This week felt weirdly calm – I am sure I just jinxed it. No AMP is WAC next week. If something interesting happens, I’m sure I won’t be able to help myself and will post on LinkedIn. Have a great Thanksgiving and I hope you remember that nothing will change that person at the table, so just let it go and have more pie.
Premiums Up, Heads Up it is Time to Shop for Plans. On Friday, the Centers for Medicare & Medicaid Services (CMS) released 2026 Medicare Parts A and B premiums and deductibles along with the Medicare Part D income-related monthly adjustment amounts. The standard Part B premium rises to $202.90 with a $283 deductible; Part D income-related monthly adjustment amounts start at $14.50 and scale with income. Pair this with 2026 Part D design changes, most notably the $2,100 out-of-pocket (OOP) cap, and the affordability story is nuanced: monthly premiums and high-income surcharges tick up, but catastrophic exposure shrinks for heavy users of specialty drugs.
The problem is that most beneficiaries live in the middle ground with higher premiums, more formulary management and higher cost-sharing that doesn’t get them to the OOP cap. Patients need to shop carefully for their 2026 Medicare plans.
Ceiling Fan. On Monday, the Maryland Prescription Drug Affordability Board added Ozempic (semaglutide) and Trulicity (dulaglutide) to the list of drugs “likely unaffordable,” and directed staff to draft upper payment limit (UPL) language for Jardiance (empagliflozin) and Farxiga (dapagliflozin). This is the final step before a vote to cap what state and local plans will pay.
Staff recommended anchoring UPLs to Medicare’s 2026 Maximum Fair Prices (MFPs) for the same products, $197 per 30-day supply for Jardiance and $178.50 for Farxiga, arguing this approach maximizes savings and is administratively workable.
Except, unlike Medicare, there is no mandate that supply chains sell the product at these prices. It does not dictate cost, just reimbursement. This could mean that patients won’t have access to these products. But now I’m just repeating myself…
Rebate Remix: Data Wins the Day. On Tuesday, Health Affairs Forefront framed the 2026 340B Rebate Model Pilot as a clean trade: stronger program-integrity controls in exchange for real cash-flow risk to safety-net providers that must buy at wholesale acquisition cost and wait for manufacturer rebates.
Even though the pilot hasn’t started, the heat is on. As Endpoints News reported, drugmakers told the D.C. Circuit court that a limited government pilot won’t resolve broader concerns about diversion and duplicate discounts. Meaning this needs to be bigger, and pharmaceutical companies need to be allowed to access the data behind the claims.
In a LinkedIn post, (the awesome) Bill Sarraille adds the key subplot: Judge Pillard repeatedly poked at why manufacturers couldn’t address duplicate-discount risk by conditioning offers on data collection – a signal, Sarraille argues, that the “data requirement” fight is effectively over. If that holds, expect a surge in manufacturer data conditions even outside the pilot, with courts viewing data-sharing as a reasonable safeguard.
Bottom line: the 340B debate is evolving from “rebates vs. discounts” to “rebates require data.” Winners will be the stakeholders most ready to validate claims, reconcile quickly, and keep cash flow stable while the model, and the case law, matures. And I do feel for 340B entities that will have difficulty with the cash flow changes. But honestly, the value of the 340B program is way over $100 billion, so data seems like a reasonable ask.
City Limits. On Tuesday, The New York Times’ Upshot spotlighted (gift link) who gets hit hardest if Republican Medicaid cuts advance — and it’s not just rural America. The companion analysis from Harvard’s Health Care Quality & Outcomes Lab shows most at-risk facilities are urban safety-net hospitals with high Medicaid mix and thin margins. Among 109 “most vulnerable” hospitals identified, 85% were urban, suggesting big-city obstetrics, behavioral health, and oncology access could take the immediate hit. And that’s less access for patients across the board.
What’s Up Doc. On Monday, JAMA published a national look at physician participation in the Medicare program from 2013–2023. Net participation rose 6.3% (about 586k to 622k clinicians), but exits were more likely among older, female, primary-care physicians and those practicing in non-metro or Health Professional Shortage Area counties. The COVID years accelerated departures to a decade high in 2023, even as the overall pool grew.
Access implications land first in rural and underserved urban markets where plan networks already lean on small practices. This raises flags for patient access, which is already a challenge in these areas.
Fast Pass, Slow Pay? A Follow Up. Last week I wrote about the National Priority Voucher pilot. This week Bloomberg Law had a story that made me think, yup, I got it right.
On Thursday, Bloomberg Law reported that health insurers may resist quick and comprehensive coverage for drugs cleared under the Food and Drug Administration’s new super-expedited pathway, the Commissioner’s National Priority Voucher (CNPV) pilot. The pilot promises team-based engagement and decisions in one to two months. It’s designed for products addressing urgent public health needs and other national priorities.
Access implications are straightforward. Faster approvals won’t automatically translate into immediate, unrestricted coverage. Plans will likely default to prior authorization (PA), step therapy, and indication-specific edits until post-market evidence matures. Expect heavier real-world data requests, tighter specialty-pharmacy channels, and requirements to use specific companion diagnostics where applicable. For manufacturers, that means building payer-ready evidence packages by launch, not after. And let’s be honest, even then… coverage is iffy. For patient advocates, watch the utilization-management guardrails: transparent PA criteria, appeal timelines that meet state and federal standards, and formulary exception pathways aligned to the labeled population.
The CNPV pilot may speed regulatory decisions, but coverage will hinge on how convincingly sponsors translate “expedited review” into clinical value that actuaries can price.
Model Behavior. Last Friday, Health Affairs Forefront published five takeaways from the Medicare Part D Senior Savings Model, which tested a maximum $35 monthly copayment for insulin. This model, voluntary for Part D plan sponsors and manufacturers from 2021 through 2023, was designed to provide beneficiaries with predictable and affordable insulin costs across the deductible, initial coverage, and coverage gap phases.
The five operational lessons are to: (1) spell out a clear theory of change, (2) align plan incentives, (3) target beneficiary outreach, (4) build a real data framework, and (5) set realistic timelines.
The CMS final evaluation confirmed that the $35 insulin cap successfully smoothed costs, increased insulin utilization, and improved patient adherence for users in participating plans. However, the report also highlighted the model’s key operational challenges: results varied due to the voluntary nature of plan participation and the significant beneficiary awareness gap. The evaluation confirmed that achieving the full intended value of such a model is dependent not just on the policy, but on the underlying mechanics of measurement, execution, and communication. This operational focus must inform the development of future high-cost drug demos. Like GLP-1s perhaps?
Reviewing the Fundamental: Cash may be King but Coverage is Aces.
A proposal making the rounds would replace Affordable Care Act (ACA) premium subsidies with government-funded Health Savings Accounts (HSAs). It’s simple to describe, but problematic in practice.
HSAs are a financing tool for high-deductible health plans; ACA subsidies buy entry into a regulated, risk-pooled market with defined benefits. Swapping one for the other trades protection for exposure and assumes away the reality that many people will have sizable, unpredictable expenses. And that they understand what an HSA is and how to use one.
A little background… HSAs work only with Internal Revenue Service–qualified high-deductible plans. Those designs push costs to patients first, then coverage kicks in. The ACA framework provides essential health benefits, out-of-pocket maximums, risk adjustment across plans, appeals rights, and rate review. HSAs do not purchase any of that; they fund the front end of cost sharing. That’s it. Full stop.
Marketplace enrollment skews toward lower income individuals. Many enrollees select silver plans because cost-sharing reductions convert them to quasi-gold coverage for outpatient care and drugs. To replicate that protection, an HSA grant would need to be large and recurring; otherwise, patients face deductibles they cannot overcome. HSAs are most attractive to higher-income households that can add their own contributions and tolerate cash-flow shocks. The net effect is more underinsurance where risk is highest.
Prescription drugs make the trade-offs visible. In high-deductible designs, pharmacy spending often applies to the deductible unless plans adopt preventive drug lists and put key medications before the deductible. Even then, with less pooling and more individual exposure, plans will be forced to manage costs that will put in barriers to access (tighter formularies, more utilization management, etc.)
The theory that HSAs will discipline prices by giving consumers “skin in the game” does not match how health spending works. Most dollars flow through emergencies, complex episodes, and chronic care where the pathway is clinician-led, prices are opaque, and choices are limited. The main price drivers sit upstream of the patient’s wallet.
Putting in HSAs muddies the water. The administration could keep ACA rules in place, and HSAs would simply offset some patient costs while premiums skyrocket without the subsidies. Loosen the rules to cut premiums, and coverage becomes skinnier and less predictable, with weaker drug protections and narrower networks. Either way falls short of ideal.
It isn’t that HSAs are a bad idea; they are just a bad idea to replace the subsidies for 2026. Insurance premiums are going up across the board – for employers too. Giving money in an HSA puts a Band-Aid on a broken leg. We need to set the leg first.
If HSAs are the desired path forward, we need to focus on the mechanisms that drive prices and access barriers, rather than shifting risk to households. We need to target unit prices and market power with site-neutral payment and scrutiny of vertical integration and steering. We need to keep patient costs predictable with clinically informed pre-deductible coverage, copay caps for selected high-value drug classes, and monthly out-of-pocket smoothing.
Bottom line: replacing ACA subsidies with HSA deposits moves from pooled protection to individual exposure. If the goal is coverage people can use, and medications patients can start and stay on, then we must keep the risk pool together, maintain defined benefits, and fix prices and incentives upstream. A debit card is not the right reform, at least for now.
