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Week in Washington 08/13/26

No Surprises Litigation –  A federal appeals court ruled against HHS regarding the No Surprises Act (NSA). The court ruled that the qualifying payment amount (QPA) which is central to disputes between insurers and providers in out-of-network billing disputes. HHS can appeal but in the interim dispute resolution may temporarily halt.  Shift in PBM Usage ... Continue reading

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ACA Marketplace Insurer Exits Are Reshaping the Market. Here’s How Health Plans Should Respond.

Opportunity After Exit: Strategic Responses to ACA Exits Key Takeaways Health insurers participating in the individual Affordable Care Act (ACA) Marketplace are facing one of the most challenging operating environments since the program’s early years. As enhanced subsidies expire, regulatory uncertainty grows, enrollment declines, and claims costs increase, many insurers are reevaluating their participation in ... Continue reading

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Potential CMS ACA Marketplace Disenrollments: Implications for Health Insurers

A recent US Department of Health and Human Services (HHS) report indicates that the Centers for Medicare & Medicaid Services (CMS) is taking action to identify and remove potentially unauthorized Affordable Care Act (ACA) Marketplace enrollments. These actions could have significant implications for individual ACA market issuers, including changes in morbidity, risk adjustment transfers, financial ... Continue reading

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Newsworthy Findings

Kennedy, Oz Contend Fraud Crackdown, Not Skyrocketing Prices, Led Millions To Leave Obamacare

The Trump administration credits its fraud control efforts for the disappearance of millions of people from Obamacare rolls rather than a sharp rise in premiums, a claim disputed by policy experts that glosses over the reality that many more Americans now find themselves without health insurance.

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Editor's Note
EDITOR’S NOTE: ACA enrollment fell by nearly 3 million people in 2026, with average premiums and deductibles rising substantially. The Trump administration attributes much of the decline to the removal of potentially fraudulent or improper enrollments, while health policy experts argue that higher costs and reduced subsidies are also major factors driving people out of the market.

CMS' Mandatory VBC Programs Brought Substantial Administrative Costs For Hospitals: Study

Participation in mandatory value-based payment programs is tied to higher annual administrative costs for hospitals, according to a comparative study published in JAMA Health Forum.

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Editor's Note
EDITOR’S NOTE: A study found that Medicare value-based payment programs were associated with more than $3 billion in additional administrative costs across participating hospitals form 2008-2020, likely reflecting added staffing and work related to reporting, care coordination, documentation and risk adjustment. The findings raise questions about whether the administrative costs of mandatory programs are adequately accounted for when evaluating their potential savings and quality improvements, particularly as CMS expands bundled payment models.

DentaQuest Breach Exposes Data of 15M People, a Record this Year

A hacker breached the Massachusetts-based dental and vision benefits administrator this spring.

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Editor's Note
EDITOR’S NOTE: DentaQuest, the second-largest dental benefits administrator in the U.S., serves approximately 32 million beneficiaries across its dental and vision plans. The company reported that a hacker accessed its systems between May 17 and May 20, potentially exposing sensitive information belonging to 15 million people. Compromised data may include Social Security numbers, Medicaid and Medicare IDs, as well as diagnosis, treatment, and billing information.

Trump Signs Order Seeking to Upend Childhood Vaccine Schedule

The executive order aims to split the MMR vaccine into three separate shots and revive a court-stalled attempt to narrow the immunization schedule.

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Editor's Note
EDITOR’S NOTE: The executive order signed Monday reduces the number of universally recommended childhood vaccines from 17 to 11. However, its practical impact remains unclear. Changes to federal vaccine recommendations typically flow through a CDC advisory panel, while states, not the federal government, generally determine which vaccinations are required for children attending schools and daycare facilities.

CMS ends Medicaid, CHIP Funding for Gender-Affirming Care for Minors

The Trump administration has finalized a rule that would pull funding for gender-affirming care for minors from Medicaid and the Children's Health Insurance Program.

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Editor's Note
EDITOR’S NOTE: The agency concluded "that the evidence supporting these interventions for children remains insufficient to justify federal taxpayer funding." It said that some medical associations, such as the American Society of Plastic Surgeons, are also updating their positions on these services.

Bonus Article

Just for Fun

Math Joke:

I’m odd, but if you take away one letter, I become even. What am I? 

Prior Week

Q: Why was the calculus student so optimistic?  

A: Because they believed every problem has limits.   

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