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红领巾瓜报 Insights 鈥� including our new podcast 鈥� puts the vast depth of 红领巾瓜报鈥檚 expertise at your fingertips, helping you stay informed about the latest healthcare trends and topics. Below, you can easily search based on your topic of interest to find useful information from our podcast, blogs, webinars, case studies, reports and more.

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Blog

Building State Capacities for Medicaid Work and Community Engagement Requirements

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Medicaid covers nearly 80 million people nationally, with an estimated 20 million covered through the Medicaid expansion. As state legislatures pass work requirement laws, governors consider executive actions, and Congress contemplates a nationwide mandate, vetting key implementation issues can significantly impact the direction of related policies.

It is difficult to generate accurate projections given the lack of specificity in the current legislation and state implementation variables. According to Congressional Budget Office estimates, approximately 5 million people with coverage because of the Medicaid expansion would lose their coverage as a result of not meeting community engagement requirements.聽The current federal legislation gives a start date of 2029, but individual states could move forward on a variety of timelines. Even before implementation, states must test operations, enable systems, and establish connections to beneficiaries to reduce potential implementation missteps, inappropriate disenrollments, and litigation risks.

If the goal of Medicaid work requirement policies is to stimulate connections between health benefits and employment/workforce, building state and federal capacities to support these approaches is critical to effectuating that change. This blog focuses on introducing operational dynamics that need to be discussed, tested, and built.

Legislative and Other Context

Most people expect Congress to authorize or mandate some type of work requirement and community engagement as criteria for eligibility for state Medicaid programs. In the language that House Energy and Commerce Committee advanced, all states would be obliged to implement work and community engagement requirements for adults without dependents for at least 80 hours per month.[1] Employment, work programs, education, or community service (or a combination of those activities) would satisfy the requirement. Though the federal authorization has received a great deal of attention, at least 14 states have moved forward (see Table 1) in advance of the current federal debate by passing laws and submitting work requirement demonstration requests to the Centers for Medicare & Medicaid Services (CMS).

Table 1. A Review of 2025 States’ Approaches to Work Requirements in Medicaid
StatusStatePopulation CriteriaRequirementsExemptions/ NotesPublic Comment
Work Requirement Request SubmittedArizonaAges 19鈭�5580 hours/monthMultiple exemptions; 5-year lifetime limitClosed
Work Requirement Request SubmittedArkansasAges 19鈭�64; covered by a qualified health plan (QHP)Data matching to assess whether on track/not on trackNo exemptionsClosed
Work Requirement Amendment Request SubmittedGeorgiaAges 19鈭�64; 0-100% FPL80 hours/monthAlready has approval but is requesting reporting be changed from monthly to annually and adding more qualifying activitiesFederal comment period open through June 1, 2025
Work Requirement Request SubmittedOhioAges 19鈭�54; expansion adultsUnspecified hoursLimited list of exemptionsClosed
Legislation PassedIdahoAges 19鈭�6420 hours/week requiredLimited list of exemptions鈥�
Legislation PassedIndianaAges 19鈭�64; expansion adults20 hours/week requiredLimited list of exemptions鈥�
Legislation PassedMontanaAges 19鈭�5580 hours/month requiredMultiple exemptions鈥�
Ballot Initiative PassedSouth DakotaExpansion adults鈥�2024 ballot initiative asking voters for approval for state to impose work requirements for expansion adults passed鈥�
Legislation PendingNorth Carolina鈥�鈥�Pursue requirements that are CMS approvable鈥�
Work Requirement Request DraftIowaAges 19鈭�64; expansion adults100 hours/month requiredLimited list of exemptions Separate bill would end expansion if work requirements are withdrawn/ prohibited (80 hr./mo.)Closed
Work Requirement Request DraftKentuckyAges 19鈭�60; no dependents; enrolled more than 12 monthsConnected to employment resourcesMultiple exemptionsState comment period open through June 12, 2025
Work Requirement Request DraftSouth CarolinaAges 19鈭�64; 67%鈭�100% FPLSpecified activities (work specific is 80 hours/month)Limiting participation to 11,400 individuals based upon available state fundingState comment period open through May 31, 2025
Work Requirement Request DraftUtahExpansion adults ages 19鈭�59Register for work, complete an employment training assessment and assigned job training, and apply to jobs with at least 48 employers within 3 months of enrollmentSeveral exemptions, largely aligned with federal SNAP exemptionsState comment period open through May 22, 2025
Anticipated Waiver RequestAlabamaNon-expansion population鈥�Potential to resubmit previous work requirement demonstration request鈥�

Key Questions Regarding State Policy Options

Considerable research and findings put policymakers in a better position to be prepared to act on a new law since previous attempts and implementing similar policies exposed fundamental problems. Some previous findings include the high cost of administration relative to potential savings, the importance of systems that support foundational items like logging an enrollee鈥檚 compliance activities and exemptions, as well as developing an efficient appeals process. The Medicaid and CHIP Payment and Access Commission, General Accounting Office, National Institutes for Health, and multiple researchers have published assessments regarding previous experiences that could improve policymaking.

Below we discuss critical issues and considerations including:

  1. Exemptions, particularly medical frailty definitions and assessments
  2. Developing and streamlining systems and process to promote continued coverage for eligible individuals
  3. Clinical and utilization data that promotes eligibility assessment
  4. Managed Care engagement in Work Requirements/Community Engagement initiatives
  5. Measuring impact and adapting policies where needed

1. Which populations are exempt from work requirements?

The requirements in the current House Committee on Energy and Commerce legislation would apply only to individuals between the ages of 19 and 64 without dependents, and the following groups are exempted: women who pregnant or entitled to postpartum medical assistance, foster and former foster youth younger than 26 years old, members of Tribes, individuals who are medically frail (i.e., people who are blind, disabled, with chronic substance use disorder, serious or complex medical conditions, or others as approved by the Secretary of the U.S. Department of Health and Human Services), parents or caregivers to a dependent child or individuals with a disability, veterans, people who are participating in a drug or alcoholic treatment and rehabilitation program, or individuals who are incarcerated or have been released from incarceration in the past 90 days.[2] In addition, individuals already in compliance with work requirements through other programs such as Temporary Assistance for Needy Families (TANF) or the Supplemental Nutrition Assistance Program (SNAP) would be considered exempt. Lastly, the legislation includes temporary hardship waivers for natural disasters and areas with an unemployment rate greater than 8 percent or 150 percent of the national average.

The federal government and/or states will identify individuals classified as “medically frail” and make them exempt them from the mandates. This includes those with chronic, serious, or complex medical conditions. Various methods may be employed to identify these individuals, such as analyzing historical medical and pharmacy data to categorize complex conditions, using proprietary algorithms to stratify individuals with multiple comorbidities, and enabling physicians to evaluate enrollees without relying on a claims history.

2. Which systems best align to build from and support coverage?

The Medicaid unwinding from the COVID Public Health Emergency taught lessons about the complexities of Medicaid systems (e.g., assessing cases to ensure eligible children retain coverage if a parent is removed), patient engagement, and reliable methods of member outreach (e.g., email, text, and member portals rather than paper communication). Call abandonment rates, call center wait times, and application processing times surfaced as practical measures of performance (or lack thereof) during the Medicaid unwinding. Multiple informal sources point to poor mailing address or 鈥渞eturn to sender鈥� as being anywhere between 15 and 50 percent, bringing tangibility to an implementation baseline. TANF and SNAP programs have work requirement provisions. While those programs are regulated and administered by multiple federal and state agencies, the platforms that support those provisions and the potential for integration are critical vehicles to explore. 

State Workforce Commissions and Departments of Labor are clear partners, as they manage integrated eligibility systems and data-sharing agreements across programs like SNAP and TANF, which also serve many Medicaid participants. These and other partnerships will need to be explored to address engagement challenges for many populations, including individuals facing housing instability, which disrupts communication, engagement, and compliance tracking.[3] It is essential that states develop targeted outreach and education strategies to support awareness of participation requirements and ways for individuals to meaningfully engage.

3. Do we have a sense of the healthcare needs/chronic conditions among the Medicaid enrollees that will be affected by work requirements?

Many individuals with chronic diseases may be exempt from the requirements, but not all of them. To that end, insights regarding pharmacy claims may be a useful lens through which we can ascertain an understanding of the potential impact on utilization trends. Notably, the Medicaid expansion population still has significant healthcare utilization rates for services related to behavioral health and for chronic health conditions like hypertension and diabetes. In fact, a recent 红领巾瓜报 (红领巾瓜报), analysis of CMS data indicated that the top pharmaceuticals spending classes for the Medicaid expansion population were hypoglycemics ($7.6 billion), antivirals ($5.5 billion), and anti-inflammatories ($3.3 billion). The drugs are used to treat autoimmune conditions, including rheumatoid arthritis and psoriatic arthritis. Knowing the health status and chronic conditions of the populations affected and which conditions qualify for exemption are variables as implementation issues like the definition of medically frail are addressed.

4. What does this mean for managed care organizations?

Approximately of Medicaid expansion beneficiaries are enrolled in comprehensive managed care organizations (MCOs). States will need to review the scope of existing vendor contracts as well as determine the need for new services, roles, third-party reporting, oversight, and potential exemptions for emergencies. Work requirements can disrupt MCO risk pool stability and care coordination because of administrative burdens and disruptive, less predictable enrollment cycles. That said, MCOs not only have a financial incentive to drive down inappropriate disenrollments, but are also uniquely positioned to support state responsibilities, including maintenance of up-to-date contact information. The delineation of roles and clarification of contracts and responsibilities  among states, MCOs, TPAs, and other specialty organizations supporting work requirements will be a critical early-stage framing point for a functional infrastructure.

Many states have sought to support more seamlessness among insurers, with a goal of having the same insurers provide coverage to people as they transition through Medicaid, Marketplace, and employer-sponsored insurance (ESI) as their employment status changes over time. States like Nevada, Rhode Island, and New Mexico require Medicaid MCOs to participate in the Marketplace. Additionally, states like North Carolina, Utah, and West Virginia not only require MCO participation in the Marketplace, but also enable MCOs to co-market Medicaid and Marketplace products for individuals who lose their Medicaid eligibility.

As Figure 1 indicates, Marketplace enrollment in non-expansion states has received considerable traction in recent years and has outpaced expansion states with respect to member growth in the past five years. Though multiple factors affect those Marketplace growth rates, including congressional decisions regarding the continuation and funding of the enhanced premium tax credit program, Marketplaces have undeniably carved out large roles in the health coverage infrastructure in non-expansion states鈥攁 point that was less clear just a few years ago.

5. Can states measure and be nimble with policies as the impacts are determined?

Federal and state regulations that identify contextualized and dynamic metrics that provide actionable information to federal and state policy makers will support effective oversight and monitoring. States starting with listening sessions in the near term can help identify goals and metrics. The focus of such efforts could include actively monitoring potential changes and cost shifts for the uninsured population to non-public payers and providers.

The Medicaid unwinding also demonstrated that the story was far less of a red/blue story than a series of complex tasks that required many administrative resources, provider and community partnerships, and enrollee outreach to create a path that would limit unnecessary disruptions and expenses. CMS guidance for goals and evaluations as well as state inputs will need to emerge prior to implementation so policymakers can be well-equipped to be nimble and dynamic with policy changes as well as understanding the short-term and longitudinal effects of this fundamental shift.

[1] U.S. House of Representatives. Committee Print Providing for Reconciliation Pursuant to H. Con. Res. 14, the Concurrent Resolution on the Budget for Fiscal Year 2025. 119th Congress, 1st session, May 13, 2025. .

[2] Ibid.

[3] Soni A, Blackburn J. Health Characteristics of Adults Unable to Complete Medicaid Renewal During the Unwinding Period. JAMA Health Forum. 2025;6(3):e250092. doi:10.1001/jamahealthforum.2025.0092

Solutions

Supporting Medicaid Dental Benefit Administrators: Oral health and dental care are vital for the health of communities聽

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红领巾瓜报 Spotlight

Supporting Medicaid Dental Benefit Administrators: Oral health and dental care are vital for the health of communities聽

Whether performing under risk-based prepaid ambulatory health plan (PAHP) contracts or non-risk (administrative service organizations), Medicaid dental managed care organizations (MCOs) and dental benefit administrators (DBAs) face the same challenges as Medicaid MCOs, and state Medicaid agencies, including but not limited to:

Getting into and staying in compliance with state regulatory and contract requirements
 
Understanding and responding to new federal and state rules and regulations
 
Growing market share including success in state procurements, in MCO solicitations for DBAs, and attracting and retaining enrollees

Improving utilization to meet quality measure targets, medical loss ratios, and margin expectations including increased utilization of preventive oral health care, and decreased utilization of unnecessary care such as avoidable emergency room care for dental diagnoses

Excelling in benefit administration operations including member services and engagement, provider network development and provider services, claim/encounter administration, reporting, and other functional areas
 
Managing financial risk including developing or validating capitation rates and developing value-based payment arrangements

The importance of oral health and dental care

Oral health is integral to the overall health and quality of an individual鈥檚 life, and lack of access to oral health care negatively impacts entire populations.

Tooth decay affects 90% of adults 20 to 64 years of age and costs the U.S. about $45.9B in lost productivity in 2015. This frequently results in visits to hospital emergency rooms where care is often palliative but does not treat the root cause of problems1

Gum disease affects almost 50% of adults 45 to 64 years of age and is a risk factor for nearly 60 other adverse health conditions, including Alzheimer鈥檚 disease, diabetes, and heart disease2

More than half of working-age adults living in poverty have untreated caries (52%), whereas only 1 out of 5 adults with incomes of twice the federal poverty guideline or higher have untreated caries (20%)3

Tooth decay is preventable but impacts nearly 46% of U.S. children. Left untreated, tooth decay can cause chronic pain, impaired development, disfiguration, and social isolation. In severe cases, bacteria from a tooth infection can even travel to the brain and cause death. Caries disproportionately affect children who experience poverty, belong to certain racial and ethnic groups, or are affected by other social factors4

OUR EXPERTISE

At 红领巾瓜报, our consultants have led MCOs, state Medicaid agencies, and include senior officials from Medicare, directors of large nonprofit and social services organizations, top-level advisors, C-level executives at hospitals, health systems and health plans, and senior-level physicians. We know that oral health, access to dental care, and oral health literacy play a vital role in the health of communities supported by Medicaid MCOs. 红领巾瓜报 can support the work that DBAs do and the challenges they face in the changing Medicaid environment.

How 红领巾瓜报 can help

红领巾瓜报 has decades of experience working with Medicaid MCOs, DBAs, state Medicaid agency dental policy makers, and oral health providers. 红领巾瓜报 can:

Provide actionable insights into new federal and state regulations and guidance to help clients understand potential impacts and opportunities for their business. We assist clients to determine what must be done, what can be done, and develop recommendations for what should be done, and to implement those activities. DBAs are frequently performing as PAHPs and are subject to many of the federal rules related to interoperability, prior authorization, access, and eligibility that apply to Medicaid MCOs. 红领巾瓜报 provides our Medicaid provider and payer clients with analyses about those rules, which could also benefit DBAs.

Perform validation and compliance support to help clients identify and address any compliance gaps and support clients in validating their own compliance with any state or MCO imposed Corrective Action Plans. We also support clients to grow and strengthen their own capabilities and infrastructure to perform these functions.

Support client growth with end-to-end procurement assistance, including market conditioning and strategy, writing, mock scoring, orals preparation, implementation, and operations stabilization assistance; and with market analysis.

Support delivery system, reimbursement, and provider network design by conducting research and analysis on oral health delivery system approaches, provider reimbursement structures, coverage, and access trends.

Identify, assess, and help implement best practices in oral health care programs related to special populations, including children鈥檚 access to oral health care and dental access in rural communities.

Support quality improvement and utilization management initiatives that increase appropriate and desired utilization and curb inappropriate utilization. This can include help achieving Healthcare Effectiveness Data and Information Set (HEDIS) measure goals and developing oral health literacy programs, achieving accreditation, developing and implementing Performance Improvement Plans (PIPs), and conducting data analysis to understand utilization and evaluate the impact of program changes on utilization.

Provide actuarial services in support of benefit and program design, capitation rate development, and capitation rate validation.

Design and evaluate value-based payment models that tie provider payments to quality and value.

Project spotlight

Minnesota Medicaid Dental Program Study

The 2021 Minnesota Legislature directed the Department of Human Services (DHS) to conduct a review of Medicaid dental program delivery systems in states that have enacted and implemented a 鈥渃arve out鈥� dental delivery system. This legislation also directed DHS to conduct an analysis of dental provider hesitancy to participate in the Medical Assistance (MA) program as an enrolled provider. DHS contracted with 红领巾瓜报 to conduct the analyses mandated in the legislation. 红领巾瓜报 reviewed the Medicaid dental program delivery systems in states that have implemented a carve-out dental delivery system, including comparing state program designs, program costs and rates where available, and quality metrics for children one through 20 years of age with at least one preventive dental service within a year. 红领巾瓜报 also surveyed dental providers to better understand hesitancy to participate in Medicaid and opinions on policy approaches to improve provider participation.
The final report, available at , described the analysis of state dental carve-out experiences and the dental provider survey results.

Contact our experts:

Headshot of Sarah Arvey

Sarah Arvey

Associate Principal

Sarah Arvey is a trained medical anthropologist and qualitative researcher with expertise in the impact of social determinants, cultural norms, … Read more
Headshot of Rebecca Kellenberger

Rebecca Kellenberg

Principal

Rebecca Kellenberg specializes in assisting public and private health care organizations with Medicaid and CHIP policy analysis and implementation. With … Read more
Headshot of Beth Kidder

Beth Kidder

Managing Principal

Beth Kidder is a transformative and innovative health care leader with more than 20 years of experience working within the … Read more
Headshot of Stephen Palmer

Stephen Palmer

Managing Principal

Stephen Palmer, PhD has a broad range of expertise and skills, which enable him to easily join most types of … Read more
Headshot of Caroline Rosenzweig

Caroline (Carrie) Rosenzweig

Principal

Carrie Rosenzweig is an experienced consultant specializing in health policy analysis, qualitative research, grant writing, and project management. Her research … Read more

[1] Oral Health in America – April 2022 Bulletin, National Institute of Dental and Craniofacial Research, accessed 4/1/2025,

[2] Oral Health in America – April 2022 Bulletin, National Institute of Dental and Craniofacial Research, accessed 4/1/2025,

[3] National Institutes of Health. Oral Health in America: Advances and Challenges. Bethesda, MD: US Department of Health and Human Services, National Institutes of Health, National Institute of Dental and Craniofacial Research, 2021,

[4] Big Hopes for Little Teeth, National Institute of Dental and Craniofacial Research, accessed 4/1/2025,

Blog

From Policy to Practice: 红领巾瓜报 Offers New Toolkit for Tackling the Challenges of Implementing the 1115 Justice-Involved Reentry Demonstration in Carceral Settings

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The Section 1115 Justice-Involved (JI) Reentry Demonstration marks a transformative step in closing the healthcare gap for incarcerated individuals. By allowing Medicaid coverage to resume up to 90 days prior to release, the demonstration aims to improve care continuity and reduce recidivism. Yet, translating this vision into action within jails, prisons, and juvenile detention facilities presents a host of operational challenges. For implementation to succeed, jurisdictions must navigate fragmented systems, strained resources, and competing priorities. That鈥檚 where structured tools鈥攍ike implementation checklists鈥攂ecome essential.

The Challenges: Implementation in Complex, High-Stakes Environments

Implementing the 1115 JI Reentry Demonstration is more than a policy shift鈥攊t鈥檚 a systemic overhaul that requires cross-agency collaboration, infrastructure alignment, and cultural change. Among the most significant challenges:

1. Fragmented Systems and Data Silos

Carceral systems, Medicaid agencies, and community-based providers often operate in silos, using different data platforms and standards. This fragmentation hinders real-time information exchange and care coordination during the transition from incarceration to the community.

2. Operational Readiness Gaps

Many facilities lack established procedures for conducting Medicaid eligibility screenings, care plan development, and referrals to community-based services within the release window. Without predefined workflows, implementation can stall.

3. Workforce Capacity and Training Needs

Reentry planning demands coordination among correctional officers, social workers, nurses, behavioral health clinicians, and Medicaid staff. Many jurisdictions face staffing shortages and limited training on trauma-informed care, care management, or reentry protocols.

4. Policy Misalignment and Legal Constraints

Local policies may restrict access to Medicaid-related functions during incarceration, or limit facility staff鈥檚 ability to share data. Misinterpretation of federal and state rules can create implementation delays.

5. Trust and Engagement Barriers

Justice-involved individuals often face stigma or mistrust from systems they鈥檝e interacted with. Culturally responsive engagement strategies are crucial but frequently underdeveloped.

The Solution: Using a Checklist-Based Implementation Framework

To navigate these hurdles, stakeholders need more than vision鈥攖hey need structure. Implementation checklists tailored to jails, prisons, and juvenile facilities serve as a practical roadmap that transforms policy goals into operational plans. Here’s how they help:

  • Clarify Roles and Responsibilities

Checklists break down complex goals into clear, role-specific tasks鈥攚ho enrolls individuals in Medicaid, who develops care plans, and who ensures warm handoffs to community providers.

  • Promote Cross-Sector Coordination

Structured checklists prompt regular touchpoints across agencies鈥攃orrections, health services, Medicaid, and behavioral health鈥攅nsuring alignment and accountability.

  • Standardize Procedures and Tools

By specifying recommended workflows, assessment tools, and communication protocols, checklists minimize variation and streamline implementation across facilities.

  • Track Progress and Gaps

Built-in progress indicators make it easier to monitor what鈥檚 completed, what鈥檚 pending, and where additional support or training is needed.

  • Support Compliance and Evaluation

A checklist-based approach provides the documentation trail needed for program audits, reporting, and continuous quality improvement.

Conclusion: A Strategic Tool for Lasting Impact

Implementing the Section 1115 JI Reentry Demonstration is a bold, necessary move toward health equity and system transformation. But success depends on more than ambition. With structured checklists in hand, agencies can move from aspiration to execution鈥攂uilding a thoughtful, well-orchestrated reentry infrastructure that improves health outcomes, reduces recidivism, and meets federal expectations.

Download the 红领巾瓜报 JI Toolkit here.

Other 1115 demonstration resources that may be of interest:

Brief & Report

Section 1115 Justice-Involved Reentry Demonstration Implementation Toolkit for Jail, Prison, and Juvenile Settings

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This toolkit provides a set of implementation checklists for Section 1115 Justice-Involved Reentry Demonstrations tailored to three carceral settings: jails, prisons, and juvenile facilities. Each checklist outlines operational tasks across core domains to support effective planning, coordination, and continuity of care pre- and post-release.

This toolkit is intended to provide information for jails, prisons, and youth detention centers in states contemplating submitting a 1115 Justice-Involved Reentry Demonstration, as well as states that have an approved demonstration. All states with approved demonstrations must provide core services, including care management for physical and behavioral health, medication assisted treatment for individuals when clinically indicated before release, and medication in hand at release. It is important to note that states may vary in their populations of focus, care management models, and processes for submitting claims. It is essential to cross-reference your state鈥檚 demonstration when planning to operationalize this initiative.

Case Study

A Revenue Cycle Management Success Story: Advanced Diabetes Supply/US Medical Supply

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The Client

Advanced Diabetes Supply (ADS) acquired US Medical Supply (USMed), a Florida-based durable medical equipment provider, in 2021. At the time, ADS and USMed generated $400 million and $250 million in revenue, respectively. Over the next three years, the combined organization experienced rapid growth, reaching over $1 billion in annual revenue.

Background

While the top-line growth was significant鈥�59% over a three-year span鈥攃ash collections failed to keep pace. This created a classic case of an organization outgrowing its infrastructure. The foundational tools, technology, and operational structure simply weren鈥檛 in place to support the accelerated growth, particularly on the revenue cycle side.

Compounding these challenges were issues stemming from the integration of the two companies, including billing inconsistencies and reimbursement delays. USMed, like many in the industry, was severely impacted by the Change Healthcare ransomware attack, disrupting billing and collections operations nationwide. At the time this project began, USMed was facing a $40 million backlog in accounts receivable and struggling to meet payroll. The revenue cycle team was understaffed and overwhelmed.

红领巾瓜报 had previously performed a successful revenue cycle gap assessment at an ADS office in California. Based on those results, the newly hired CFO of ADS/USMed asked 红领巾瓜报 to replicate the process for the Florida office. The goal: support the recently appointed VP of Revenue Cycle in stabilizing operations, implementing recommendations, and aligning practices to industry best standards.

Download and read the approach and results.

Blog

President Issues Executive Order Calling for Most Favored Nation Drug Pricing

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On May 12, 2025, the President signed an Executive Order (EO), .鈥� The EO calls for or, in some cases, presumes a range of manufacturer, administrative and regulatory actions to reduce drug prices, but ultimate outcome remains unclear.

红领巾瓜报 experts, including Leavitt Partners, an 红领巾瓜报 company, are closely following executive agency and stakeholder responses to the EO. In this article, our experts summarize the EO and identify key considerations for healthcare stakeholders.

Policy Overview

Since his first administration, President Trump has consistently criticized disparities in brand-name prescription drug prices between the United States and other developed countries. In 2018, the previous Trump Administration issued a  to institute an International Pricing Index (IPI) model targeting Medicare payments for a subset of clinician-administered drugs. The IPI model would have set a Medicare payment amount for select Part B drugs at a lower amount to align with international prices and allow for negotiation of prices, while still providing a drug add-on payment to providers consistent with historical drug costs.  In November 2020, the administration issued an interim final rule (IFR) instituting an escalated version of this concept, entitled the . Both the IPI proposal and the MFN final rule, the latter of which was enjoined by the courts on largely procedural grounds and later rescinded by the Biden administration, would have been implemented under the Center for Medicare and Medicaid Innovation鈥檚 (CMMI) demonstration authority.

On May 12, 2025, the President signed an EO, , which reaffirms the Administration鈥檚 concerns regarding what it perceives to be American funding of pharmaceutical research and development 鈥渨hile foreign health systems get a free ride.鈥� In an effort to address the Administration鈥檚 concerns, the EO notes that the Administration 鈥渨ill take immediate steps to end global freeloading鈥� and that 鈥渟hould drug manufacturers fail to offer American consumers the most-favored-nation lowest price, my Administration will take additional aggressive action.鈥�

The EO outlines efforts to implement this policy, including:

  • Trade Efforts.聽The US Department of Commerce and United States Trade Representative (USTR) are directed to ensure that foreign countries are not engaged in actions with the effect of forcing Americans to 鈥減ay for a disproportionate amount鈥� of R&D costs.
  • Direct-to-Consumer (DTC) Sales at MFN Price.聽The US Department of Health and Human Services (HHS) is directed to facilitate DTC sales programs for manufacturers to offer MFN prices.
  • MFN Targets.聽The HHS Secretary is directed to provide MFN targets to manufacturers within 30 days with the expectation that manufacturers will 鈥渂ring prices for American patients in line with comparably developed nations.鈥�
  • If 鈥渟ignificant progress鈥� toward MFN pricing is not made, HHS will be directed to propose a rulemaking plan to impose it.
  • The order suggests that the HHS Secretary certify, on a case-by-case basis, that reimportation will pose no additional risk to public health and will result in savings, as well as to create standard mechanisms for importation. It is unclear how this direction aligns with the current statutory framework, which is focused on Canada.
  • Federal Trade Commission/Department of Justice Action.聽The EO calls for efforts 鈥渃onsistent with law鈥� to undertake enforcement action against anticompetitive practices identified in the prior drug pricing EO, including use of the Sherman Antitrust Act.

Key Considerations

At this stage, the scope and practical effects of the EO remain uncertain, as the administration has not yet provided details regarding the regulatory and subregulatory actions envisioned under the document. With respect to trade policy, for instance, the EO does not outline explicitly what particular tools it expects USTR or the Commerce Department to leverage in combating 鈥渇oreign freeloading.鈥�

Similarly, the EO does not elaborate on the steps that the administration plans to take in 鈥渇acilitat[ing]鈥� voluntary MFN target pricing under DTC purchasing arrangements. Such efforts could theoretically bring waivers or other regulatory flexibilities to bear, or else they could take a more hands-off approach, simply encouraging drugmakers to take action on their own.

Without further clarifications around how the administration might define or assess 鈥渟ignificant progress鈥� towards MFN pricing targets on the part of manufacturers, nor the form, manner, or timeline that 鈥渁ggressive action鈥� in the absence of such progress might take, the EO serves principally as an illustration of the President鈥檚 posture, perspective, and priorities with respect to prescription drug affordability and access.

Even in the absence of immediate pricing or payment interventions, the EO could provide a preview of future executive actions aligned with the document鈥檚 focus. Such actions could include CMMI models building on the IPI or MFN initiatives from the first term, explicit trade negotiation priorities, regulatory measures related to DTC purchasing arrangements, FDA reimportation program flexibilities, or any number of other drug-related policies.

Our experts will continue to monitor these activities as they progress.

Connect With Us

For details regarding the EO and potential impact on the healthcare sector, contact our featured experts below at聽[email protected]

Blog

House Committees Consider Policies to Meet Budget Reconciliation Instructions

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This week, key committees in the House of Representatives released recommendations for legislative language that meets their federal savings and spending targets required in the fiscal year (FY) 2025 budget resolution. On May 11, 2025, the House Energy and Commerce Committee released legislation鈥攁nd subsequently a substitute amendment鈥攖hat contains several substantive Medicaid proposals designed to address eligibility and enrollment; financing; fraud waste, and abuse; and to institute mandatory work and community engagement requirements and cost sharing. The Committee completed its markup on May 14, 2025, voting to approve the provisions in the substitute amendment.

The release of text and committee markups are key steps in Congress鈥檚 budget reconciliation process; however, proposals may change during Senate proceedings.

红领巾瓜报 (红领巾瓜报), and Leavitt Partners, an 红领巾瓜报 company, are tracking these developments and analyzing the extensive health and health-related legislative text, including the Medicaid, Medicare, and Affordable Care Act (ACA) Marketplace proposals. Below, we review the status of congressional efforts and key policies.

Background

The budget reconciliation process is a powerful tool for enacting significant fiscal policy changes, as it allows for expedited consideration and passage of budget-related legislation. It has been used in the past to enact major tax reforms, healthcare legislation, and other important budgetary measures.

In 2025, Congress has been actively working to develop its budget bills through a series of steps. The House adopted a budget resolution on February 25, 2025, which sets the framework for federal spending, revenue, and the debt limit for fiscal year 2025 and outlines budgetary levels for the following years through 2034. The Senate passed an amended version of the budget resolution on April 5, 2025. The Senate鈥檚 amendments included reconciliation instructions that require $4 billion in gross deficit reductions and allow a $5.8 trillion net deficit increase. On April 10, 2025, the House agreed to the Senate鈥檚 amendments with a vote of 216鈭�214. This agreement set the stage for the development of a reconciliation bill.

House Energy and Commerce Markup

On May 14, 2025, the House Committee on Energy and Commerce completed its second day of legislative language to comply with the Concurrent Resolution on the Budget for Fiscal Year 2025, voting to advance the proposals out of committee. The committee鈥檚 proposal excluded certain significant structural reforms that had generated concern among some members and stakeholders, such as broad reductions in the federal matching rate (enhanced federal matching assistance percentage (FMAP)) for Medicaid expansion populations, per-capita caps on federal Medicaid cost growth, or reductions in the safe harbor threshold for state Medicaid provider taxes. The proposal does, however, contain more than a dozen provisions that would reduce federal health care spending by $715 billion with the funding reductions mostly focused on Medicaid, which the Congressional Budget Office projects will reduce the federal share of Medicaid spending, including:

  • Adding mandatory work and community engagement requirements for individuals ages 19鈭�64 without dependents, subject to exceptions for pregnant women, people who are medically frail, people with disabilities, people in compliance with other government program work requirements, people living in areas experiencing a temporary hardship, and other individuals
  • Adding cost sharing for beneficiaries in the expansion population who earn more than 100 percent of the Federal Poverty Level, not to exceed $35 per item or service
  • Pausing implementation of several final rules published during the Biden Administration, including: the final rule published September 21, 2023, 鈥淪treamlining Medicaid; Medicare Savings Program Eligibility Determination and Enrollment鈥�; the April 2, 2024 rule, 鈥淪treamlining the Medicaid, Children鈥檚 Health Insurance Program, and Basic Health Program Application, Eligibility Determination, Enrollment, and Renewal Processes鈥�; and the May 10, 2024, final rule, 鈥淢inimum Staffing Standards for Long Term Care Facilities and Medicaid Institutional Payment Transparency Reporting鈥�
  • Adding provider screening requirements
  • Increasing frequency of eligibility redeterminations for certain individuals and adding enrollee address verification policies
  • Reducing expansion FMAP for certain states that provide Medicaid coverage to undocumented individuals and families, regardless of the source of funding
  • Preventing certain spread pricing arrangements in Medicaid between states and pharmacy benefit managers
  • Restricting funding for certain essential community providers that furnish family planning services, reproductive health, and related healthcare services
  • Ending a temporary increased FMAP to new states adopting Medicaid expansion, revising policies governing the use of Medicaid provider taxes, and payment limits for state directed payments

Committee Markups

Various other House committees have begun holding markups for the reconciliation package. The Committee on Ways and Means conducted its markup on May 13, 2025, to discuss its  of the reconciliation bill, which involves $4.5 trillion in deficit increases. The initial Ways and Means proposal did not include many significant healthcare proposals, but on May 12, 2025, the committee released a substitute amendment that includes several changes that would affect private insurance coverage and Medicare. Key provisions include:

  • Changes to Medicare and ACA premium tax credit (PTC) eligibility requirements related to immigration status
  • Improvements to ACA PTC eligibility verification checks
  • Changes to Health Savings Account flexibilities
  • Codification and renaming of individual coverage health reimbursement accounts, which serve as a defined contribution that employees can use to purchase insurance in the individual market

Other committees, such as the Education and Workforce, Judiciary, Armed Services, and Homeland Security Committees, also have conducted markups and approved their respective portions of the reconciliation bill.

Connect With Us

These steps are part of the ongoing process to finalize the budget and reconciliation legislation for FY 2025. Our federal policy experts with Leavitt Partners and across 红领巾瓜报 are monitoring the legislative policies and ongoing negotiations in Congress and with the administration. They work with healthcare organizations and industry to plan for the range of scenarios and policies Congress is debating.

For more information about the impact of these policies, contact our featured federal policy experts聽below.

Webinar

Ask 红领巾瓜报 Experts: Behavioral Health Town Hall

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Join us for a dynamic and interactive Behavioral Health Town Hall hosted by 红领巾瓜报 (红领巾瓜报). Our experts will be available to answer your questions live on a wide range of critical topics, including:

  • Federal policy, personnel, and funding changes;
  • Emerging strategies for addressing social determinants of health, substance use disorder and crisis coordination (including 988);
  • Behavioral health revenue cycle management and alternative payment models; and
  • Innovations in addressing workforce shortages, integrated service delivery, digital mental health tools, and best practices for community mental health service delivery.

Whether you鈥檙e navigating regulations, searching for new funding, designing service delivery systems, or just trying to understand what happens next, this town hall is your chance to ask questions, share insights, and discuss real-world solutions with industry experts.

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Health Policy in Maryland Amid Fiscal Uncertainty

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The 2025 Maryland General Assembly session closed on April 7th. While the budget deficit consumed a large portion of legislative bandwidth, there was significant action on health-related programs, including supporting the implementation of the Centers for Medicare & Medicaid Services (CMS) All-Payer Health Equity Approaches and Development (AHEAD) Model, expanding access to care, paving a way for Prescription Drug Affordability Board (PDAB) expansion and increasing access to affordable insurance. The AHEAD Model is an innovation in healthcare finance that drives improvements in population health through increased investments in activities likely to improve health outcomes, and benefits hospitals that participate by providing stable funding through hospital global budgets.

Budget Deficits and Federal Funding Fears Limited New Spending

After intense debate and discussion, House and Senate fiscal leaders reached a budget agreement on the final day of session. From the beginning, significant projected general fund shortfalls existed in the current and future fiscal years. Primarily these shortfalls were due to higher than anticipated Medicaid enrollment and growth in obligations to fund K-12 education under the Blueprint for Maryland鈥檚 Future. Through a combination of actions including budget cuts, increasing hospital assessments to cover Medicaid costs, shifting costs to counties, and new taxes and fees, the budget passed along party lines. Due to concerns about the potential harm from federal budget cuts, particularly in the Medicaid program, the final plan includes a trigger provision requiring the Governor to engage lawmakers on solutions should federal funding to the state fall by $1 billion.  

The State Readies for the AHEAD model

Despite fiscal concerns, the General Assembly established two new funds, the Population Health Improvement Fund, and the Maryland Primary Care Program Fund, to support the implementation of the AHEAD model. Revenues to both funds are collected through an increase in hospital assessments.

  • The Population Health Improvement Fund will support efforts to reach statewide population health targets under the AHEAD model.
  • The Maryland Primary Care Program Fund will support the implementation of a Medicaid advanced primary care model and support primary care providers through investments in reimbursements for evaluation and management codes, care management fees to eligible practices, and quality incentives.

Supporting Access to Care

Lawmakers passed several bills aimed at increasing or protecting access to care.

  • The Preserve Telehealth Access Act of 2025 makes permanent provisions of law requiring reimbursement parity between telehealth and in-person services and includes 鈥渁udio-only鈥� services as telehealth under certain circumstances.
  • Legislation passed to address children and youth boarding in hospital settings beyond medical necessity. The bills define a 鈥減ediatric overstay鈥� and requires the Maryland Department of Health and the Maryland Department of Human Services to establish a pediatric overstay coordinator in each department to ensure that each patient is served in the least restrictive environment.

Several pieces of legislation passed to address behavioral health and substance use disorders including:

  • Eliminating the prohibition on using 9-1-1 trust fund dollars to support the 9-8-8 suicide prevention hotline, improving coordination between 9-1-1 and 9-8-8.
  • Establishing a buprenorphine training grant program to support training paramedics to administer the drug.
  • Further delineating uses of opioid restitution fund dollars and creating additional reporting requirements for the Office of Overdose Response.

Since the Dobbs decision, rolling back protections for abortion care in states, Maryland has been on the forefront of protecting reproductive freedom. Legislation passed establishing the Public Health Abortion Grant Program and Fund to support eligible organizations providing equitable access to abortion care services.

Regulating Prescription Drug Prices

Maryland established the Prescription Drug Affordability Board (PDAB) in 2019 joining ten other states in regulating the cost of prescription drugs through affordability boards. The goal of PDABs is to address high prescription costs by setting upper payment limits (UPLs) for drugs that cause or are likely to cause affordability challenges. Currently, Maryland鈥檚 PDAB is authorized to set UPLs for prescription drug products purchased by or on behalf of a unit of state or local government.  Legislation passed creating a pathway for the PDAB to set UPLs on prescription drug products paid for by additional state regulated payors if the board determines that the product has led or will lead to an affordability challenge.

Access to Affordable Health Insurance

The General Assembly made permanent the State-Based Young Adult Health Insurance Subsidy program and requires the Maryland Health Benefit Exchange in consultation with the Maryland Insurance Commissioner to establish and implement a state-based health insurance subsidy program for all individuals. The Maryland Health Insurance Protection Commission was reestablished to monitor federal changes that could impact coverage.

Change in Leadership at the Maryland Department of Health

During the busy legislative session, Secretary Laura Herrera Scott, MD, announced she was stepping down from her position as leader of the Maryland Department of Health. Former CMS administrator, Meena Seshamani, MD, was announced as Dr. Scott鈥檚 successor and sworn in on April 9th. Secretary Seshamani will be tasked with leading the transition from Maryland鈥檚 Total Cost of Care model to the AHEAD model and leading the department through a period of uncertainty and expected budget shortfalls.

Maryland State of Reform Conference to Cover Many of these Issues

These issues and more will be covered at the on June 12th at the Baltimore Marriott Waterfront. The day will include a panel of legislative leaders as well as sessions focused on the AHEAD Model, value-based care, behavioral health, public health, and prescription drug costs.

Blog

Governor Asa Hutchinson Announced as Keynote Speaker at 红领巾瓜报 2025 Conference

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We鈥檙e excited to welcome former Arkansas Governor Asa Hutchinson as the keynote speaker at the 2025 红领巾瓜报 Conference October 14-16 in New Orleans, LA.聽 Governor Hutchinson brings over 40 years of leadership in law, national security, and public service. As the 46th Governor of Arkansas (2015鈥�2023), he championed innovation in maternal healthcare, initiating programs and policies focused on improving maternal health outcomes during his time in office. He established the Maternal Life360Home program, expanding access to home visitations and intensive care coordination services for women with high-risk pregnancies and for children after birth, and improving the safety and wellbeing of children in foster care. He launched the Healthy Active Arkansas program, a 10-year plan to encourage schools and businesses to promote healthier eating and more activity.

His prior federal roles include Drug Enforcement Agency (DEA) Administrator, the first Under Secretary for Border and Transportation Security at the Department for Homeland Security (DHS), U.S. Congressman, and the nation鈥檚 youngest U.S. Attorney. We鈥檙e excited to welcome his perspective on advancing health outcomes across America.

In keeping with changes being made at the federal level affecting all aspects of the healthcare system, Governor Hutchinson will be discussing “The Policy and Politics of Making America Healthy.” In his address, he will share聽insights from his tenure in Arkansas, his perspective on effective health policy development, and the challenges to implementation at both state and federal levels. Join us for what promises to be an enlightening session as he explores the evolving relationship between federal and state governments and the opportunities for innovative health policy development that gives states more flexibility.

Don’t miss this opportunity to hear from one of our nation’s respected political leaders on issues that directly impact our industry and the health of Americans.

Date: October 14-16, 2025

Time: 8:30 a.m.

Location: Four Seasons New Orleans

Following the Governor鈥檚 talk, you will join with industry leaders to discuss new directions in payment and financing of publicly funded healthcare programs, community-level strategies designed to meet the needs of special populations, tailwinds driving the expanding universe of digital health policies, and innovations to strengthen access to behavioral health services. Come for the informative plenary sessions and workshops, explore strategies for navigating changes in funding, access, and coverage to ensure success in a shifting environment, and expand your network with federal and state policymakers, healthcare providers, insurers, philanthropists, and C-suite industry leaders. 

Brief & Report

What鈥檚 Really Causing the Rise in Insurance Premiums, and What Can States Do About It?

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Healthcare cost increases are outpacing general inflation, which jeopardizes access to coverage and care, as well as investments in other priorities. As a result, states are looking for ways to reduce the cost burden for consumers, employers, and taxpayers. The State of Maine engaged Wakely Consulting Group, an 红领巾瓜报 Company, to analyze historical medical trends and the associated impact on premiums in Maine鈥檚 health insurance market for the period of 2021 to 2025. The goal was to assess what factors are driving rising insurance costs. This project was supported by an 红领巾瓜报 contract with Arnold Ventures, under which we provide technical assistance to states seeking to reduce healthcare cost growth.

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