Health Care Matters | November 21
GOP Proposals Shift ACA Subsidy Debate Toward Consumer-Controlled Accounts
With enhanced ACA premium subsidies set to expire December 31, Republicans are proposing to redirect federal assistance away from direct premium support and into consumer-controlled spending accounts. Senator Bill Cassidy (R-La.) has outlined a framework that would maintain the ACA's original baseline premium tax credits but convert the approximately $30 billion in annual enhanced subsidies into health savings accounts (HSAs) tied to bronze marketplace plans to help consumers pay deductibles and other out-of-pocket costs rather than reducing monthly premiums. President Trump has demanded Congress send subsidy money "directly to the people" so they can "buy their own, much better, insurance," though details remain vague. Senate Majority Leader John Thune has committed to a vote in mid-December, but any legislation requires 60 votes to overcome a filibuster, and Democrats have rejected the approach arguing it would destabilize ACA marketplaces by triggering adverse selection as healthier enrollees drop comprehensive coverage, leaving sicker patients in the risk pool and causing premium spikes. Read here and here.
Why It Matters
The policy shift poses severe risks for lower-income Americans who currently rely on enhanced subsidies that make marketplace coverage affordable, with many paying $10 or less per month in premiums. Converting these subsidies to HSAs tied to high-deductible bronze plans would expose families to deductibles of $7,000 or more before coverage becomes meaningful, and unlike premium assistance that automatically reduces monthly costs, HSAs require upfront cash to cover medical expenses while they cannot be used for premiums themselves. For health systems and payers, if adverse selection materializes with healthier enrollees dropping coverage, insurers will face a sicker risk pool forcing premium increases while providers may see rising uncompensated care. The compressed timeline forces organizations to finalize 2026 provider networks and value-based contracts without knowing the subsidy structure, while state marketplace administrators must communicate with consumers during open enrollment despite being unable to provide accurate affordability information. The lack of clarity leaves rural and low-income regions at highest risk of insurer exits and coverage deserts.
CMMI Operationalizes Trump Administration Priorities Through Three Core Model Design Principles
In a recent Health Affairs blog, CMMI leadership detailed how they are translating the current administration's policy priorities into concrete model requirements. The agency outlined three core principles shaping all future demonstrations: first, embedding evidence-based utilization controls from model launch through mechanisms like prior authorization for low-value services; second, mandating direct provider accountability through downside risk arrangements that eliminate intermediary risk-bearing; and third, implementing standardized, formula-driven benchmarking methodologies that promote market competition and fiscal discipline. These design elements operationalize the administration's emphasis on protecting taxpayer dollars, reducing regulatory burden through market mechanisms, and ensuring provider (not third-party) accountability for outcomes. Read here.
Why It Matters
CMMI's approach directly implements the reform framework outlined in the Paragon Institute report we analyzed last month. Paragon's call for mandatory demonstrations, competitive benchmarking, and broadened participant types is now embedded in models like TEAM, the proposed ASM, and WISeR. This signals that success in the Innovation Center's portfolio will require organizations to demonstrate operational readiness for mandatory participation, data infrastructure capable of supporting real-time utilization management, and financial capacity to assume direct downside risk without intermediaries. The shift from voluntary experimentation to mandatory, market-oriented accountability represents a fundamental realignment of CMMI's role: one that prioritizes fiscal restraint and competition over provider flexibility and increased voluntary participation. Organizations that can align their strategic planning with these administration priorities, particularly around direct risk assumption, will be positioned to participate as CMMI's reform agenda unfolds.
Look for the Helpers: Supporting Community-Based Public Health in Philadelphia
The Penn Center for Public Health has launched a new Impact Hub to help community-based organizations strengthen their ability to deliver local health solutions. The Hub provides hands-on support including training, staffing assistance, and guidance on grant applications and data use to help smaller organizations expand services such as healthy food access and violence prevention programs. By equipping local leaders with the tools and capacity they need, the initiative is empowering communities to advance health and well-being from the ground up. Read here.
What We're Writing
Key Focus Areas in State Rural Health Transformation Program Initiatives
In our latest blog, we examine themes from 37 state applications to the Rural Health Transformation Program. Despite differences in geography and local context, states overwhelmingly focus on seven shared priorities: workforce development, telehealth, mobile care, chronic disease prevention, maternal and child health, payment reform, and infrastructure modernization. We also highlight our State Initiative Tracker, which captures where states are directing energy and where TA needs may emerge. Read the full blog post here.
What We Are Reading
Value-Based Payments Associated With Improved Quality Of Care At Federally Qualified Health Centers
A recent study in Health Affairs finds that value-based payment arrangements are linked with modest quality improvements at FQHCs, though participation barriers remain for many centers. Read here.
Focus on Value Results in Higher Quality of Care for Aetna Medicare Members
A recent whitepaper published by Aetna presents comparative data showing that Medicare Advantage members treated under its value-based-care models experienced clearer preventive-care gains, improved chronic-condition control and lower total costs than those in traditional fee-for-service arrangements. Read here.
Federal Investment in Primary Care Transformation: A Systematic Review and Qualitative Analysis
A JAMA Health Forum systematic review finds that federal initiatives to strengthen primary care since 2011 have improved clinical delivery and provider experience, though effects on utilization, patient experience, and cost savings remain inconsistent. Read here.
UnitedHealthcare Pays Optum Providers More Than Non-Optum Providers
A Health Affairs article finds that provider groups affiliated with Optum and paid by UnitedHealthcare receive significantly higher reimbursement rates than non-Optum groups, raising concerns about market power and payer-provider alignment. Read here.
CMS Advances Interoperability Initiative, Showcases Early Look at National Provider Directory
A Fierce Healthcare article reports that CMS held an industry event in Washington D.C. where it unfolded a beta version of its national provider directory built on FHIR-based APIs and demonstrated industry-partner interoperability tools to advance its broader data-sharing agenda. Read here.
What We're Watching
The Future of Health Forum
The Future of Health Forum, hosted by Semafor in partnership with West Health and Gallup brought together policymakers and health leaders to discuss how Americans are experiencing the health system today and unveiled a new digital platform with state level data on cost, quality and access. Watch the full event recording here. Check out their new website here.
New Resource
Caregiving in the US 2025
This updated, comprehensive report by National Alliance for Caregiving and AARP offers deep data on the 63 million Americans providing ongoing care, including state-level breakdowns, intensity metrics, and links between caregiver strain and health system impact. Read the full report here.
