insurance.”

Between the lines: 

It’s one thing to bash insurers, but quite another to match the talk with substantive health system changes.

  • “I think it’s interesting that they’re adopting some of the anti-insurer, populist rhetoric, but it needs to be backed up with actual policies that hold the health industry to account,” said Anthony Wright, executive director of consumer group Families USA.
  • He added that the hearing also should not be used to “distract” from the need to extend the ACA subsidies.

The other side: 

Insurers agree that health care costs are too high, but say they’re the part of health care that’s working to bring costs down. Executives blame high premiums on the prices charged by hospitals and drug companies.

  • “Congress is doing its job,” Mike Tuffin, CEO of the insurer trade group AHIP, told Axios when asked about the pressure from Republicans.
  • But he added that “a thorough evaluation of the causes of higher premiums clearly demonstrates that it’s the underlying cost of medical care that is the reason that premiums continue to go up.”

What they’re saying: 

Stephen Hemsley, CEO of UnitedHealth Group, will strike a note of contrition in his testimony, saying “like all of you, we are dissatisfied with the status quo in health care,” according to prepared remarks.

  • “The cost of health insurance is driven by the cost of health care,” he adds. “It is a symptom, not a cause.”
  • Still, Hemsley will say his company will rebate its profits this year from ACA coverage back to consumers, though he notes the company is a “relatively small participant” in that market. It’s unclear how much money will be rebated.
  • UnitedHealth became the object of widespread consumer anger just over a year ago, when the killing of CEO Brian Thompson unleashed a wave of social media-fueled rage over coverage denials and other business practices.

The big picture: 

Insurers say they support a range of policies aimed at lowering health care costs by targeting hospitals and drug companies.

  • Those include “site-neutral” payment policies to address hospital outpatient billing, efforts to curb hospital consolidation and a crackdown on tactics drug companies use to delay cheaper generic competition.
  • But lawmakers have broached other changes that would directly strike health plans, like targeting what many experts say are overpayments in Medicare Advantage, or restricting pretreatment reviews that can lead to denials of care.

What’s next: 

Trump earlier this month said he wanted a meeting with health insurance executives to press them on costs, but nothing is on the schedule and it’s unclear if that will happen.

  • Tuffin said he also expects future House hearings on health care costs with other parts of the health care industry besides insurers.
  • An Energy and Commerce Committee spokesperson confirmed there’s more to come but declined to provide details.