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Monday, August 31 · 111 stories
- Industry
Employers Reassess Health Benefits as GLP-1 Drug Costs Strain Budgets
Employers are fundamentally reconsidering health benefit design as spending on GLP-1 medications (Ozempic, Wegovy, Mounjaro) drives unprecedented cost increases. Self-insured employers and commercial health plans are implementing new coverage restrictions, prior authorization requirements, and cost-sharing structures to manage expenses that some benefit managers describe as unsustainable under current benefit designs. The shift is occurring across 2026 plan years as employers finalize benefits for 2027. This development matters primarily for commercial payers but has spillover implications for Medicaid programs in states that cover GLP-1s for weight loss, as commercial market strategies often preview Medicaid managed care utilization management approaches.
- Federal Policy
KFF Survey Finds LGBTQ+ Adults More Likely to Forgo Healthcare Due to Cost
A KFF survey of 2,640 LGBTQ+ adults found 60% missed needed healthcare in the past year due to cost or provider availability, compared to 38% of non-LGBTQ+ adults. Transgender adults, those under 30, and those with lower incomes or no insurance were most likely to forgo care. Among uninsured LGBTQ+ adults, over three-quarters reported missing needed healthcare. Nearly a third of LGBTQ+ adults said their health worsened as a result, with transgender adults and those on Medicaid or self-purchased plans experiencing higher rates of insurance denials and delays.
- Managed Care · MA
New England Senior Care Provider Discusses Immigration and Medicaid Policy Impacts on Long-Term Care
Adam Scott, leader of New England's largest nonprofit senior care and housing provider, discussed how immigration policy changes and Medicaid program shifts are affecting long-term care operations during a Harvard T.H. Chan School of Public Health interview. The discussion addressed rising demand driven by Massachusetts' aging population and workforce challenges in the long-term care sector. Scott outlined how policy changes at the federal and state level are creating operational pressures for providers serving Medicaid beneficiaries in residential and community-based settings. The conversation highlights staffing shortages and reimbursement adequacy as key concerns for nonprofit LTSS providers.
- Industry
FDA Expands Mounjaro Approval to Reduce Cardiovascular Risk in Type 2 Diabetes
The FDA approved Mounjaro (tirzepatide) to reduce major adverse cardiovascular events — cardiovascular death, nonfatal heart attack, and nonfatal stroke — in adults with type 2 diabetes at high cardiovascular risk. The approval follows the Surpass-CVOT trial involving over 13,000 participants across 30 countries. The expanded indication is effective immediately. This matters for Medicaid managed care organizations because cardiovascular disease is a leading driver of costs in diabetic populations, and the new indication may affect prior authorization policies, formulary placement, and utilization management for tirzepatide in high-risk beneficiaries.
- Legal · FL
Florida AG Sues Express Scripts and Prime Therapeutics for Alleged Price Fixing
Florida's attorney general filed a lawsuit against pharmacy benefit managers Express Scripts and Prime Therapeutics alleging their partnership agreement artificially depressed pharmacy reimbursement rates through price fixing. The complaint represents the latest legal challenge to the Express Scripts-Prime arrangement. The lawsuit alleges anticompetitive conduct that affects how pharmacies are paid under prescription drug benefit arrangements. This matters for Medicaid managed care organizations that contract with these PBMs or their affiliates for pharmacy services, as the allegations relate to fundamental pricing mechanisms that affect both network pharmacy relationships and overall drug cost structures.
- Federal Policy
New Maternity Care Billing Codes Take Effect in 2027 for All Payers
New maternity care billing codes will be implemented across all insurance payers beginning in 2027. The coding changes are designed to improve transparency and payment accuracy across the continuum of maternity care services. State Medicaid agencies must adopt these codes alongside other major program changes scheduled for 2027, including work reporting requirements. The new codes are intended to provide better data on maternity care delivery and enable more precise reimbursement for services throughout the pregnancy and postpartum period.
- Federal Policy
NAMD Publishes Overview of Medicaid and Ryan White Program Coordination for HIV Care
The National Association of Medicaid Directors has published an explainer on how Medicaid and the Ryan White HIV/AIDS Program coordinate to provide comprehensive care for low-income people with HIV. The overview describes each program's distinct eligibility and coverage criteria and how they work together to ensure access to the full continuum of HIV care. The resource is available now on NAMD's website. It provides state Medicaid agencies with foundational information on program coordination and coverage responsibilities for this population.
- Managed Care · RI
Rhode Island Launches Phone Consultation Program Connecting Primary Care to Behavioral Health
Rhode Island has implemented a phone-based consultation program that allows primary care physicians to connect directly with behavioral health specialists to support patient care. The program addresses the challenge of integrating behavioral health services into primary care settings, where physician shortages mean every visit carries increased clinical weight. The initiative aims to improve access to behavioral health treatment by enabling real-time specialist consultation without requiring separate referrals or appointments. For Medicaid providers and managed care organizations, this represents a care coordination model that can reduce emergency department utilization and improve outcomes for members with co-occurring physical and behavioral health needs.
- State Policy · CA
California Bill Would Ban AI Chatbots From Advertising as Therapy
California SB 903, authored by Sen. Steve Padilla, would prohibit companies from marketing AI chatbots as therapy, require licensed professional review of AI therapeutic decisions, and mandate patient consent before using AI tools to record sessions or triage mental healthcare. The bill is backed by professional associations and the National Union of Healthcare Workers, which recently filed a complaint against Kaiser Permanente for alleged use of automated algorithms in mental health triaging. Supporters say safeguards are needed to protect consumers and licensed professionals; opponents focus on restrictions for clinical AI use. The legislation comes amid wrongful death lawsuits in California federal courts accusing AI chatbot makers of contributing to user suicides.
- State Policy · MO
Missouri Abortion Ballot Measure Campaign Draws $1.25M Bloomberg Donation Ahead of November Vote
A campaign opposing Missouri's November ballot measure to reinstate abortion restrictions has raised over $6.5 million, including a $1.25 million donation from Michael Bloomberg reported August 6, 2026. Amendment 3 would repeal the 2024 reproductive rights amendment and reinstate a near-total abortion ban with limited exceptions, while also constitutionally banning gender-affirming care for minors. The measure already prohibits Medicaid coverage of gender-affirming care for all ages — a restriction upheld by the Missouri Supreme Court in January 2026. The vote is scheduled for November 3, 2026.
- Industry · ID
Idaho Public Housing Authorities Largely Decline HUD Work Requirement Proposal
One Idaho public housing authority has joined a HUD coalition exploring work requirements for subsidized housing, while other authority leaders remain skeptical. HUD is encouraging housing authorities to impose work rules and time limits for residents. The proposal affects public housing residents but does not directly involve Medicaid programs. While some housing authority residents may also be Medicaid beneficiaries, this development concerns housing policy under HUD jurisdiction, not Medicaid eligibility, covered services, or managed care operations.
- State Policy · WV
West Virginia Medicaid Agency Says Audit Savings Years Away, Requires Technology Upgrades
West Virginia's Department of Human Services, which administers the state's Medicaid program, told lawmakers that $68.6 million in potential annual savings identified in a May 2026 BDO audit will take years to realize. The savings depend on costly technology upgrades, including fixing the state's $400 million PATH eligibility system, reducing paper mailings, and bringing foster children back in-state from residential facilities. Governor Patrick Morrisey paid BDO USA $1 million to audit three state agencies in search of efficiencies. Legislators expressed mixed reactions, with some understanding the timeline for system overhauls and others calling the audit's projections unrealistic.
- Federal Policy
CDC Reports 3,544 Drug-Resistant Candida Auris Cases Across 28 States in 2026
The CDC has reported 3,544 clinical cases of candida auris, a drug-resistant fungus, across 28 states as of August 1, 2026, along with 3,325 screening detections. California reported the most clinical cases at 887, followed by Texas (437) and Tennessee (293). The infection primarily affects hospitalized patients and long-term care residents with severe underlying conditions, breathing or feeding tubes, or catheters. While cases have declined slightly from 2024 levels, CDC continues to classify candida auris as an urgent threat due to its resistance to multiple antifungal drugs and its spread in healthcare facilities.
- Managed Care
Drug-Resistant Fungal Infections Reported in 3,500 Patients Across 28 States
Twenty-eight states reported over 3,500 clinical cases of candida auris, a drug-resistant fungus, as of August 1, 2026, according to CDC surveillance data. The infection primarily affects severely ill patients in healthcare and long-term care facilities, particularly those with breathing tubes, feeding tubes, or catheters. California reported the highest number of clinical cases at 887, followed by Texas (437) and Tennessee (293). The fungus is resistant to multiple antifungal drugs and spreads easily in healthcare settings, with an additional 3,325 screening detections of patients who are colonized but not yet ill.
- State Policy · NH
New Hampshire Child Food Insecurity Rises to 15.5% in 2024
Child food insecurity in New Hampshire increased from 36,160 children (14.5%) in 2023 to 38,430 children (15.5%) in 2024, according to Feeding America's Map the Meal Gap report. Coös County experienced the highest rate at 22.1% of children food insecure, while Rockingham County had the lowest at 11.6%. The state remains below the national average of 19.5%. Data on the impact of 2025 federal SNAP restrictions—including tighter work requirements, benefit reductions, and migrant eligibility changes enacted through the One Big Beautiful Bill Act—will not be available for several years due to federal reporting delays.
- State Policy · NV
Nevada Spent $2.7 Billion on Federal Deportations Through July 2026, EPI Analysis Shows
Nevada taxpayers paid $2.7 billion toward federal mass deportations through July 2026 under the One Big Beautiful Bill Act, averaging $2,421 per taxpayer, according to an Economic Policy Institute analysis. Clark County accounted for $1.8 billion and Washoe County for $600,000. The 2025 legislation expanded Department of Homeland Security detention budgets while cutting SNAP, Medicaid, and other public assistance programs. Nationwide, $268.9 billion in taxes funded deportations ($2,358 per taxpayer), representing funds that could have supported Medicaid for 187,000 Nevada residents or other public services.
- State Policy · ME
Maine Reports 20.7% Child Food Insecurity Rate, Highest in New England
Maine had the highest child food insecurity rate in New England in 2024 at 20.7%, with overall food insecurity affecting 14.5% of residents—more than 200,000 people. Forty-six percent of food-insecure Mainers earn too much to qualify for SNAP. Federal SNAP changes under the One Big Beautiful Bill Act will require Maine to pay 15% of SNAP benefit costs starting in 2028—approximately $50 million annually—based on its payment error rate. Maine lawmakers responded by funding payment error reduction efforts and maintaining state-funded food assistance for immigrants excluded from federal SNAP.
- State Policy
GAO Reports Gig Platform Workers Lead All Employers in SNAP, Medicaid Enrollment
A Government Accountability Office report found that workers at DoorDash, Lyft, and Uber now have the highest rates of SNAP enrollment among major U.S. employers and rank third for Medicaid enrollment, a sharp increase from 2020 when these companies were not in the top five. The shift reflects gig work transitioning from supplemental to primary income for many workers, with nearly half of gig workers surveyed saying the work is essential or important to meeting basic needs. New Medicaid work requirements passed in 2025 — mandating 80 hours per month — may create verification challenges for gig workers who lack traditional pay stubs or single-employer documentation, potentially pushing workers off coverage despite meeting work thresholds. The trend highlights taxpayer-funded safety net programs subsidizing low-wage platform employment that does not provide traditional benefits.
- Federal Policy · ND
Federal SNAP Restrictions Cut Refugee Eligibility, Expand Work Requirements Through Age 64
The 2025 One Big Beautiful Bill Act restricted noncitizen access to SNAP, eliminating benefits for refugees, and expanded work requirements for able-bodied adults without dependents from age 54 to 64. In North Dakota, approximately 1,000 noncitizens and 5,600 adults are losing benefits. Affected adults must now work, train, or volunteer at least 80 hours monthly to maintain eligibility or face a three-year lockout after three months. The maximum dependent age for exemptions dropped from 18 to 14. Refugee resettlement agencies report families losing nutrition support while seeking employment.
- State Policy · NC
North Carolina Governor Signs Budget Corrections Including $319 Million Medicaid Appropriation
North Carolina Governor Josh Stein signed House Bill 268 on April 30, 2026, approving technical corrections to the 2026 state budget including $319 million in Medicaid funding. The legislation also includes a provision requiring cabinet members to vacate their positions if the Senate does not confirm their nomination by the end of the legislative session. The governor signed three additional bills including Senate Bill 445, the Regulatory Reform Act of 2026, and House Bill 562, which makes further technical budget corrections. The measures took effect upon signing.
