https://bridgemi.com/michigan-health-watch/online-pharmacies-aid-rural-health-care-but-threaten-michigan-drugstores/

Online pharmacies aid rural health care but threaten Michigan drugstores
By Blace Carpenter - August 12, 2026

Mail-in prescriptions are becoming increasingly popular as more insurance plans use them as their ‘preferred’ pharmacy
Over 200 independent pharmacies closed their doors in Michigan in 2024. Officials are blaming pharmacy benefit managers
While mail-in pharmacies have become popular, pharmacists say they have flaws when it comes to basic health care
For the past five years, Alpena resident Selena Kenny has received a bulk supply of medication every three months from Express Scripts.

Her Medicare Advantage plan labels mail-in services as its preferred pharmacy because it offers the lowest price for her blood pressure and cholesterol medication.

“For most of the medications that I take on an ongoing regular basis, it’s very convenient to have them come through the mail,” Kenny said.

Mail-in prescription services from pharmacy benefit managers like CVS Caremark, Express Scripts and Optum Rx have been an answer for patients in rural areas that lack quick access to a pharmacy.

Independent pharmacies also rely on pharmacy benefit managers to negotiate drug prices and handle prescription reimbursements.

Over the years, these managers and their parent companies have gained control of several aspects of the nation’s health care system, such as online pharmacies and connections to various insurance companies.

State officials and independent pharmacists are now saying these companies are helping cause pharmacy closures. According to the Michigan Pharmacists Association, 272 pharmacies closed their doors in 2024, 91 of them being independent pharmacies.

Many of those closures were part of the chain pharmacy Rite Aid’s withdrawal from Michigan after filing for bankruptcy two years in a row.

Pharmacists fear that if more brick-and-mortar pharmacies close, patients will lose out on services that mail-in orders can’t provide — such as vaccinations, timely antibiotic refills and basic clinical care.

“What we’re seeing is a reduction in the quality of care for Michiganders when an independent pharmacy closes, and the patients in that community only have the ability to use mail order as an alternative,” said Eric Roath, the director of government affairs for the Michigan Pharmacists Association.

Ashley McGinn is a counselor for Michigan’s State Health Insurance Assistance Program. She said some patients won’t leave their local pharmacy for a “$100 difference.”

But as drug prices remain costly, people continue to switch to more online services.

“Last year, I helped a little over 100 people, and I’d say probably 80% are going with the mail order,” McGinn said.

She said it’s because insurance companies often prefer them.

“Insurance plans are going toward mail order as their preferred pharmacy, which in turn gives you a cheaper prescription,” said McGinn. “In Presque Isle County, a lot of our older residents have transportation issues, so that eliminates their transportation problem, but our local smaller pharmacies are seeing a hit in that.”

Major retailers like Walmart and Amazon have also started speedy mail-in prescription services, following a trend of online medical services that have grown since the COVID-19 pandemic.

According to pharmacists, it’s also a struggle to keep up with the costs of maintaining a brick-and-mortar store because of the reimbursement rates set by the managers.

Losing business to mail-in orders’ competitive co-pay pricing is not helping.

“Not only is there not money to pay for the cost of the pharmacist, the techs, the lights, the insurance and everything that goes into filling a prescription … there’s not even a payment that’s covering the cost of the drug that we’re purchasing to give to the patient,” said John Gross, an independent pharmacist who owns six stores across central Michigan.

He said that the rates can make turning a profit a challenge for pharmacists.

“You don’t make a pizza for $5 and sell it for $4 if you’re a pizza place, because you’ve got overhead that’s involved with that,” Gross said. “It’s the same thing with a pharmacy.”

In July 2024, the Federal Trade Commission reported that CVS Caremark, Express Scripts and Optum Rx managed around 80% of all prescriptions filled in the United States.

The commission stated that because these managers control over the drug industry’s supply chain, they can “exercise significant power over Americans’ access to drugs and the prices they pay.”

They released another interim report in 2025, saying the companies “marked up numerous specialty generic drugs dispensed at their affiliated pharmacies by thousands of percent, and many others by hundreds of percent.”

Pharmacy benefit managers dispute role in pharmacy closures

“We save Michigan’s business community and its employees money while strengthening health outcomes with the help of our coordinated model, which recognizes the important role that independent pharmacies have today,” wrote an Express Scripts spokesperson in an email to Bridge Michigan.

“That’s why employers, government entities, and other health plan sponsors across the state choose to work with us, because our coordinated model provides them the ability to choose a network that can incorporate large chain, regional and independent pharmacies, in addition to home delivery, so that the unique and evolving needs of their business and their employees are met.”

Pharmacy benefit managers continuously deny that they are the cause of pharmacy closures across the country. The Pharmaceutical Care Management Association, a national organization that represents managers, claims that the independent pharmacy industry is stable.

They reported that independent pharmacies have increased from 1,086 to 1,091 (0.5%) across the state since 2022.

“Optum Rx gives people several ways to get their medications, including through community and independent pharmacies, retail pharmacies, specialty pharmacies and home delivery,” said Katherine Wojtecki, a spokesperson for Optum Rx. “Together, these options help make medications more accessible and convenient for the people we serve.”

As pharmacists continue to advocate against pharmacy benefit managers, state and federal officials have begun to take action against these companies.

Michigan Attorney General Dana Nessel filed a lawsuit in 2025 alleging that Prime Therapeutics LLC, a pharmacy benefit manager affiliated with Blue Cross Blue Shield, adopted “Express Scripts’ lower reimbursement rates in exchange for accessing Express Scripts’ buying power and pharmacy network” and that these practices are hurting small pharmacies.

Prime Therapeutics LLC stated that the agreement has helped patients save money.

“The arrangement in question has delivered billions of dollars in savings, while lowering costs at the pharmacy counter and helping ensure tens of millions of Americans get the medications they need,” wrote Jim Cohn, a spokesperson for the manager, in an email to Bridge Michigan. “We are committed to fair and sustainable reimbursement for pharmacies, and will continue to support solutions that promote more transparent, predictable pharmacy pricing while protecting affordability and access for the people we serve.”

President Donald Trump signed legislation toughening regulation of PBMs into law as part of February’s spending bill in an effort to lower drug prices.

However, many of the changes, such as changing how PBMs are paid by drugmakers, won’t take effect until 2028.

“The thing that has happened kind of over the past 10 years or so is that (pharmacy benefit managers) have figured out sort of loopholes in business/health care policy in the US that have allowed them to become much more profitable,” said Joe Fava, a pharmacy practice professor at Wayne State University.

Please excuse the homage to National Lampoon in the title.

Will Henry Ford Health get sued for WARN Act violations like Sturgis?

https://www.beckershospitalreview.com/finance/henry-ford-hospital-to-end-inpatient-er-care/

Henry Ford hospital to end inpatient, ER care
By Andrew Cass - August 10, 2026

Henry Ford Health will end inpatient care, emergency department services and other hospital-based operations at Henry Ford River District Hospital in East China, Mich., a spokesperson from the Detroit based system confirmed to Becker’s.

The spokesperson said the River District building requires substantial infrastructure repairs and modernization, and that continued investment in the facility is not a sustainable long-term path to safe, high-quality care. The system is consolidating inpatient care, ER and hospital-based services to nearby Henry Ford facilities as a result.

The consolidation will take effect Sept. 1, according to the health system’s website. The ED will remain open and fully staffed through Aug. 31.

Primary care practices, infusion services and some administrative functions will remain on the River District campus, the spokesperson said. Patients will keep access to labs, pharmacy and imaging through nearby Henry Ford locations.

“We are committed to supporting everyone through this transition, including helping patients identify care options at nearby Henry Ford Health locations and connecting any impacted team members with opportunities across our health system,” the spokesperson said.

Patients will receive transition information and resources in the coming weeks.

River District joined Henry Ford Health’s network through the system’s 2024 joint venture with Ascension Michigan, which brought 13 acute care hospitals into the combined organization.

Karmanos merged into McLaren Health Care Corporation on 30 October 2013.  Mike Duggan - before he was Mayor of Detroit - sold DMC to Vanguard Health Systems on 30 December 2010.  Then Tenet Healthcare Corporation bought Vanguard Health Systems on 01 October 2013.

As you might expect, this corporate tangle has produced a number of disputes arising from past agreements, mostly financial:

https://www.wxyz.com/news/karmanos-cancer-hospital-sues-detroit-medical-center-over-threats-to-patient-care-services

Karmanos Cancer Hospital sues Detroit Medical Center over threats to patient care services
Karmanos Cancer Hospital has taken legal action against Detroit Medical Center and its parent company Tenet after it accused Tenet of threatening to terminate its services
By Randy Wimbley - August 6, 2026

DETROIT (WXYZ) — Karmanos alleges DMC threatened to cut or reduce essential daily support services critical for delivering continuous patient care, restricted the cancer hospital's efforts to build new facilities and expand patient programs, and implemented unjustified service cost hikes.

Brian Gamble, president and CEO of Karmanos Cancer Hospital, said the lawsuit is a preemptive effort to bring DMC and Tenet to the table to resolve a longstanding contractual dispute.

"Recently Tenet and DMC threatened to terminate basic functions if Karmanos did not pay the arbitrarily determined amounts. They have recalculated amounts using non-contract calculations that have resulted in higher amounts due than what we've paid historically," Gamble said.

"We took this action as a preemptive action. To preserve and protect our patients to the high quality cancer care that they deserve from us on a daily basis," Gamble said.

When Karmanos separated from DMC in 2005, it entered an agreement to remain on the medical center's Detroit campus and purchase essential support services from DMC.

Gamble says Karmanos has for years worked in good faith to resolve its concerns regarding service levels, costs and delivery of essential services to no avail.

"For a cancer center caring for patients with complex and life altering diagnoses, the threat of disruption of essential services is not simply a business disagreement, it is a patient care issue," Gamble said.

Despite the contract dispute with DMC and Tenet, Karmanos says there will be no disruption to patient care.

The statement below is courtesy of DMC:

For more than 100 years, the Detroit Medical Center has been this city’s healthcare safety net. Thousands of patients are being seen and treated on our campus every day. Karmanos is owned by McLaren Health Care, headquartered in Grand Blanc, and has no other presence in our city, preferring to center their broader healthcare services in wealthier suburbs of Michigan while relying on the DMC to subsidize its operations locally.

Karmanos was built here, on DMC’s campus, with DMC, for Detroit’s patients. DMC supplies to Karmanos what a cancer hospital cannot run without: laboratory, medical records, and operating room services among others. McLaren made a long term commitment with Karmanos in Detroit and now files a frivolous lawsuit as a disguised attempt to renege on their commitments on the DMC campus.

For more than a year, McLaren decided on its own what to pay for the support services it uses every day and paid a fraction of the cost. McLaren, as one of the wealthiest hospital systems in America that also owns an insurance company spent over a year asking a Detroit safety-net hospital to subsidize it. We absorbed the loss rather than let a payment dispute reach a single bedside. When finally asked to pay fair market value, McLaren sued, skipping the private mediation its own agreements require. That was a choice about publicity, and not about principle.

DMC honored its agreements. To this day, despite subsidizing the cost of these services for Karmanos, all necessary care remains available from the DMC. We expect McLaren to honor its own commitments. We reject the allegations and will answer them in court. We will not be taken advantage of. Not when the people of Detroit are the ones who pay for it.

https://firstliberty.org/media/university-of-michigan-health-west-to-change-gender-transition-policy-conduct-trainings-and-pay-damages-resolving-case-brought-by-fired-christian-physician-assistant/

University of Michigan Health-West to Change Gender Transition Policy, Conduct Trainings, and Pay Damages, Resolving Case Brought by Fired Christian Physician Assistant
By Natalie Konstans - July 29, 2026

University of Michigan Health-West to Change Gender Transition Policy, Conduct Trainings, and Pay Damages, Resolving Case Brought by Fired Christian Physician Assistant

Under new policy, employees will not be required to assist in gender transitions or use pronouns contrary to religious beliefs.

Grand Rapids, MI—First Liberty Institute, Clement & Murphy LLP, LightStone Law, and Bossenbrook Williams PC reached a settlement with University of Michigan Health-West in favor of Valerie Kloosterman, a physician assistant who was fired because of her religious beliefs about gender. The settlement requires UMHW to create a religious accommodation policy in accordance with the law, notify and train all its employees, grant reasonable religious accommodations without retaliation, and pay $410,000 in damages and fees to Ms. Kloosterman and her attorneys.

Under the new policy, employees will not be required to perform or assist with gender transition treatments, including procedures, medications, and referrals, if doing so would violate the employee’s sincerely-held religious belief. Employees also will not be required to use pronouns in a way that violates their sincerely-held religious belief or conscience.

“Title VII prohibits employers from discriminating against and punishing employees for their faith,” said Kayla Toney, Counsel at First Liberty. “Valerie is an exceptional physician assistant who cares for each of her patients. Employers cannot drive out people like Valerie just because of their sincere religious beliefs. We are grateful to have resolved this matter with University of Michigan Health-West.”

Valerie Kloosterman said, “All I wanted to do was provide the best care possible to my patients without being forced to violate my Christian beliefs. This new policy ensures that providers of faith and employees at UMHW will receive religious accommodations so that they can provide excellent care consistent with their medical judgment, because all patients are created in the image of God.”

Valerie worked as a physician assistant at UMHW for 17 years. She had an exemplary reputation with patients of all beliefs and backgrounds. But when Valerie raised her faith-based concerns about a mandatory gender identity training, she was met with hostility toward her religious beliefs and fired in August 2021. Valerie sued to vindicate her constitutional rights and to protect other healthcare providers and employees from similar discrimination. The parties now have reached a favorable settlement that vindicates Valerie’s stellar record and creates robust protections for other religious providers.

https://www.plannedparenthood.org/planned-parenthood-michigan/newsroom/planned-parenthood-of-michigan-reshapes-health-care-network-in-response-to-federal-funding-losses

Planned Parenthood of Michigan Reshapes Health Care Network in Response to Federal Funding Losses
For Immediate Release: July 30, 2026

LANSING, Mich. — Planned Parenthood of Michigan (PPMI) has announced that its Lansing, Livonia, and Warren health centers are permanently closing effective today as part of a network reorganization. The decision follows a $4.2 million decline in patient care reimbursement and federal family planning funding from the prior fiscal year. It was further compounded by closing fiscal year ’26 with an unsustainable $5.6 million in uncompensated and undercompensated care. 

PPMI is directly notifying affected patients and connecting them with continued care across its remaining health centers and expanded virtual care network. 

The decision comes as safety-net health care providers face mounting economic and operational pressure across the country and throughout the Midwest. Community health centers, safety-net clinics, and regional health systems are being forced to close physical locations and reduce essential services due to chronic public underfunding, shifting Medicaid policy landscapes, and the rising cost of delivering medical care. Across the industry, these escalating costs are making traditional safety-net operating models increasingly difficult to maintain.  

“Planned Parenthood built one of the strongest reproductive health care networks in Michigan, but the funding infrastructure that supported that network has fundamentally changed,” said Paula Thornton Greear, President and CEO of Planned Parenthood of Michigan.

"For decades, federal family planning funding and reimbursement for patient care helped Planned Parenthood expand access across the state. Republicans in Congress have now demonstrated that they are willing to block Medicaid reimbursement for Planned Parenthood patients, and the Trump administration has proposed eliminating the Title X family planning program altogether. We cannot build the future of patient care on federal funding that can be stripped away whenever political power changes hands.” 

“We have to reshape how we deliver care so Planned Parenthood of Michigan can continue serving patients for generations to come,” Thornton Greear continued. “That means concentrating our resources at regional access points and procedural sites and continuing to expand virtual care across Michigan. These are painful decisions, but they are strategic decisions grounded in where we can preserve access for the greatest number of patients.” 

“Maintaining continuity of care for our patients is our highest priority,” said Dr. Kate Starr, Chief Medical Officer of Planned Parenthood of Michigan. “We are working directly with patients to make sure their treatment plans, prescriptions, and ongoing care continue. Whether patients see us in person at one of our health centers or through virtual care, our commitment to person-centered, evidence-based medicine remains absolute.” 

The return of Medicaid reimbursement is welcome news for PPMI patients, and the organization will resume billing Medicaid in the coming days. However, the restoration of billing does not recover nearly a year of lost revenue or eliminate ongoing threats to safety-net health care funding. That is why PPMI is working with counties and state partners across Michigan to build funding it can rely on. That funding will not bring back what has already been lost, but it is what gives PPMI a foundation that does not depend on federal politics. 

The closures follow earlier reductions across PPMI, including the elimination of administrative functions and non-clinical positions, as the organization concentrated resources on direct patient care. PPMI identified the three health centers through a comprehensive review of its statewide network. PPMI's Detroit and Ferndale health centers are within approximately 20 miles of the closing Livonia and Warren locations, and many services provided at the Lansing health center are available through PPMI's virtual care network. None of the three health centers provides procedural abortion care, which cannot be replaced through virtual care. 

Patients can continue to access services through PPMI's seven remaining health centers, the Virtual Health Center (currently serving over 10,000 patients annually), and the PP Direct app, which offers 24/7 access to birth control, medication abortion, emergency contraception, and UTI treatment. PPMI is also working directly with impacted staff to transition them into open roles within the remaining network where available. 

“The measure of this organization has never been how many buildings we operate, it is whether people can get the care they need when they need it,” Thornton Greear added. “We are making these painful decisions today so that Planned Parenthood of Michigan stays grounded, resilient, and ready to serve the next generation.” 

Michigan Medicine is now seeking a Chief Revenue Cycle Officer (CRCO) in Ann Arbor to improve their bottom line at your expense.  The job proffer, from Kirby Partners:

https://www.kirbypartners.com/jobs/chief-revenue-cycle-officer/

Chief Revenue Cycle Officer
Michigan Medicine Ann Arbor, MI

Michigan Medicine has exclusively retained Kirby Partners to support its search for a Chief Revenue Cycle Officer.

Michigan Medicine is one of the largest health care complexes in the world and has been the site of many groundbreaking medical and technological advancements since the opening of the U-M Medical School in 1850. Michigan Medicine comprises over 30,000 employees, with a vision to attract, inspire, and develop outstanding people in medicine, sciences, and healthcare to become one of the world’s most distinguished academic health systems. In some way, great or small, every person at Michigan Medicine helps to advance this world-class institution. Work at Michigan Medicine and become a victor for the greater good.

Michigan Medicine is one of the largest academic health care organizations focusing on clinical care, research, and education including:

• U-M Health – the clinical care arm, including the Academic Medical Center in Ann Arbor, UH-Sparrow in Lansing, and UH-West in Grand Rapids, along with associated medical staff practice groups.
• University of Michigan Medical School – one of the nation’s largest biomedical and health science research and education facilities.
• Michigan Health Corporation — a 501(c)(3) established to respond to the dynamic healthcare landscape through partnerships, affiliations, joint ventures, and other projects that support the tripartite mission.

• Top 25 Universities in the World by Times Higher Education for 2026
• University of Michigan Health named one of the World’s Best Hospitals in 2026, and #12 in the United States, by Newsweek and Statista
• Michigan Medicine recognized as one of America’s Best-in-State Employers for 2025 by Forbes
• University of Michigan was recognized in Crain’s 2025 Best Places to Work in Southeast Michigan
• Michigan Medicine named one of America’s Best Employers for New Grads 2025, among the top 10 Michigan employers evaluated by Forbes and Statista
• U-M Health named to the nation’s Honor Roll of Best Hospitals by U.S. News & World Report, the #1 hospital in Michigan, ranked among the nation’s best in 11 different specialties for 2025
• Michigan Medicine C.S. Mott Children’s was recognized as one of America’s Best Children’s Hospitals 2025 by Newsweek and Statista
• University of Michigan Health-Michigan Medicine earned Top 25 Environmental Excellence award from Practice Greenhealth for 2025 & 2026
• Michigan Medicine named one of the Best and Brightest Companies to Work For in metropolitan Detroit in 2024 by the National Association for Business Resources
• Nationally recognized for work/life effectiveness by WorldatWork

Facts and Figures

 ~48.6K hospital discharges
 ~54K surgical cases
 870 survival flight missions
 2,000+ licensed beds (medical & surgical) system wide
 ~118.5K emergency / urgent care visits
 ~2.98M outpatient clinic visits
 5,425 deliveries
 30,516 employees
 100+ residency and fellowship programs
 1,885 active clinical trials

(Source: Patient Care Activity FY 2025 and Michigan Medicine By the Numbers 2025.)

Position Overview

• Develop and execute an enterprise revenue cycle strategy and metric-driven operating model aligned with Michigan Medicine’s clinical, research, and financial goals.
• Lead the revenue cycle workstream for the One Epic initiative, establishing the governance framework to align billing operations across entities and minimize customizations that limit enterprise scalability.
• Provide revenue cycle guidance on service expansion, consolidation, and growth initiatives, including financial due diligence, operating model design, and readiness assessments.
• Maintain a current perspective on healthcare reform, regulatory change, and the reimbursement environment, and translate that intelligence into operational and strategic priorities.
• Define business priorities and accountability for revenue cycle automation and Artificial Intelligence technology utilization. Partner with digital, Epic, and vendor teams to ensure solutions are integrated and measurable. Lead the workforce and workflow redesign that automation requires.
• Partner with Managed Care and Contracting to manage payer relationships and contracts across the Academic Medical Center and the Regional Health Network, using data to benchmark performance, negotiate effectively, and protect revenue.
• Collaborate on clinical documentation integrity, research billing compliance, coverage analysis, and physician and faculty coding education across the clinical enterprises.
• Improve the patient financial experience from pre-service through final billing, including transparency, payment options, financial assistance, and patient-facing digital tools.
• Maintain a metrics-driven operation focused on clean claims, denial prevention, avoidable write-offs, accounts receivable, and cost-to-collect performance.
• Identify root causes of net revenue loss and act quickly to put corrective measures in place.
• Oversee revenue cycle functions, including Patient Access, Coding, Health Information Management, Facility and Professional Billing, Accounts Receivable, Payment Posting, Patient Customer Service, Revenue Analytics, Compliance, Technology, and Training.
• Lead a large, distributed revenue cycle team across multiple geographies, building a culture of performance, engagement, and continuous improvement.
• Manage budgets, staffing models, and vendor relationships with cost discipline and operational accountability.

Qualifications

Education

• Bachelor’s degree in business administration, healthcare administration, or a related field required.
• Master’s degree is strongly preferred.

• Fifteen or more years of progressive revenue cycle leadership, including experience in a large, complex health system.
• Demonstrated enterprise-scale financial results in net revenue improvement, accounts receivable reduction, denial management, and cost-to-collect performance.
• Proven experience navigating large-scale system conversions or consolidations from a business leadership perspective.
• A track record of maintaining high operational performance and staff engagement during significant organizational change.
• Experience building collaborative relationships in a matrixed governance environment, including balancing regional needs with central standards.
• Experience leading revenue cycle technology adoption, automation, and related change management.
• Demonstrated financial management skills, including budgeting, forecasting, AR and reserve analysis, and financial reporting.

• Deep experience in the governance and financial structures of a university-based health system or academic medical center, including funds flow environments.
• Specific experience with research billing compliance, clinical trial coverage analysis, and faculty and physician group support.
• Familiarity with the strategic capabilities of Epic Resolute, Prelude, and related revenue cycle modules.
• Knowledge of Medicare Advantage, HCC coding, and value-based care contract management.

• Ability to build trust and alignment among faculty, clinicians, and administrative peers in a highly matrixed academic environment.
• Skilled at communicating financial strategy and operational priorities with clarity, transparency, and credibility at the executive level.
• Proven ability to execute multi-year initiatives with measurable financial outcomes, disciplined risk management, and accountability across teams.
• Effectiveness in leading large organizations through technology-driven transformation, including workflow redesign, staff development, and vendor management.
• Ability and willingness to exhibit behaviors consistent with standards of performance improvement and organizational values (e.g., efficiency & financial responsibility, safety, partnership & service, teamwork, compassion, integrity, and trust & respect).

If you had your druthers, this would be the one position you would prefer Michigan Medicine fill with a DEI empty suit.  Won't happen, though, because it is too important to the bottom line.

https://www.detroitnews.com/story/news/local/michigan/2026/07/22/michigan-henry-fordhospitals-sue-cvs-95m-alleged-drug-savings-scheme/91011064007/

https://dockets.justia.com/docket/michigan/miedce/2:2026cv12435/396075

https://www.frierlevitt.com/wp-content/uploads/2026/05/University-of-Michigan-v.-CVS-Health-Corp.-et-al.pdf

Michigan hospitals say CVS improperly kept $95M in drug savings scheme
By Kara Berg - July 22, 2026

Several Henry Ford Health and University of Michigan hospitals are suing CVS Health for allegedly manipulating reimbursements from a federal drug pricing program and keeping a combined $95 million for itself instead of sending the money back to hospitals to fund care for indigent and uninsured patients.

Hospitals like Detroit-based Henry Ford and Ann Arbor-based UM are able to receive discounts on drug costs and use those savings to finance medical care for people in need under the federal pricing program, according to two lawsuits, one filed by Henry Ford on July 16 and the other filed by UM in May. But CVS and its pharmacies have allegedly conspired to redirect a "substantial portion" of those savings to itself, stopping the money from reaching indigent and uninsured patients, according to the lawsuits.

CVS Health is a company that owns a major retail pharmacy chain of about 9,000 pharmacy locations, the health insurance provider Aetna and a pharmacy benefits manager.

CVS Health spokesperson Phil Blando said "these legal complaints are riddled with erroneous accusations, and we plan to vigorously defend against these lawsuits."

But other hospital systems have sued over the same issue, including the University of Kansas. A CVS spokesperson told Fox Business in May that the company doesn't comment on ongoing litigation.

Henry Ford said it estimates CVS has led to more than $29 million in losses since 2020, and UM said it estimates the actions of CVS have led to $66 million in losses in that period, according to each of the lawsuits. CVS has allegedly refused the hospital's requests to access data and conduct an audit to determine the full scope of CVS's alleged profits from the 340B program.

"Indeed, both payors and patients are paying for the drugs at the full standard reimbursement rate, and they are not refunded the difference, which is pocketed by Defendants," according to the lawsuits. "Defendants’ fraudulent, unlawful, and deceptive practices have harmed Plaintiffs by taking millions of dollars that were supposed to flow to Plaintiffs to fund the provision of charitable medical care to the uninsured and under-insured."

Congress enacted the 340B drug pricing program to provide financial support to community hospitals, federally qualified health centers, and other safety net providers that serve low-income and uninsured patients. They're able to receive discounts on drug costs and use those savings to fund medical care for people in need. But CVS and its pharmacies have allegedly conspired to redirect a "substantial portion" of those savings to itself, stopping the funds from reaching indigent and uninsured patients.

Under this program, drug manufacturers are required to charge hospitals and other 340B providers no more than a significantly discounted ceiling price on some outpatient prescription drugs, according to the lawsuits. The hospitals are then able to "pass on" those savings to patients through lower costs for medications or through reimbursements for the drugs that then can be used to finance other unfunded areas of their operations.

Hospitals like Henry Ford and UM aren't always able to fill prescriptions at their own pharmacies, so they entered agreements with CVS pharmacies, according to the lawsuits. The hospitals allowed CVS to keep a dispensing fee, and CVS was supposed to send back all payments received for the drug.

But CVS has allegedly been keeping more revenue from the drugs than it should have by conducting a "secret pricing scheme" for the drugs, allowing CVS to keep a "significant portion" of the money intended to go to the hospitals, according to the lawsuits.

Henry Ford said CVS and Caremark pocketed about 55% of the 340B savings, compared with 44.5% of the savings the hospitals saw. UM said CVS and Caremark pocketed about 60% of the savings, and UM got about 40%.

Henry Ford and UM are seeking the lost revenue from the 340B program and are looking to be reimbursed three times the 340B revenue and extras that CVS allegedly improperly retained.

https://www.michigandaily.com/news/news-briefs/michigan-medicine-ceo-david-miller-will-depart-post-to-lead-vanderbilt-health/

Michigan Medicine CEO David Miller will depart post to lead Vanderbilt Health
By Glenn Hedin - July 15, 2026

Michigan Medicine CEO David Miller will leave his post at the University of Michigan to become the CEO of Vanderbilt Health and Dean of Vanderbilt University School of Medicine, according to a Michigan Medicine press release posted Wednesday.

Miller has served as Michigan Medicine’s CEO since July 2025 after the resignation of his predecessor Marschall S. Runge, and has been the president of U-M Health since January 2021. He will remain in his post until Dec. 1, 2026, and begin his position at Vanderbilt on Jan. 1, 2027.

Miller’s departure marks the latest episode in a series of leadership shake-ups at the University over the last year, including the University’s ongoing search for a new president, and the resignations of the University’s general counsel and the dean of the College of Engineering. In the press release, University President Domenico Grasso praised Miller for his contributions to the institution.

“David has created a culture of trust, transparency and communication strengthening the entire organization,” Grasso said. “We are deeply grateful for his steadfast leadership, his unwavering commitment to our mission and the countless contributions he has made to our patients, learners, faculty and staff.”

During his tenure, Miller oversaw the construction of the $920 million D. Dan and Betty Kahn Health Care Pavilion, as well as the resolution of contentious health insurance and union contract negotiations with Blue Cross Blue Shield of Michigan and the University of Michigan Professional Nurse Council, respectively. He also presided over Michigan Medicine’s termination of gender-affirming care for patients under the age of 19, which has sparked significant protest and feelings of betrayal among many community members.

In the press release, Miller thanked Michigan Medicine community members for his time at the hospital system.

“This has been one of the most consequential decisions of my career,” Miller wrote. “Michigan Medicine has been far more than my workplace — it has been my professional home. Leaving a community that I care so deeply about is incredibly difficult. I will always be grateful for the privilege of serving alongside such remarkable and committed team members.”

https://michiganadvance.com/briefs/u-m-health-system-and-nurses-union-reach-tentative-contract-avoid-strike-vote/

U-M health system and nurses union reach tentative contract, avoid strike vote
By Jon King - July 9, 2026

Registered nurses represented by the Michigan Nurses Association at the University of Michigan have reached a tentative three-year contract with Michigan Medicine, averting a planned strike authorization vote.

The tentative agreement, announced Thursday by both the union and the university, still must be ratified by members of the MNA-University of Michigan Professional Nurse Council, which represents more than 7,200 registered nurses and advanced practice registered nurses employed by U-M Health, the clinical organization of Michigan Medicine.

The previous contract expired March 31.

According to the union, the tentative agreement includes an overall 13.25% wage increase over three years, with raises of 4% in the first year, 4.5% in the second and 4.75% in the third. Other provisions include a ratification bonus, improved staffing ratios, stronger workplace violence protections, gains for advanced practice registered nurses centered on full union representation and an end to pre-scheduled patient assignments for charge nurses, providing them more flexibility to oversee patient care and safety.

Union leaders said the deal follows months of bargaining and collective actions, including an informational picket.

“Our success is a testament to not only countless days at the bargaining table, but also to the collective solidarity by MNA-UMPNC members,” Kara Ayotte, president of the MNA-UMPNC said in a press release. “By standing strong together, we showed Michigan Medicine that we would not settle for less than what nurses and patients deserve.”

University officials also praised the agreement.

“We appreciate the dedication and professionalism of both bargaining teams in reaching this tentative agreement,” Julie Ishak, chief nurse and operations executive for Michigan Medicine’s academic medical center, said in an emailed statement. “This agreement aims to support our nurses, strengthen our workforce, and ensure the highest quality care for the patients and families we serve.”

The union said members will vote on ratification in the coming weeks.

The Peterson-KFF Health Tracker Report is long winded, but provides very insightful commentaries from select insurers on the specific causes of medical care inflation:

https://www.healthsystemtracker.org/brief/how-much-and-why-aca-marketplace-premiums-are-going-up-in-2027/#Distribution%20of%20proposed%202027%20rate%20changes%20among%2077%20ACA%20Marketplace%20insurers

How much and why ACA Marketplace premiums are going up in 2027
By Matt McGough, Jared Ortaliza, Ashley Ferguson, Imani Telesford, Shameek Rakshit, Emma Wager Twitter, Lynne Cotter, and Cynthia Cox
July 8, 2026

Every spring and summer, health insurers submit rate filings to state regulators detailing expectations and premium rate changes for individual market health plans for the coming year. This analysis focuses on individual market filings for plans selling Affordable Care Act (ACA) Marketplace coverage. These filings provide insight into what factors insurers expect will drive health costs for the coming year. The individual market is mostly comprised of people enrolled in Affordable Care Act (ACA)-compliant health plans, particularly those sold through the Marketplaces (Healthcare.gov and state-run platforms like Covered California). While less than 10% of Americans get their health coverage through the individual market, many of the factors driving premiums in this market – like growth in hospital or pharmaceutical costs – are similar across all private plans, and the detailed filings available for ACA-compliant coverage provide insight into these cost drivers. There are also issues unique to ACA Marketplace plans, including federal premium assistance for most purchasers and regulations governing how they operate.

For 2027, across 77 insurers participating in the ACA Marketplaces from the 16 states and the District of Columbia with publicly available filings, this analysis shows a median proposed premium increase of 14%. This is the second consecutive year of double-digit premium hikes. Last year’s median nationwide proposed rate change was 18%, and the median finalized rate change was 20%. While this proposed rate change is lower than last year, it represents the second-highest requested rate change since 2018, as premium growth had been relatively flat in this market for several years. If these early indications of median premium increases for 2027 hold, typical premiums for insurers participating in the ACA Marketplaces will have jumped by more than one-third over a two-year period.

ACA Marketplace insurers are proposing a median premium increase of about 14% in 2027

States with publicly available proposed rates included in this analysis are Connecticut, the District of Columbia, Hawaii, Illinois, Indiana, Iowa, Kentucky, Maine, Maryland, Massachusetts, Minnesota, New York, Oregon, Rhode Island, Texas, Vermont, and Washington. Note that Hawaii, Illinois, and Texas only have publicly available filings for a portion of their state’s participating insurers.

Based on a detailed analysis of available documents from insurers in these 16 states and the District of Columbia, growth in underlying healthcare prices, as in prior years, stood out as a key factor driving costs in 2027. As discussed in more detail below, insurers cite the rising cost of health services, general economic inflation, and labor shortages as contributing to cost growth.

Insurers also cite some factors that are unique to the individual market, particularly the expiration of enhanced premium tax credits at the end of 2025 and a related increase in the risk pool’s morbidity, as contributing to rising rates for 2027. The expiration of these tax credits led to a decrease in enrollment in 2026, with healthier enrollees more likely to drop their coverage. Individual market insurers are expecting the market to continue to deteriorate in 2027 as a result of the expiration of these enhanced tax credits. Other federal policy changes, such as the Trump administration’s ACA Marketplace Integrity and Affordability Rule, the 2027 Notice of Benefit and Payment Parameters, and H.R. 1 – The Working Families Tax Cut Act were also discussed, though to a lesser extent.

Among the 77 ACA Marketplace participating insurers from 16 states and the District of Columbia, premium changes range from 1% to 52%, but most proposed premium changes for 2027 fall between 10% and 20% (the 25th and 75th percentile are 12% and 21%, respectively). Of the insurers included in this analysis, none proposed decreasing premiums. At the other end of the spectrum, 20 insurers requested premium increases of more than 20%. These filings are preliminary and may change during the rate review process. Rates for 2027 will be finalized in late summer.

There are several ways to assess premium changes in this market. This analysis measures a given insurer’s premium increase as the enrollment-weighted average rate change across all of its products within a state (bronze, silver, gold, and platinum plans). These weighted averages differ from changes in the benchmark silver plan, which is the basis for federal subsidies. In 2026, the median proposed rate increase was 18%, while benchmark silver premiums rose 26% on average once finalized, so it is not an “apples-to-apples” comparison.

Most people who signed up for an ACA Marketplace plan receive a premium subsidy (87% in 2026) and may be insulated from premium increases depending on the plan they select. But the expiration of enhanced premium tax credits reduced financial assistance across the board, resulting in a smaller share of people receiving subsidies and higher average premium payments driving people to opt for lower-premium bronze plans that tend to have higher deductibles. For the federal government, premium increases also translate directly into higher subsidy spending.

The double-digit rate increases proposed for 2027 follow an already steep climb. For enrollees with incomes just above four times the federal poverty level — who are newly ineligible for subsidies with the expiration of the enhanced premium tax credits — that cumulative increase is especially sharp over the last two years. Consider a 40-year-old in Indianapolis, Indiana, enrolled in Anthem Heart Healthy Silver Essential 4500 earning $65,000 per year: with enhanced premium tax credits, their premium payment was $316 per month (their unsubsidized monthly premium would have been $388 in 2025), then the premium climbed to $477 in 2026 as those credits expired and premiums rose, and it will reach $546 per month in 2027 if these rates are approved — a cumulative increase in monthly premium payments of $158, or 41%, over just two years.

What is driving 2027 premium changes?

Rising healthcare costs

Trend
As in most years, rising healthcare costs — a function of the price of care and increased utilization — are the primary driver of higher premiums. Hospitalizations, physician visits, and prescription drugs all tend to get more expensive each year, and insurers raise premiums accordingly. For 2027, the median change in the underlying cost of medical care and prescription drugs (medical trend) was 10%. This is higher than the average medical trend of 8% in each of the last few years.

Below are some illustrative quotes from insurer rate filings:

“The most significant component is trend and experience. Rising medical cost trends, contract increases with providers, and 2025 experience performing worse than expected account for a significant portion of the rate increase. Annualized trend is 10.2%. This component contributes about $78 PMPM to the overall premium increase.” – Moda Health Plan, Inc. (Oregon)

“Medical inflation related to the utilization and cost of covered services increased claims by 9.2%. Trend is one of the primary contributors to an increase in rates. Changes in provider contracting rates also contributes to the regional rate changes.” – ConnectiCare Benefits, Inc. (Connecticut)

General economic inflation

In addition to rising healthcare prices, many insurers also cited general economic inflation as a driver of higher provider costs. Broader inflationary pressure has strained supply chains and pushed prices higher across the economy, including the healthcare sector.

“Significant inflation in the cost of goods and services in all sectors of the economy has had a profound impact on the cost of medical services, and BCBSRI expects to see substantial increases in provider unit costs for 2027.” – Blue Cross Blue Shield of Rhode Island (Rhode Island)

“We have not included an explicit adjustment for tariffs in our pricing. However, our rate development reflects broader economic factors that may influence medical unit costs and pharmacy pricing, including potential impacts to supply chain and input costs. These considerations are incorporated into our overall assumptions, including a modest incremental increase to trend above typical contracting adjustments to account for evolving economic conditions.” – Anthem Insurance Companies (Indiana)

Labor supply

Some insurers also point specifically to healthcare labor costs as a component of medical trend, driven by persistent workforce shortages and elevated wages, as a meaningful contributor to rising premiums. Providers facing higher staffing costs and lingering post-pandemic financial pressures are seeking steeper reimbursement rates in contract negotiations, and insurers incorporate those increases into their trend assumptions.

“Local hospital systems have been challenged financially due to both economic inflationary pressures as well as staffing shortages. Excellus Health Plan has responded to these provider challenges through additional contractual cost increases for our provider systems, resulting in more spending for hospital services.” – Excellus Health Plan, Inc. (New York)

“For 2026 and 2027, THPP expects there to be continued upward pressure on medical cost increases, driven by the higher inflationary environment and labor shortages that have led to providers requesting higher rates of reimbursement. While THPP expects to successfully partner with hospitals and physicians across the state to moderate these cost increases, and continue to make quality care accessible for all, the increases are expected to be above historical levels.” – Tufts Health Public Plans, Inc. (Massachusetts)

Increasing severity of claims

Several insurers also cite increasing claims severity — the complexity and costliness of individual claims — as a notable driver of rising premiums. Providers are increasingly coding and billing for higher-acuity services, resulting in claims that reflect more intensive levels of care and higher reimbursement rates, which contributes to higher medical trend. Whether driven by genuine increases in patient complexity or shifts in billing practices – such as using AI to maximize billable services – this trend toward higher-severity claims translates directly into higher costs for insurers and, ultimately, higher premiums.

“We’ve seen use and severity trend accelerate through the end of 2025. This is not an anomaly, but rather reflects observable, sustained increases in underlying medical utilization and severity identified by our Trend Analytics Team. We are experiencing persistent utilization pressures across multiple service categories, most notably in outpatient surgeries (including digestive and cardiovascular surgeries), rising behavioral health visit volumes, and increased medical pharmacy use. We have also observed and measured an increase in the severity component of trend. We have measured the impact of changes in the way providers are billing both inpatient and outpatient services to increase provider revenue with no appreciable difference in the way care is delivered.” – Blue Cross Blue Shield of Massachusetts HMO Blue (Massachusetts)

GLP-1s

Over the past few years, the high cost and growing demand for GLP-1 medications have been adding significant upward pressure and leading to higher premiums for insurers. In response, some insurers have dropped coverage of these drugs for weight loss while continuing to cover them for diabetes management and say this change will have a downward effect on 2027 premium increases. Other insurers say the increased utilization of these drugs will continue to have an upward effect on premiums in 2027.

“Despite discontinuing coverage for GLP-1s for weight loss, we continue to see rising utilization for diabetic GLP-1s as these treatments increasingly are being used to treat diabetes and expanded for other conditions.” – Mass General Brigham Health Plan (Massachusetts)

“Beginning January 1, 2026, MVP is no longer covering weight loss GLP-1 drugs except for certain medically accepted indications. MVP found, after analyzing the emerging data for the 1st quarter of 2026, that utilization of weight loss GLP-1 drugs has dropped. MVP has therefore reduced the experience period data to only reflect $4 PMPM, which is our best estimate of 2026 expense based on emerging trends and seasonality. This adjustment reduces the premium by $8.71 PMPM. Please note that this is the net impact on claim expense after considering any reduction in manufacturer rebates as a result of this policy change.” – MVP Health Care (Vermont)

“For Healthfirst, the QHP gross cost PMPM of GLP-1s has more than tripled over the past two years (in the graph and table below, see the Feb-24 PMPM of $13 vs. the Feb-26 PMPM of $49), as has the proportion of adult QHP members utilizing GLP-1s since early 2024 (in the table below, see the Feb-24 proportion of 1.6% vs. the Feb-26 proportion of 5.4%).” – Healthfirst PHSP (New York)

“EHP is expecting the increasing costs of GLP-1 drugs to be a major impact in 2027 claim experience. The cost for these drugs is expected to increase by $28.30 PMPM from 2025 to 2027.” – Excellus (New York)

Provider consolidation

In a very small number of filings, insurers also point to provider consolidation, through hospital mergers and acquisitions, as contributing to higher contracted prices for services due to increased provider market power.

“The high unit cost increases reflect continued pressure from provider contract negotiations, including provider requests for double-digit reimbursement increases in certain markets. Limited competition and regional monopolies have reduced downward pricing pressure, and some hospital systems and health care providers have shown a willingness to allow our contracts to expire.” – Premera Blue Cross (Washington)

No Surprises Act

The No Surprises Act (NSA), enacted in 2022, introduced consumer protections against certain surprise medical bills, most notably by requiring that patients who receive out-of-network services at in-network facilities be charged only for in-network cost sharing. To resolve payment disputes between providers and insurers, the NSA instituted an independent dispute resolution (IDR) process. In practice, providers have initiated a large majority of payment disputes and have prevailed in most of them, frequently securing payments exceeding the median in-network rate, driving up costs for insurers and contributing to higher premiums, an outcome that stood in stark contrast to projections from the Congressional Budget Office. The IDR process has also faced a series of legal challenges since its inception, creating ongoing uncertainty around its implementation and scope. One insurer mentioned the No Surprises Act as a driver of healthcare costs.

“A rate impact of 0.8% is added for costs associated with the Independent Dispute Resolution process, including both the federal program and additional New York-specific requirements.” – UnitedHealthcare of New York (New York)

Federal policy changes that uniquely affect the individual market

Expiration of the enhanced premium tax credits

Insurers in the individual market must also account for the lasting effects of the enhanced premium tax credits’ expiration at the end of 2025, which has reshaped the risk pool in 2026 and is expected to continue to lead to further market deterioration heading into 2027. As anticipated, many healthier enrollees left the ACA Marketplaces in 2026 as their subsidies decreased – leading to an average increase in premium payments after subsidies of 58% this year – leaving behind an enrollee base that is on average somewhat sicker and more expensive to cover. For 2026, this dynamic was estimated to drive rates an average of 4 percentage points higher than they otherwise would have been, and insurers are now building 2027 rates on top of that adjusted, less-healthy risk pool — compounding the effect into next year’s premiums as well. In 2027, among those adjusting for the expiration of the enhanced premium tax credits, insurers are projecting this dynamic to continue driving premiums up again by roughly 4 percentage points higher than otherwise would have been.

“For the rating period, morbidity for enrollees overall is expected to be higher compared to the morbidity of members in the experience period data due to market contraction as a result of subsidy changes in the Individual market. The expected relative cost of new members coming into the pool is expected to be lower than the cost of continuously enrolled members” – Kaiser Foundation Health Plan of the Mid-Atlantic States (District of Columbia)

“The enhanced Advanced Premium Tax Credit (eAPTC) subsidies first introduced through the American Rescue Plan Act (ARPA) and later extended by the Inflation Reduction Act (IRA) expired at the end of 2025, and while we observe an increase in 2026 open enrollment relative to 2025 open enrollment, we anticipate a reduction in the overall market size between the base period and projection period as effectuated enrollment develops throughout the year and additional consumers leave the market in 2027. This will lead to increased average statewide morbidity in 2027 as consumers either lose access to subsidies (for those at or above 400% of the Federal Poverty Level) or face higher net premiums due to less generous subsidies. We anticipate the remaining risk pool in 2027 to have higher healthcare needs, on average, as healthier consumers are more likely to lapse coverage. Given these considerations, we incorporate a morbidity adjustment of 6.0% to reflect greater anticipated changes in statewide average morbidity in 2027 relative to the manual rate.” – Antidote Health (Texas)

“We expect to see a reduction in the overall market size in 2027. We expect the expiration of the enhanced premium subsidies first introduced through the ARPA – and later extended by the Inflation Reduction Act (IRA) – at the end of 2025 to result in fewer individual members enrolled in exchange plans … We anticipate the remaining risk pool in 2027 will have higher healthcare needs, on average, as healthier individual consumers are more likely to lapse coverage and healthier small groups move to alternate funding arrangements. To account for these changes, we included a morbidity adjustment of 4.7%.” – Maine Community Health Options (Maine)

“The enhanced premium subsidies first introduced through the American Rescue Plan Act (ARPA) and later extended by the Inflation Reduction Act (IRA) expired at the end of 2025. We observe a reduction in the overall market size in early 2026, and we expect continued decline in enrollment throughout 2026 and into 2027 as consumers have either lost access to subsidies (for those at or above 400% of the Federal Poverty Level) or face higher net premiums due to less generous subsidies. We expect this will lead to an increase in average statewide morbidity in 2027 relative to the manual rate experience.” – AmeriHealth Caritas (Indiana)

“The enhanced premium tax credits that were created by the American Rescue Plan expired on December 31, 2025. Per a source provided by DFS on April 14, 2025 (the letter from the Congressional Budget Office (CBO)) by not extending premium tax credits CBO expects: ‘That healthier-than-average people will exit the marketplace…and in response insurers will raise premiums for the remaining enrollees…Without a permanent extension, CBO estimates, gross benchmark premiums will increase by 4.3 percent in 2026, by 7.7 percent in 2027 and by 7.9 percent, on average, over the 2026-2034 period.’ As a result, we increased our projected claims by 7.7%.” – Health Insurance Plan of Greater New York (New York)

Federal regulatory changes

Some insurers cite federal regulatory changes, including the recent Notice of Benefit and Payment Parameters (NBPP) and the Marketplace Integrity and Affordability Rule, as having an upward effect on premiums.

“The impact of the expiration of the American Rescue Plan Act expanded subsidies and the CMS Marketplace Integrity and Affordability Proposed Rule account for 12.7% of the requested rate change.” – UnitedHealthcare of New York (New York)

“Specifically, Oscar anticipated changes to the market morbidity associated with the change in New York’s enrollment for the projection period relative to the experience period, due to the ending of the enhanced subsidies introduced by the American Rescue Plan Act, as well as the several new enrollment and eligibility procedures and requirements introduced by regulations including, but not limited to, the 2025 Marketplace Integrity and Affordability Proposed Rule and the HHS Notice of Benefit and Payment Parameters for 2027 Final Rule.” – Oscar (New York)

The NBPP is released annually and establishes guidance for how the Marketplaces will operate. However, the 2027 NBPP was not finalized until after some insurers had already prepared their 2027 premium rate filings. Some insurers noted that the late finalization of the NBPP created uncertainty in their 2027 rate filings.

“The Final 2027 NBPP has not been released. Should it differ materially from the draft 2027 NBPP with relation to de minimis ranges or any of factors pursuant to standard plan designs, it could impact the accuracy of this report.” – Coordinated Care Corporation (Washington)

“The U.S. Department of Health and Human Services Notice of Benefit and Payment Parameters for 2027 Final Rule was finalized on May 15, 2026. To meet the May 21 submission deadline, the URRT template submitted with this filing includes limited information for CSR base period reporting. The final rule indicated that issuers should use the standard methodology for CSR reporting prior to rates being finalized. Accordingly, the URRT will be updated once further guidance is provided through NY DFS, and we will work toward completing the base period CSR reporting using the standard methodology in the interim.” – MetroPlus (New York)

Some specific provisions from the NBPP that were mentioned among the reviewed rate filings are pre-enrollment special enrollment period verification requirements and multi-year catastrophic coverage.

“Rates also reflect provisions regarding pre-enrollment SEP verification as specified in the 2027 NBPP proposed rule.” – Iowa Total Care (Iowa)

“We recommend maintaining an annual rating framework for catastrophic plans for plan year 2027. If multi-year terms are finalized, they should be limited to shorter durations with delayed implementation. Extending plan terms beyond one year introduces uncertainty related to adverse selection, enrollment volatility, and risk adjustment, which may complicate actuarially sound pricing and increase solvency risk, particularly given limited experience data and ongoing market changes. Allowing time for guidance and operational updates would reduce solvency and pricing risk.” – Anthem Insurance Companies (Indiana)

H.R. 1 – Working Families Tax Cut Act

The budget reconciliation legislation, also known as the “One Big, Beautiful Bill” or “Working Families Tax Cut Act,” was signed into law in July 2025 and affected several federal health programs, including the ACA Marketplaces and Medicaid. Implementation of policies related to the ACA Marketplaces began in 2026, though others are set to begin later. Starting in 2026, a person enrolling in the Marketplace through a non-qualifying life event (QLE) special enrollment period (SEP) and low-income immigrants who are ineligible for Medicaid due to their immigration status are ineligible from receiving financial assistance on the Marketplace.

The budget reconciliation legislation was rarely mentioned in rate filings, but when referenced, discussed the law’s impact on coverage eligibility.

“The implementation of the federal law H.R. 1 also known as the One Big Beautiful Bill Act is driving significant shifts in how individuals and families qualify for coverage and what they pay for their health plans. Further, the expiration of enhanced premium tax credits has affected affordability, reducing the financial support that previously made health insurance more accessible for our members. These federal policy changes negatively affect the risk pool, through the loss of lower-risk members and limit access to more affordable plan options, particularly for our Health Connector members.” – Mass General Brigham Health Plan, Inc. (Massachusetts)

“CHPW anticipates that the potential influx of former Medicaid members related to new HR1 requirements could also affect morbidity and risk adjustment dynamics.” – Community Health Plan of Washington (Washington)

“In accordance with the federal Public Law 119-21 (the “One Big Beautiful Bill” or “OB3”), an additional adjustment of 1.056 was applied to account for temporary legal immigrants losing APTC eligibility in 2027, as well as the continued 2026 impacts of immigrants earning less than 100% FPL losing APTC eligibility. This factor also reflects expected impacts of the reduced state premium subsidies for 2027 and the continued impacts of the subsidy cliff returning for consumers above 400% FPL beginning in 2026.” – Optimum Choice – UnitedHealthcare (Maryland)

Go to the hyperlink, above, for some graphics and a detailed data set in the report's appendix.