Top News
Roundtable-Supported Drug Pricing Legislation Passes Senate
On July 23, the Senate unanimously voted to pass the Affordable Prescriptions for Patients Act (S. 1041). The bill aims to address “patent thickets,” a strategy that pharmaceutical companies use to overlap patents on a single drug, which blocks competition and keeps drug prices high. This bill, which has broad bipartisan support, limits the number of patents a drug company can place on a single product. The legislation is expected to encourage innovation, allow generics to enter the market, and help prevent prescription costs from rising further. The Public Sector HealthCare Roundtable has been a leading supporter of the Affordable Prescriptions for Patients Act for many years and will closely monitor the legislation as it moves on to the House.
CMS Releases July-December 2025 No Surprises Act Data
CMS recently released new federal data related to the No Surprises Act from the second half of 2025 (July-December), highlighting the continued surge of dispute numbers and payouts. In the last two quarters alone, the Independent Dispute Process (IDR) saw 1.4 million disputes brought by payers and providers alike. Of these, providers initiated 76% of disputes and prevailed in roughly 85% of cases. The companies that accounted for the largest share of disputes remained largely unchanged, with HaloMD accounting for 19% of disputes each quarter, followed by TeamHealth and SCP Health. The recently released data showed that the winning offer was higher than the median rate (i.e., the qualifying payment amount) in 87% of decisions made. Payouts from the IDR process for all of 2025 totaled nearly $15 billion, more than three times the amount paid in 2024, and over six times what providers would have received for in-network care. The data from the latter half of the year revealed that arbiters are taking on more cases and deciding them in a timelier manner. Due to process improvements, they are also able to more easily determine whether or not a claim is NSA eligible when a dispute is challenged.
Overall, trends identified in the first half of 2025 continued through the end of the year. The continued high provider win-rate and determination value fuel concerns that the process is being used as a revenue stream for providers and creating downstream consequences for payers, premiums, and overall healthcare spending.
Trump Announces Plans to Impose Tariffs on Generic Drug Imports
On Tuesday, July 21, President Trump announced plans in a social media post to impose a 100 percent tariff on imported generic drugs beginning in August 2028, with the rate increasing to 200 percent in 2029. A formal executive order has not yet been issued, but according to a White House official, the tariffs would be implemented under Section 232 of the Trade Expansion Act of 1962, which allows the administration to restrict imports based on national security concerns. The proposal follows the administration’s earlier action on branded pharmaceuticals, which resulted in tariffs of up to 100 percent on certain imported brand-name drugs beginning later this month. The administration has provided exemptions for some companies that commit to building U.S. manufacturing capacity, as well as certain trading partners with broader trade agreements. Overall, the tariffs are part of President Trump’s broader effort to encourage domestic pharmaceutical production and address drug costs.
Administrative Action
HHS Defers Over $1 Billion in Medicaid Payments to California and Minnesota Amid Fraud Review
On July 21, Health and Human Services (HHS) Secretary Kennedy and Centers for Medicare and Medicaid Services (CMS) Administrator Oz announced actions to combat healthcare fraud. HHS and CMS deferred more than $1 billion in federal Medicaid payments to California and Minnesota pending additional financial documentation on high-risk claims, as part of the administration’s ongoing effort to combat fraud, waste, and abuse in Medicaid. CMS is deferring approximately $867.5 million in payments to California after reviewing claims for certain in-home programs, citing spending growth that exceeds national trends along with other claims requiring additional documentation. In Minnesota, CMS is deferring approximately $199 million after reviewing claims across 14 high-risk service areas, including expenditures tied to providers flagged in program integrity reviews and claims with potential eligibility or billing concerns. HHS characterized both actions as payment deferrals rather than permanent funding cuts, with each state given the opportunity to submit documentation showing the claims meet federal requirements. Separately, HHS announced it will expand exclusion authority for both CMS and the HHS Office of Inspector General, enabling broader use of this tool to remove providers from federal healthcare programs, including permanent bars in some cases. The action follows a February 2026 Durable Medical Equipment, Prosthetics, Orthotics enrollment moratorium and an earlier Minnesota Medicaid funding deferral, as well as the June 2026 National Health Care Fraud Takedown, which resulted in charges against 455 defendants and more than $6.5 billion in alleged false claims.
Congressional Action
House Passes CR Months Before Shutdown Deadline
The House passed a continuing resolution (CR) in a 220-205 vote on Tuesday, July 21, evening to extend government funding through December 4. The vote comes more than two months before the September 30 deadline to avoid a government shutdown. House Republicans moved the legislation early in an effort to increase pressure on Senate Democrats ahead of broader government funding negotiations and the upcoming midterm elections, emphasizing that the bill is a “clean” CR without unrelated policy provisions. Democrats opposed the measure, criticizing Republicans for advancing the legislation without bipartisan input and raising concerns that it does not include restrictions on the use of new funding for Border Patrol and Immigration and Customs Enforcement (ICE). The bill now heads to the Senate, where Senate Majority Leader John Thune (R-SD) is expected to advance a separate CR with anomalies, including some from the White House list of special exceptions, before the August recess.
House Energy and Commerce (E&C) Committee and Senate Health, Education, Labor, and Pensions (HELP) Committee Advance Key Legislation in Full Committee Markups
Congress advanced a wide slate of legislation this week through committee action in both chambers. The House E&C Committee held a markup of 29 bills on July 20, followed by the Senate HELP Committee’s markup of 11 bills on July 22. All the bills advanced, including the following:
Biosimilars & Drug Approval Pathways
These bills streamline biosimilar licensure by removing default requirements for immunogenicity, pharmacodynamics, or comparative efficacy studies, and simplify interchangeability determinations with reference products. A companion bill tightens the citizen petition process, giving HHS authority to reject petitions filed mainly to delay competitor approvals rather than raise legitimate scientific concerns. The Roundtable has supported the first two bills in the past and expressed support for provisions similar to the STOP GAMES Act.
- S. 1414 / H.R. 9661 – Expedited Access to Biosimilars Act: Removes the default requirement for pharmacodynamics and comparative efficacy studies in biosimilar licensure (S. 1414 also removes immunogenicity).
- H.R. 5526 – Biosimilar Red Tape Elimination Act: Streamlines interchangeability determinations for biosimilars.
- H.R. 8908 – STOP GAMES Act of 2026: Requires citizen petitions to be filed within 60 days and gives HHS authority to deny petitions filed primarily to delay drug approvals or lacking a valid scientific basis, targeting a common tactic used to stall generic and biosimilar competition.
Drug Pricing & Supply Chain Integrity
These bills cap insulin copays at $35 pre-deductible, require drug labels to disclose original manufacturer and supply chain information, and increase oversight of compounding pharmacies, restricting compounding of drugs that are essentially copies of commercially available products. Together they target both affordability and supply chain transparency and safety. The Roundtable has expressed support for the INSULIN Act.
- S. 4189 – INSULIN Act of 2026: Caps insulin copay at $35, applied pre-deductible.
- S. 3788 – Clear Labels Act: Mandates disclosure of original manufacturer and supply chain info on drug labels.
- S. 3794 – SAFE Drugs Act: Increases oversight of compounding pharmacies; limits compounding of drugs that are essentially copies of commercial products.
Price & Cost Transparency
These bills require hospitals, insurers, labs, imaging centers, and ASCs to publicly disclose standard charges, discounted cash prices, and negotiated rates in consumer-friendly, machine-readable formats. Health plans and PBMs must also share cost-sharing details and spread pricing, while insurers face new requirements to disclose what share of premiums goes to claims versus overhead. Enforcement includes civil penalties, though rural and underserved providers get compliance exceptions. The Roundtable has expressed support for the Lower Costs, More Transparency Act in the past.
- S. 2355 – Patients Deserve Price Tags Act: Requires hospitals, insurers, labs, imaging providers, and ASCs to disclose standard charges, discounted cash prices, negotiated rates, and de-identified min/max charges in consumer-friendly formats.
- H.R. 9393 – Lower Costs, More Transparency Act of 2026: Requires hospitals to post pricing information, with civil penalties for non-compliance that scale by facility size and duration of violation (rural and underserved providers are exempt); requires health plans to disclose in-network rates, out-of-pocket costs, and spread pricing used by PBMs.
- H.R. 9390 – Prices on the Wall Act of 2026: Requires hospitals, ASCs, labs, and imaging providers to post discounted cash prices for CMS-specified shoppable services.
- H.R. 9397 – Premium Transparency Act: Requires insurers and MA organizations to publicly disclose the share of premium revenue spent on claims vs. overhead, effective Jan. 1, 2027.
Prior Authorization Reform
These bills push insurers toward electronic prior authorization systems and require public disclosure of denial rates, PA-covered services, and use of automated decision-support tools. HHS gains authority to set enforceable response timeframes, including 24-hour turnarounds for expedited requests, with a 2028 deadline for full electronic PA implementation.
- H.R. 9396 – Prior Authorization Accountability Act: Requires issuers with PA requirements to disclose denial rates to HHS and publicly; mandates disclosure of services subject to PA and use of decision-support technology.
- H.R. 3514 – Improving Seniors’ Timely Access to Care Act of 2025: Establishes electronic PA program by 2028, annual reporting on approval/denial/appeal rates, and HHS authority to enforce response timeframes (e.g., 24-hour expedited determinations).
Medicare Advantage Data & Transparency
These bills require MA organizations to report more granular data, including allowed amounts, cost-sharing figures, health risk assessment usage, and enrollee-level detail on supplemental benefits like eligibility, utilization, and out-of-pocket costs. The goal is to give regulators and beneficiaries better visibility into how MA plans actually pay for and deliver care.
- H.R. 9392 – Medicare Advantage Cost Transparency Act: Requires encounter data to include allowed amounts, cost-sharing details, and health risk assessment indicators.
- H.R. 5243 – Requires MA organizations to submit enrollee-level data on supplemental benefits (eligibility, utilization, payments, out-of-pocket costs).
Health Workforce & Access
These bills expand funding and training programs for the broader health workforce and nursing specifically, aiming to address staffing shortages through 2030. A related bill targets rural areas directly, funding emergency obstetric care and readiness programs at facilities that lack dedicated OB units.
- S. 4110 – EMPOWER for Health Act: Expands health workforce programs and training funding through 2030.
- S. 1874 – Nursing Workforce Reauthorization Act: Expands nursing education, training, and retention programs.
- S. 380 – Rural Obstetrics Readiness Act: Federal programs for emergency obstetric care/workforce readiness in rural facilities without dedicated OB units.
The Roundtable will continue to monitor and advocate for legislation that aligns with our priorities as it progresses through the legislative process.
CDC Nominee Advances While ASPR Pick’s Vote Quietly Pulled
The Senate Health, Education, Labor, and Pensions (HELP) committee is poised to advance Erica Schwartz, President Trump’s nominee to lead the Center for Disease Control and Prevention (CDC), after Chairman Bill Cassidy (R-LA) said he would back her despite earlier concerns she wouldn’t stand up to HHS Secretary Robert F. Kennedy Jr. Senator Cassidy said he grew confident in Schwartz after re-reviewing her hearing testimony and speaking with colleagues, and noted HHS had since modified a CDC webpage that had suggested a vaccine-autism link. The vote, expected today, July 23, was delayed due to the absence of Senator Lisa Murkowski (R-AK), who was dealing with a family emergency. In her absence, the committee would have required one Democratic member to vote “yes”, who unanimously oppose the confirmation. The CDC has not had a permanent director in nearly a year following the ouster of immunologist Susan Monarez, who says the Secretary pushed her out for refusing to alter vaccine schedules.
Separately, a vote on Sean Kaufman, the President’s nominee for HHS Assistant Secretary for Preparedness and Response, was pulled from today’s agenda without explanation. Kaufman had faced sharp criticism from Senator Cassidy over past social media posts questioning the hepatitis B birth-dose vaccine and other immunizations, which Cassidy called dangerous given his medical background treating hepatitis patients. Kaufman told the committee he deleted the posts because they misrepresented his views and that he now considers the vaccines safe.
Judicial Action
CMS Appeals Ruling Over Medicare Advantage Star Ratings
The Trump administration is appealing a May federal court ruling that forced the Centers for Medicare and Medicaid Services (CMS) to recalculate its 2026 Medicare Advantage star ratings. The case, in which a federal judge in Georgia sided with Clover Health, tossed out 20 measures CMS used to calculate scores: 10 because CMS exceeded its statutory authority in the data sources used, and another 10 because CMS failed to meet rulemaking and comment requirements. The ruling triggered follow-up lawsuits from other insurers, including Elevance Health, Alignment Healthcare and SCAN Health Plan, since CMS’s recalculation approach didn’t precisely match the methodology from the Clover ruling.
More broadly, insurers have been on a “winning streak” with aggressive challenges to the star ratings system, and experts expect plans to keep pursuing similarly aggressive litigation regardless of how this appeal turns out. While others have contested methodological aspects of the rating system, this case is notable because it directly calls into question CMS’s statutory authority. The battle over rating calculations feeds into a wider debate about whether ratings should remain tied to Medicare Advantage payments at all, given that the Medicare Payment Advisory Commission (MedPAC) estimates roughly $22 billion of bonus payments in 2026 came from star-rating-linked quality payments.
Industry News
Healthcare Costs Worry Voters Ahead of Midterms
A new poll released from KFF this month finds that health care costs continue to dominate the public’s economic worries this year. With midterm elections around the corner, Democrats and Independents reported that they consider the future of Medicare and Medicaid to be a top issue for candidates to address, while Republican voters indicated that fraud in government health programs is their top concern. Notably, though, voters don’t see health programs as unusually fraud-ridden compared to other parts of government: larger shares of survey participants believe there’s significant fraud in the federal tax system, foreign aid, and defense contracts than in Medicaid, Medicare, or Affordable Care Act (ACA) marketplaces. Additionally, voters across party lines are far more likely to say fraud is mostly carried out by health care providers, including doctors’ offices and hospital systems, than by individual patients. Despite believing fraud exists, most voters prioritize protecting access to care over aggressive fraud enforcement. In fact, seven in ten voters say ensuring eligible people can access needed Medicaid services should take priority over preventing potential fraud. This comes in the wake of the administration’s billion-dollar deferral in Medicaid funds from California and Minnesota, two blue states, less than three months before the midterm elections. The majority of voters polled saif they believe these deferrals are likely to cause eligible low-income individuals to lose access the healthcare, and two-thirds consider the enforcement actions by the administration as politically motivated.
MedPAC Finds Medicare Spent $1 Trillion on Health Care in 2024
The Medicare Payment Advisory Commission (MedPAC) released the July 2026 Data Book on Health Care Spending and the Medicare Program. In 2024, the U.S. spent $4.5 trillion on personal health care, 23 percent of which was paid for by Medicare ($1 trillion). Medicare spending represented 3.9 percent of gross domestic product (GDP) in 2025, up from 3.0 percent in 2006. The Medicare Trust Funds Boards of Trustees and the Congressional Budget Office (CBO) expect Medicare spending to continue rising over the next decade, though their predictions vary. MedPAC found that this expected rise is due mostly to factors other than price, number of beneficiaries, and beneficiary mix — which may include rising volume and intensity of items and services.
Since 2011, the share of Medicare beneficiaries enrolled in MA plans has continued to grow. MedPAC found that as of February 2026, MA enrollment reached 35.5 million beneficiaries, representing 55 percent of all eligible Medicare beneficiaries. From 2025 to 2026, the percent of beneficiaries enrolled in MA plans remained unchanged.
The full Data Book includes additional detail on each of these trends and more statistics, offering policymakers and researchers a comprehensive baseline for understanding Medicare’s current financial and demographic landscape. As Medicare spending continues to climb and enrollment in MA plans holds steady above half the eligible population, these findings will likely inform ongoing debates over program sustainability and payment reform in the months ahead.
Save the Date: 2026 Annual Conference
HealthCare Roundtable 22nd Annual Conference
November 4-6, 2026
The Mayflower Hotel
Washington, D.C.
