Health Policy Report – November 18, 2025

Government Shutdown Ends

On November 12, the House of Representatives narrowly ended the longest government shutdown in history in a 222-209 vote to fund the government until January 30. Earlier in the week, a group of eight Senate Democrats voted to advance the bipartisan deal, which reopens the government, funds key agencies, and undoes federal layoffs. The agreement also extends Medicare telehealth coverage through January 30 and pay retroactively for virtual care services delivered during the government shutdown.

The deal didn’t ultimately extend enhanced premium tax credits (EPTCs) under the Affordable Care Act (ACA), the core issue of the shutdown. However, Republican and Democratic members signaled that the issue is top of mind and have begun pushing different iterations of a subsidy extension, with legislation in both the House and Senate.

While next steps for the enhanced ACA subsidy extension remains unclear, Democrats and Republicans are turning to healthcare as they move closer to the 2026 midterm elections.

To read more, CLICK HERE.

CMS Announces New Voluntary Medicaid Model to Incorporate Most Favored Nation Drug Pricing

The Centers for Medicare & Medicaid Services (CMS) recently announced a new drug payment model – the Generating cost Reduction for U.S. Medicaid (GENEROUS) model – for manufacturers to offer supplemental rebates to programs. The announcement follows a series of agreements between the White House and pharmaceutical manufacturers to address high drug pricing in the U.S.

The voluntary model is set to begin in 2026 and run for five years. Participating manufacturers will adjust pricing to align with what other countries pay via supplemental rebates to participating states. Soon after the announcement, CMS released a request for applications from drug manufacturers and letters of intent for state Medicaid agencies interested in participating.

“Under the leadership of President Trump and Secretary Kennedy, CMS is making a historic commitment to driving down the cost of drug prices and ensuring Americans have access to life-saving medications,” CMS Administrator Mehmet Oz, MD, said. “The GENEROUS Model will help ensure state Medicaid programs are paying a fair and reasonable price for prescription drugs—furthering our efforts to preserve funds for our most vulnerable.”

To learn more about the GENEROUS model, CLICK HERE and HERE.

Hospitals Sound the Alarm on 340B Drug Rebate Program
Nonprofit hospitals and health clinics are expressing concern about a new change to the 340B Drug Pricing Program. In January, Health and Human Services (HHS) Health Resources and Services Administration (HRSA) will begin a pilot program allowing drugmakers to participate voluntarily in a rebate-based discount system. Hospitals will have to pay full price for the drugs and then receive rebates, rather than receiving price reductions beforehand. The program is set to run for at least one year and only drugs that have been selected for Medicare price negotiations are eligible.

The pilot aims to boost transparency, but hospitals and health systems are sharing growing concerns that the model would introduce financial challenges and administrative burden, particularly for smaller, safety net providers that 340B was originally intended to assist. Hospitals have also noted that this change comes as providers prepare for cuts in Medicaid reimbursement.

To read more about the 340B drug rebate program, CLICK HERE and HERE.

House Democrats Introduce Bill to Repeal WISeR
House Democrats, including Representatives Suzan DelBene (D-WA), Greg Landsman (D-OH), Ami Bera, MD (D-CA), Kim Schrier, MD (D-WA), Mark Pocan (D-WI), and Rick Larsen (D-WA), have introduced the Seniors Deserve SMARTER Care Act. This legislation would repeal the Wasteful and Inappropriate Services Reduction (WISeR) model proposed by the Centers for Medicare and Medicaid Services (CMS).

WISeR, which is set to begin in January 2026 across six states, would impose new prior authorization requirements for some services, including skin and tissue substitutes and electrical nerve stimulator implants. The approval process would be outsourced to private companies, which rely on artificial intelligence to determine whether care should be approved, with these companies getting paid based on the costs they prevent through denials of care.

CMS argues that the model will root out unnecessary care and cut costs for patients and the federal government. Democratic lawmakers, however, argue that this payment structure will create an incentive to deny medically necessary treatment, creating unnecessary red tape that delays or blocks care for Medicare recipients.

To read more, CLICK HERE.

NCPA and USC Introduce Pharmacy Shortage Area Mapping Tool
The National Community Pharmacists Association (NCPA) and the University of Southern California (USC) have launched an interactive pharmacy shortage area mapping tool. Within the last few years, pharmacy closures have left people across the country with fewer options to access essential medicines.

The tool is intended to serve as a resource to help the public identify pharmacy shortage areas and provide a better understanding of the issues facing rural and underserved communities. Those who use the tool will be able to identify designated shortage areas, track new pharmacy openings and closings, identify “critical access” pharmacies, and view this data at the state, county, and congressional district level.

To read more, CLICK HERE.