Health Care Matters | February 13
House Republicans Subpoena ACA Insurers Over Subsidy Fraud Concerns
House Judiciary Committee Republicans issued subpoenas to eight major Affordable Care Act insurers seeking documents related to premium tax credits and fraud prevention practices. The action follows federal audit findings that identified weaknesses in eligibility verification and raised concerns about improper enrollments tied to advanced premium tax credits. Lawmakers are requesting internal communications, data, and documentation outlining how insurers verify applicant information, prevent fraudulent enrollments, and reconcile subsidy payments. The inquiry examines oversight of the individual marketplace, including the period when enhanced pandemic-era subsidies were in effect and contributed to record enrollment levels before expiring at the start of this year. Insurers have indicated they are cooperating with the investigation as congressional leaders signal continued interest in marketplace accountability. Read more here and here.
Why It Matters
This development places the ACA individual market under intensified congressional scrutiny at a pivotal moment for the program. Enhanced subsidies significantly reduced net premiums and expanded coverage access in recent years, making their recent expiration a focal point for debate about marketplace affordability and stability. The fraud-focused inquiry is likely to inform how policymakers balance program integrity with access considerations, potentially shaping future eligibility verification standards, subsidy reconciliation processes, and insurer reporting requirements. It also comes amid broader reporting on enrollment growth, premium pressures, and funding challenges tied to the expiration of enhanced subsidies and federal oversight efforts. Depending on its findings, the investigation could influence legislative discussions around whether and how to extend or modify subsidies, while also affecting operational expectations for insurers and exchanges. As Congress weighs competing priorities of fraud prevention and coverage accessibility, the outcome may have meaningful implications for consumers, carriers, and state marketplaces navigating an evolving policy landscape.
Look for the Helpers: Community Health Workers Strengthen Care in Ohio
Community health workers trained through Ohio University’s expanding program are serving as trusted connectors between health systems and diverse communities across the state, helping residents overcome care barriers such as transportation challenges, language access, and mistrust while strengthening health outcomes in both rural and urban areas. These frontline professionals use lived experience and cultural understanding to link individuals to preventive services, social supports, and follow-up care, reducing disparities and improving continuity of care where it’s needed most. Read here.
New Resource
CMS Ambulatory Specialty Model (ASM) Participant Readiness Roadmap
CMS released a Participant Readiness Roadmap to help organizations prepare for ASM, a new Innovation Center model set to begin in 2027 that holds outpatient specialists accountable for proactive management of chronic conditions like low back pain and heart failure. The roadmap outlines key pre-implementation steps including verifying participation status, preparing for data reporting, understanding performance metrics and quality requirements, collaborating with primary care partners, and aligning internal resources to meet model expectations. It also highlights important timelines, upcoming CMS resources, and action items to help participants gear up for the model launch. Read here.
What We Are Reading
Beyond Star Ratings: Proposal For A Medicare Advantage Transparency Scorecard
In a recent Health Affairs article, authors propose the creation of a Medicare Advantage transparency scorecard to supplement Star Ratings by increasing visibility into non-clinical aspects of plan performance and accountability beyond traditional quality measures. Read here.
ACOs Improve Primary, Preventive Care Delivery for Medicare Beneficiaries
An analysis published in the American Journal of Managed Care finds that accountable care organizations participating in Medicare Shared Savings Programs are associated with higher rates of primary and preventive care delivery for Medicare beneficiaries compared with traditional Medicare. Read more here.
Bundled Payments For Care Improvement Advanced: Effects On Hospital And CMS Spending, 2018–21
A Health Affairs research article examines the effects of the Bundled Payments for Care Improvement Advanced (BPCI-A) program, evaluating how this episode-based payment model has influenced hospital spending and Medicare outcomes under the Centers for Medicare & Medicaid Services’ initiative. Read here.
What We're Attending
2026 Health Policy Conference: Driving Health Policy Transformation in the Next Decade
Health policy leaders, researchers, and federal and state policymakers will convene March 2–3 in Washington, DC for the Health Policy Conference 2026 to examine critical issues facing the health care system, including payment reform, affordability, and workforce challenges. The agenda will feature keynote speakers, panel discussions, and deep dives into policy levers to advance access and quality while restraining costs. Attendees can expect insights on emerging federal and state priorities, strategies for system transformation, and opportunities to engage with cross-sector stakeholders shaping health policy this year. Register here.
Value-Based Payment Summit 2026
The Fifth Virtual Value-Based Payment Summit will take place March 2–6, 2026 as part of Health Care Value Week, convening policymakers, health system leaders, payers, and innovators for a week of sessions focused on advancing value-based care. The agenda includes discussions on bundled payments, accountable care, quality measurement, social drivers of health, and practical approaches to implementing and scaling risk-based models. Participants can expect actionable insights on emerging payment reforms and strategies shaping the future of value-oriented care. Register here.
Pop Health Podcast
New Model Mania: Unpacking CMS's RHTP, ASM, LEAD, ACCESS, and ELEVATE
In the latest episode of the Pop Health Podcast, we break down CMS’s expanding portfolio of payment and delivery reform models, from the Rural Health Transformation Program and the Ambulatory Specialty Model to the new LEAD and ACCESS initiatives and the emerging ELEVATE framework, and discuss what these shifts mean for providers, payers, and health care leaders navigating value-based care in 2026 and beyond.