In this edition of AcademyHealth’s Situation Report, we highlight CMS’s proposed changes to ACA marketplace plan standards, a bipartisan bill targeting vertical integration across insurers, PBMs, and providers, and House subpoenas examining enrollment integrity safeguards. We also examine the launch of an independent vaccine review process and renewed federal investments in nursing home workforce capacity, which could reshape long-term care delivery. Read on to learn about an opportunity to submit a public comment on the proposed ACA changes.
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In today’s issue:
- CMS Proposes Major Changes to ACA Marketplace Plans for 2027
- Bipartisan Bill Seeks to Break Up Health Care Conglomerates
- House Subpoenas Insurers Over Alleged ACA Enrollment Fraud
- A New, Independent Vaccine Review Process Breaks from the Federal Government
- CMS Expands Financial Incentives to Strengthen Nursing Home Staffing
CMS Proposes Major Changes to ACA Marketplace Plans for 2027
The Centers for Medicare & Medicaid Services (CMS) has proposed changes that could significantly reshape Affordable Care Act (ACA) marketplace plans in 2027, including allowing insurers to offer more plan options and expanding access to long-term catastrophic coverage. The proposed “Notice of Benefit and Payment Parameters” for the 2027 plan year (i.e. the 2027 Payment Notice proposed rule) sets the standards insurers must follow when offering coverage through the ACA marketplaces.
CMS also plans to roll back a Biden-era limit that restricted insurers to two standardized plan designs per metal tier (e.g., Bronze, Silver, Gold). That policy was intended to make it easier for consumers to compare plans; removing the limit could result in more plan variation — and potentially more complexity The 2027 Payment Notice proposed rule also outlined a pathway to allow insurers to offer catastrophic coverage in one-year terms, or longer consecutive terms, up to a maximum of 10 years. Changes to catastrophic coverage may not adequately cover consumers’ health needs, while offering higher out-of-pocket maximums that are often $12,000+ for individuals in 2027, a 13.2 percent increase from 2026.
CMS also proposes clarifying its authority to audit insurers participating in the marketplaces, framing the change as a way to strengthen oversight and protect federal funds.
Critics of the proposed rule expressed concerns that multi-year catastrophic plans could increase the financial risk for patients. In a press release, Senator Ron Wyden (D-Oregon), stated,” "Here are just a few things on offer: raising the out-of-pocket maximum, allowing insurance companies to offer even more complicated and indecipherable plans that include fewer in-network providers, and rolling out the red carpet for junk plans that don't cover essential healthcare..."
The 2027 Payment Notice proposed rule is available through the Federal Register and is open for public comments through March 13, 2026. As the proposal raises important questions about plan design, consumer choice, affordability, and oversight, we encourage health services research to consider submitting a comment to help bring the evidence into the policy discussions.
Bipartisan Bill Seeks to Break Up Health Care Conglomerates
Senators Elizabeth Warren and Josh Hawley introduced the Break Up Big Medicine Act, a bipartisan proposal aimed at restricting the vertical integration of large health care corporations. The bill would bar parent companies from simultaneously owning key parts of the delivery and financing chain, such as medical providers, pharmacy benefit managers (PBMs), insurers, and certain drug or device suppliers, in an effort to reduce conflicts of interest and restore competition.
The legislation responds to growing concerns that consolidation across PBMs, insurers, and provider organizations has increased prices, limited patient choice, and crowded out independent practices. With three PBMs, CVS Caremark, Express Scripts, and OptumRX, controlling nearly four‑fifths of U.S. prescription drug claims, and each owned by a major insurer, policymakers and researchers have increasingly scrutinized how integrated corporate structures influence cost, access, and transparency.
The bill raises significant questions about how ownership structures affect care quality, referral patterns, drug pricing, and market power. It also introduces new potential research avenues related to antitrust enforcement, competition policy, and the downstream effects of unwinding vertically integrated entities. Since the proposal would empower multiple federal and state agencies, as well as private citizens, to challenge violations, it signals heightened attention to how consolidation shapes patient experience and system performance.
House Subpoenas Insurers Over Alleged ACA Enrollment Fraud
House Judiciary leaders issued subpoenas to eight major insurers, Blue Shield of California, Centene, CVS Health, Elevance, GuideWell, Health Care Service Corporation, Kaiser Permanente, and Oscar Health, for documents on safeguards against fraud in Affordable Care Act (ACA) enrollments. The move follows a GAO analysis flagging unauthorized broker change, repeated use of phone numbers across applications, and consumer complaints about being enrolled or switched without consent. Committee leaders say the responses could inform potential changes to the Administrative Procedure Act after courts paused parts of the administration’s earlier rule aimed at curbing “improper enrollments.”
Enrollment integrity intersects directly with subsidy accuracy, plan continuity, and network access. Allegations of unauthorized enrollments and eligibility misstatements risk both waste in advanced premium tax credits spending and consumer harm. Unauthorized plan switches can leave people enrolled in coverage that does not include their regular providers or needed medications, disrupting ongoing treatment and forcing out‑of‑network care. These changes can also alter deductibles and copays mid‑year and, when income or eligibility information is misreported, lead to tax‑time repayment of premium credits.
For the HSR community, this development elevates research needs around broker and plan accountability, verification processes that minimize administrative burden on eligible enrollees, and the balance between fraud prevention and access to care, especially for populations relying on assistance to navigate plan selection.
A New, Independent Vaccine Review Process Breaks from the Federal Government
As the CDC continues to change U.S. vaccine recommendations, and trust in the agency dwindles, evidence-based review processes are more crucial than ever. The American Medical Association (AMA) and the Vaccine Integrity Project announced that they will independently assess vaccine safety and effectiveness for the 2026-2027 respiratory virus season. The review will focus on immunizations for influenza, COVID-19, and respiratory syncytial virus (RSV). The Vaccine Integrity Project, based at the University of Minnesota, was formed in 2025 to promote the continued grounding of immunization policies and programs in the best available science and focuses on optimizing protection of individuals, families, and communities against vaccine-preventable diseases.
The dismissal of all 17 members of the CDC’s Advisory Committee on Immunization Practices (ACIP) last June was a clear indication that the administration would be taking a different approach to producing data to understand the risks and benefits of vaccine policy decisions, one that does not necessarily rely on an evidence-based review process. The AMA and Vaccine Integrity Project’s review process will be independent from the federal government, relying on funding through philanthropy.
Health services researchers can look to this as an example of how to effectively translate evidence into policy through independent efforts that don’t rely on government oversight or funding. This shows how researchers and institutions can step in to fill the gaps left by these ongoing federal policy changes.
CMS Expands Financial Incentives to Strengthen Nursing Home Staffing
The Centers for Medicare & Medicaid Services has republished a Notice of Funding Opportunity aimed at addressing ongoing nursing home staffing shortages. The agency is again accepting applications to provide financial incentives, including student loan repayment and stipends, to registered nurses and licensed practical nurses who commit to working three years in an eligible nursing home or state oversight agency. This renewed funding builds on a series of staffing investments over the past two years, including more than $75 million committed in April 2024 and the launch of a $20 million Nursing Home Staffing Campaign focused on student loan debt relief. The announcement comes amid continued policy shifts, including the repeal of the 24-hour registered nurse requirement in long-term care facilities.
For health services researchers, this development highlights the importance of evaluating which policy tools meaningfully strengthen the long-term care workforce. Financial incentives are increasingly being used as a strategy to recruit and retain nurses, but questions remain about their long-term impact, cost effectiveness, and ability to improve staffing stability across different markets and facility types. Researchers can examine how these investments affect turnover, resident outcomes, quality of care, and regulatory compliance, as well as whether incentives reduce disparities between rural and urban facilities or across states. As federal staffing standards evolve and new funding streams are deployed, rigorous HSR will be essential to assess what works, for whom, and under what conditions, and to inform future workforce and long-term care policy decisions.
Previous Editions
This is the latest in a series of Situation Report updates from AcademyHealth. You can find prior issues here.
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