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Wednesday, September 30 · 35 stories
- Industry
AMA Report: Top Four PBMs Now Control 75% of Market
The American Medical Association's September 2026 Policy Research Perspective, drawing on Decision Resources Group data from 2022 to 2024, found the four largest pharmacy benefit managers now control 75% of the national market, up from 70% in 2022. The report documents continued consolidation among PBMs and insurers tracked over the study period. Becker's Hospital Review summarizes six key findings from the analysis. The data underscores ongoing concentration trends affecting drug pricing and negotiation leverage across the pharmaceutical supply chain.
- Industry · MI
Family Fights Nursing Home Over Sedating Drugs for Dementia Patient
A Michigan family's dispute over whether to sedate their mother, who has dementia and lives in a long-term care facility, highlights the continued widespread use of potent sedating medications on agitated dementia patients despite federal efforts to discourage the practice. The sons sought to keep their mother off the drugs, clashing with facility staff over her care. The case illustrates the difficult decisions families, guardians, and facilities face when balancing behavioral symptom management against the risks and side effects of antipsychotic and sedative medications. Federal oversight has pushed nursing homes to reduce inappropriate antipsychotic use, but enforcement gaps and staffing pressures continue to drive reliance on these drugs.
- Industry
Survey: Rural Voters Say MAHA Policies Haven't Reached Them
A KFF-Associated Press survey finds rural voters who support the Make America Healthy Again (MAHA) movement report that Trump administration health policy changes have not materially reached their communities. Respondents include rural residents who back the movement's goals but say they see little visible change in local health services or outcomes. The survey does not specify a policy effective date, but reflects an ongoing gap between federal health messaging and rural on-the-ground experience. The findings matter for rural health stakeholders, including Medicaid providers and state agencies, who must gauge whether federal initiatives are translating into resources or program changes at the community level.
- Federal Policy
Senate Democrats Question HHS Over Delayed Pediatric COVID Vaccine Access
Senate Minority Leader Chuck Schumer and other top Senate Democrats sent a letter to CDC Director Erica Schwartz and HHS Secretary Robert F. Kennedy Jr. questioning an apparent delay in making COVID-19 vaccines available to low-income children through a federal program. The lawmakers are seeking answers about why access through this program has stalled and what HHS plans to do to restore timely vaccine availability. The letter does not specify a response deadline in available reporting. Low-income children who rely on federally funded vaccine access programs, often coordinated with state Medicaid and CHIP populations, are the primary group affected by any delay.
- Industry
Becker's: 2027 Drug Pricing Changes Pose Cash Flow, Not Margin, Risk
In a Becker's Hospital Review commentary, the author argues that three federal drug pricing changes taking effect Jan. 1, 2027 should be understood primarily as a cash flow timing problem rather than a permanent margin loss for providers and pharmacies. The piece pushes back on recent coverage characterizing the changes as catastrophic, arguing the actual financial mechanics are more nuanced. The commentary frames the issue around how multiple federal changes converging on the same prescription create timing mismatches in reimbursement rather than structural profitability declines. The author's argument centers on encouraging providers and pharmacy stakeholders to reassess their operational and financial planning assumptions ahead of the effective date.
- State Policy · WV
WV Advocates Press State to Fix Autism Therapy Workforce Shortage
Advocates for children with autism in West Virginia are urging state officials to address a shortage of workers who provide applied behavior analysis and other therapy services covered by Medicaid. Families report long waitlists and difficulty accessing care due to insufficient numbers of trained providers, particularly in rural areas. The advocates are calling on state leaders to take action on reimbursement rates, provider recruitment, or other policy levers to expand the workforce. No specific legislative or regulatory proposal has yet been detailed in this report.
- Federal Policy
Census Bureau Proposes 2030 Rule Changing Residency, Apportionment Rules
In a resource brief, State Health and Value Strategies examines a Census Bureau proposed rule, published September 10, 2026, that would overhaul 2030 Census residence criteria and demographic data collection, alongside a new Disclosure Avoidance Order changing privacy protection methods for public data products. The residency proposal would exclude many non-citizens from population counts and establish a new January 3–April 1 enumeration period, while also excluding undocumented immigrants and other groups from congressional apportionment counts. State health agencies rely on Census products like the American Community Survey and Current Population Survey for Medicaid and CHIP funding formulas, coverage monitoring, disparity analysis, and program cost projections. Comments on the proposed rule are due October 13, 2026, giving states a limited window to weigh in on changes that could ripple through health policy data infrastructure.
- Federal Policy
Trump Administration Withholds Health Funds Before Fiscal Year Deadline
The Trump administration has declined to spend billions of dollars in congressionally appropriated health program funding, risking its expiration at the fiscal year-end on Wednesday. Democratic lawmakers and some Republicans argue the withholding violates federal law governing appropriated funds. The impasse tests whether Congress will act to compel spending of the funds before they lapse. The story does not specify which health programs or dollar amounts are affected.
- State Policy · MO
Missouri Lacks Mandatory Mental Health Screening for Pregnant Patients
Missouri's latest Pregnancy-Associated Mortality Review found mental health conditions and substance use disorder contributed to nearly a quarter of pregnancy-related deaths from 2019 to 2023, with 24 of 108 reviewed deaths attributed to these causes. Providers failed to complete mental health or other key screenings in 38 of the deaths reviewed, and nearly 80% of pregnancy-related deaths were deemed preventable, including all mental health and substance use deaths. Screenings for perinatal mental health conditions remain voluntary in Missouri rather than mandatory, and the state received a "C" grade in 2026 from the Policy Center for Maternal Mental Health, up from a D-minus in 2023. The mortality rate was 2.9 times higher for women on Medicaid than those with private insurance, and rural areas, especially northeast Missouri, saw the highest death rates and face acute shortages of mental health providers.
- State Policy · SD
South Dakota Ballot Measure Opponents Warn of Medicaid Expansion Repeal Risks
Opponents of South Dakota's Amendment I, on the Nov. 3 ballot, said Monday the measure would reduce health care access and shift costs to privately insured residents. Amendment I would automatically repeal Medicaid expansion if federal funding for the expansion population is reduced below current levels. South Dakota's Republican attorney general and other opponents oppose the measure, arguing it threatens coverage gained through expansion. The vote takes place November 3, and its outcome will determine whether the state's expansion population retains coverage if federal funding changes.
- Legal · CO
CWS Colorado Director Urges Congress Restore Refugee Medicaid Eligibility
In a Colorado Newsline commentary, Kristy Beachy-Quick of CWS (Church World Service) argues that federal law revoking Medicaid eligibility for refugees, asylees, humanitarian parolees, and trafficking survivors will harm vulnerable Coloradans starting October 1, 2026. She cites the 2025 federal reconciliation law (H.R.1) as eliminating this coverage for roughly 7,000 Coloradans, leaving chronic conditions untreated and shifting costs to hospitals, food banks, and nonprofits. The author contends refugees contribute significantly in taxes and economic activity, citing state estimates of $127.1 million in state/local taxes and $233.3 million in federal taxes paid by Colorado refugees in 2023. She calls on Congress to restore Medicaid eligibility for these humanitarian populations.
- State Policy · NE
Nebraska Early Data Shows Medicaid Work Requirement Verification Outcomes
A policy brief examines Nebraska's process for verifying compliance with Medicaid work requirements and reports early data on how enrollees subject to the requirement have fared. The brief details how the state confirms work, education, or other qualifying activities, and what share of affected enrollees have successfully verified compliance versus those at risk of losing coverage. Findings are relevant as more states implement or plan similar requirements following federal changes expanding work requirement mandates. The brief highlights administrative and verification challenges that could inform other states' implementation strategies.
- State Policy · CO
Colorado Warns Proposed Federal Rules Would Cut Medicaid Funding
Colorado officials say newly proposed federal rules would have a "disastrous" effect on Medicaid and other insurance funding streams, further straining an already stressed state budget. The state warns that lost federal funding under the proposal would force difficult tradeoffs in coverage and spending. Details on the specific federal rule's scope, comment deadline, and mechanism are not fully specified in the source report. State officials are raising alarms as the proposal moves through the federal rulemaking process.
- Federal Policy
Bipartisan Bill Would Make PACE a Mandatory Medicaid Service
Reps. Debbie Dingell (D-Mich.) and John Moolenaar (R-Mich.) introduced the PACE Access Improvement Act on Sept. 24, which would make the Program of All-Inclusive Care for the Elderly a mandatory Medicaid service rather than a state option. The bill also aims to ease requirements so PACE providers can expand in-home care access. States currently choose whether to offer PACE, which serves frail, dual-eligible seniors who qualify for nursing home care but wish to remain in the community. If enacted, the measure would require all state Medicaid programs to cover PACE, likely spurring growth in the number of PACE organizations and enrollees nationwide.
- Legal · NC
Whistleblowers Allege NC Officials Falsified Medicaid Tech Funding Bids
A newly unsealed federal lawsuit alleges former North Carolina health officials submitted false information to secure federal funding for a Medicaid technology overhaul, and that federal regulators approved the funding despite warning signs. Former state employees serving as whistleblowers brought the claims, which implicate both state Medicaid leadership and the federal approval process. The lawsuit was previously dismissed but the whistleblowers may seek to revive it. The case raises questions about oversight of federal matching funds for state Medicaid IT modernization projects.
Tuesday, September 29 · 26 stories
- Industry
RFK Jr., Vance Headline MAHA Summit on Health Policy Agenda
HHS Secretary Robert F. Kennedy Jr. and Vice President JD Vance are leading a daylong "Make America Healthy Again" summit in Washington on Tuesday, gathering Trump administration officials, health care and tech executives, and MAHA allies. Sessions cover health care affordability, food policy, and artificial intelligence, among other topics. The event is a policy and messaging forum rather than a rulemaking action, but it signals priorities that could shape future administration health initiatives. No specific Medicaid policy announcements are described in the available details.
- Industry
Covista Report Warns Clinician Shortage Will Double by 2040
A new report from healthcare education company Covista projects that the U.S. clinician shortage will double by 2040, warning of a looming workforce crisis across the health care system. The report highlights growing gaps in physicians, nurses, and other clinical staff that could strain care delivery nationwide. Covista argues the trend is not yet irreversible and points to workforce education and training strategies as potential mitigation steps. The report does not detail a specific timeline for policy action but frames the issue as an urgent, worsening trend.
- Industry
UnitedHealthcare Names Robert Hunter as New President
UnitedHealthcare has appointed Robert Hunter as president, tasking him with leading the company's "modernization agenda." The move is the latest in a series of leadership changes at parent company UnitedHealth Group as it seeks to rebuild its public image. No specific start date or further details on Hunter's mandate were provided beyond the modernization focus.
- Industry
McKinsey: AI Could Handle Up to 22% of Outpatient Care
A McKinsey & Co. analysis published Sept. 28 estimates AI could perform the clinical work behind 16% to 22% of U.S. outpatient claims, representing roughly 2 billion to 3 billion claims and 13% to 19% of outpatient spending. The analysis draws on 2024 commercial, Medicare and Medicaid claims data. It suggests a substantial share of outpatient services across payer types, including Medicaid, involve tasks that current AI capabilities could technically automate. The report does not specify implementation timelines or payer-specific adoption plans.
- Federal Policy · MT
CMS Awards $8.7 Million for Rural Montana Ambulance Upgrades
CMS announced $8.7 million in federal funding to purchase new ambulances and medical equipment for rural emergency medical service providers across Montana. The funding is intended to help rural communities replace aging equipment and improve emergency response capacity. Federal officials framed the award as part of a broader push to support rural health infrastructure. Specific implementation timelines and grant recipient details were not detailed in the announcement.